Abstract Number ‐ 119: Stent‐Coil Embolization Of A High Riding Jugular Bulb For Symptomatic Pulsatile Tinnitus

Introduction Tinnitus affects millions of people worldwide and in a significant number of people, tinnitus can be severe enough to impact day‐to‐day life. Various diseases can manifest with tinnitus, including atherosclerotic disease, AVMs, Meniere’s disease, IIH, medication toxicity, and neoplasms. Jugular bulb diverticula are a significant contributor to the incidence of persistent tinnitus. One study of 1579 temporal bone specimens, 8.2% were found to have high‐riding jugular bulbs. Other sources demonstrate a prevalence of 6% in the population. Another study demonstrated a high‐riding jugular bulb in 2.4‐7% of temporal bones, a 5 times higher prevalence of a high‐jugular bulb in patients with ear related symptoms, and tinnitus in 22% of patients in a 730 cohort who presented to otolaryngology. We present 3 cases of jugular bulb diverticula causing debilitating tinnitus and their subsequent treatment with stent‐assisted coiling. Methods Retrospective chart review of patients who presented with symptoms of pulsatile tinnitus, noted to have a jugular bulb diverticulum on cerebral venogram, who underwent stent‐assisted coil embolization. Results A 71‐year‐old male with a history of migraines presented with nausea and right‐sided tinnitus that worsened on lying down. The persistence of symptoms prompted further investigation with a catheter venogram which demonstrated a high‐riding right jugular bulb measuring 10.37 mm x 8.61 mm. The patient underwent stent‐assisted coiling and embolization with improvement in his symptoms. A 57‐year‐old male with recent history of right ischemic infarct secondary to intracranial atherosclerosis had worsening left sided pulsatile tinnitus over one year to the point where it prevented sleep, waking him hourly. A CT‐Venogram revealed a left jugular bulb diverticulum measuring 5.33×5.02 mm. A cerebral angiogram and venogram confirmed this diagnosis and ruled out an AVM/dAVF. Stent‐assisted coiling resulted in immediate relief. The above patients were treated with a Zilver stent (Cook Medical, Bloomington, IN) and Target Coils (Stryker Neurovascular, Kalamazoo, MI). A 40‐year‐old woman presented with severe abrupt‐onset pulsatile right‐sided tinnitus and associated hearing loss, without any associated relieving factors. Due to the severity of her symptoms, she goes to counseling. A cerebral venogram revealed a right internal jugular diverticulum measuring 6.73 mm x 14.5 mm, without any associated dural sinus stenosis. She is scheduled for stent assisted coil embolization. Conclusions High‐riding jugular bulb or jugular diverticulum should be suspected as a potential and treatable cause of pulsatile tinnitus when other diagnoses have been ruled out. Our case series demonstrates that stent assisted coil embolization is safe and effective in relieving tinnitus and hearing loss, which can be debilitating in many cases

Abstract 019: Effective Diagnostic Testing For Uncommon Etiologies Of Venous Pulsatile Tinnitus

Introduction Pulsatile Tinnitus (PT) is a rhythmic sound in the ears. It can be incapacitating and is even associated with depression and suicidal ideationi. The etiology of PT can be grouped into vascular and non‐vascular causes. ii,iii While prominent venous structures may be believed to be the underlying cause of PT, interventions on these structures do not always result in symptom resolution. Successful treatment is contingent on correctly identifying culpable vascular targets. In this case series, we report 4 cases of pulsatile tinnitus that were successfully treated with endovascular intervention. Methods Retrospective chart review of patients who presented with symptoms of pulsatile tinnitus who were found to have symptoms that resolved on balloon‐occlusion‐testing of various cerebral veins. Results Case 1 A 42‐year‐old woman was referred for right‐sided PT which affected her sleep and quality of life. The initial venogram showed a right internal jugular (IJ) vein diverticulum, which was subsequently coiled. This resulted in a transient improvement in tinnitus. However, her symptoms returned within a few weeks and a repeat venogram showed an enlarged right MEV. She elected to undergo right MEV coil embolization. Two weeks post‐op she noted an improvement of her symptoms, with near resolution. On follow‐up exams, when she applied pressure on her right occipital groove, the tinnitus diminished. Under ultrasound guidance, her PT disappeared when the posterior auricular vein collapsed under applied pressure and returned when the pressure was released. For management she underwent coil embolization of the right occipital vein, as this was the vessel the posterior auricular vein was draining into. Following this intervention her tinnitus resolved. Case 2 A 73‐year‐old male was referred for bilateral pulsatile tinnitus. Initially, he underwent stent‐assisted coiling of a high‐riding jugular bulb with no change in symptoms. During a diagnostic venogram, a balloon‐occlusion test (BOT) of the right mastoid emissary vein (MEV) was performed. Following testing, he reported improved tinnitus. He underwent coil embolization of the right MEV which led to complete resolution of right‐sided PT. Case 3 A 50‐year‐old female was referred for evaluation of right‐sided PT. Catheter venography showed an enlarged right posterior condylar vein (PCV) and right IJ stenosis. Balloon occlusion test (BOT) of the PCV demonstrated improvement in PT. She underwent stent‐assisted coil embolization of the PCV and stenting of her IJ with resolution of her tinnitus. Case 4 A 56‐year‐old female was seen for left‐sided PT, ear fullness, and reduced hearing. A CT venogram revealed left IJ stenosis. Catheter venography showed minimal left IJ stenosis, but a dilated left MEV, measuring 7.31 mm in its widest dimension). BOT of the left MEV resulted in improvement in symptoms. She is scheduled for left MEV coil embolization. Conclusion In this report, we demonstrate 4 cases where abnormal venous structures were the suspected cause of tinnitus based on pre‐treatment occlusion testing. The 3 individuals who have undergone coil embolization of anomalous venous structures have experienced resolution of PT. Balloon occlusion is a useful diagnostic test for therapeutic targeting of abnormal venous etiologies of PT

Abstract 195: Changing Trends of Thrombolysis and Thrombectomy for Low Severity Stroke: National Inpatient Sample Analysis (2016‐2020)

Introduction Over the past decade, stroke management has significantly improved with the widespread use of intravenous thrombolysis (IVT) and the establishment of endovascular thrombectomy (EVT) as the standard of care for increasing patients. However, a dilemma arises in cases of low‐severity stroke (NIHSS ≤ 5), as the EVT clinical trials do not include patients with such low NIHSS. There is debate surrounding the topic of EVT and IVT for low‐severity stroke, and often practice does not reflect the patient populations included in the initial clinical trials. Some recent studies suggest a trend toward decreasing pre‐thrombectomy IVT. (1) This study aims to examine the evolving trends of intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), and their combination in low NIHSS acute ischemic stroke (AIS) management in the United States from 2016 to 2020. Methods We accessed the national inpatient sample database from 2016 through 2020. We included patients admitted with stroke and who had a recorded NIHSS ≤ 5. To determine if there were changes in the frequency of events over time, we compared the outcome measures utilizing logistic regression models with 2016 as the reference year. Results Compared to 2016 the rates of IVT have significantly decreased starting in 2018 through 2020. The rates of EVT have trended upward since 2016 and were significantly higher in the year 2020. The rates of thrombectomy plus thrombolysis have trended upward but have not significantly changed since 2016. These results can be visualized in the Figure below, * = p‐value < 0.05. Conclusion Our findings highlight a significant shift in stroke treatment, with the growing use of EVT while simultaneously decreasing rates of IVT for low‐NIHSS strokes. Current clinical trials protocol are submitted to examine EVT's efficacy for low NIHSS stroke (2), but it's also crucial to understand what is driving this change in real‐world practice. This understanding will inform treatment decisions and ensure they align with evidence‐based standards, guaranteeing optimal, standardized patient care

Abstract 176: Management of Unruptured Intracranial Aneurysms in SubArachnoid Hemorrhage

Introduction Subarachnoid hemorrhage (SAH) has an estimated prevalence of 7.9 per 100,000 person yearsi. It is primarily caused by the rupture of intracranial aneurysms, leading to severe consequences and a 60% 6‐month mortality rateii. The management of UIAs in SAH cases poses a unique dilemma due to the potential increased risk of rupture, especially when the exact source of SAH remains ambiguous in the presence of multiple UIAs. Although tools like the PHASES scoreiii and the Unruptured Intracranial Aneurysms Treatment Score (UIATS)iv help guide aneurysm management, they are not tailored specifically to the scenario of UIAs in SAH. Thus, there is a need to study and comprehend the management strategies and outcomes of these cases. We reviewed the management and outcomes of UIAs in SAH at our institution in the past 10 years. Methods A retrospective review of all patients presenting between July 2013 and July 2023 with SAH and one concomitant UIA at our institution were analyzed. Results A total of 79 patients with confirmed UIA on angiography met inclusion criteria. Of these, 20 patients (25.3%) with UIAs were intervened on, as opposed to 59 (74.7%) that were not. UIAs >7 mm in diameter were found in 6 patients, and of these, 5 patients received intervention. 45.6% of the patients had a Hunt Hess Score of ≥3, and of these, 27.8% were intervened on. 72.2% of the patients had a Modified Fisher score >2, and of these, only 22.8% of the UIAs were intervened on. 58.2% of patients had a PHASES score >3, and of these, 34.7% were intervened on. Of the patients that were intervened on, 80% had a PHASES score >3. There was no significant difference in the UIATS score between the two groups. 34.9% of patients were noted to have the UIA in the same vascular territory as the SAH and of these 36.3% were intervened on. Current use of blood thinning medication, personal history of SAH or UIA, hypertension history, age, nor gender significantly affected the rate of UIA intervention Conclusion The majority of the UIAs in SAH were not intervened on, and the PHASES score and the UIATS score did not correlate with the decision on intervention. Of the ones that were intervened on, most of them were in the same vascular territory as the SAH. The decision to intervene appears to be on a case‐by‐case basis

Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study.

Background: Small, randomized trials of cervical artery dissection (CAD) patients showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with CAD treated with antiplatelets versus anticoagulation. Methods: This is a multi-center observational retrospective international study (16 countries, 63 sites) that included CAD patients without major trauma. The exposure was antithrombotic treatment type (anticoagulation vs. antiplatelets) and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with Inverse Probability of Treatment Weighting (IPTW) to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an "as treated" cross-over approach and only included outcomes occurring on the above treatments. Results: The study included 3,636 patients [402 (11.1%) received exclusively anticoagulation and 2,453 (67.5%) received exclusively antiplatelets]. By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with IPTW, compared to antiplatelet therapy, anticoagulation was associated with a non-significantly lower risk of subsequent ischemic stroke by day 30 (adjusted HR 0.71 95% CI 0.45-1.12, p=0.145) and by day 180 (adjusted HR 0.80 95% CI 0.28-2.24, p=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR 1.39 95% CI 0.35-5.45, p=0.637) but was by day 180 (adjusted HR 5.56 95% CI 1.53-20.13, p=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR 0.40 95% CI 0.18-0.88) (Pinteraction=0.009). Conclusions: Our study does not rule out a benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings