Anticoagulation in the Treatment of Pulsatile Tinnitus Caused by Internal Jugular Vein Stenosis: A Rare Case Report

Here is an interesting case of 54 year old lady that developed symptoms of IJVS; insomnia, pulsatile tinnitus, decreased appetite (maybe nauseated), facial pressure & throbbing. Her symptoms were exasperated by lying in supine position. After going through multiple medical testing and imaging with no findings, CT angiogram finally revealed non-thrombotic, non-extrinsic compression left jugular vein occlusion. it also found the development of extensive occipital and sub-occipital collateral flow as result of the impaired jugular vein. She was treated with anticoagulation both orally & intravenously. Her symptoms and blood flow both improved within a year after the treatment.

I know a few folks such as @Emma123 are wondering whether IJVS is causing their symptoms when lying in supine position. I think this study highlighted how the symptoms of IJVS (regardless of the cause; compression, clotting, etc) can indeed worsen in lying in supine position. It also highlights the role of anticoagulation in relieving the symptoms of non-compression cases of IJVS. Although, I have also seen folks with compression improve with anticoagulation therapy as was the case with @blossom who also had scar tissue induced compression along with Styloid compression on her jugular vein.

Introduction
Tinnitus refers to a ringing sound in the ears and can be pulsatile
or nonpulsatile [1]. Pulsatile tinnitus is a specific form of tinnitus
and commonly manifests as a “whooshing” sound synchronous
with heartbeat, with its effects ranging from throbbing in ears
to hearing loss and vertigo. Pulsatile tinnitus from a vascular
etiology can be caused by blood flow turbulence if obstruction
of an arterial or venous vessel has occurred [2]. Cases of
pulsatile tinnitus associated with cerebral venous thrombosis
(sagittal sinus) have also been published in the literature
[3]. Non thrombotic IJV occlusion by itself is an uncommon
condition. Most common causes of IJV occlusion are attributed
to thrombosis secondary to IJV cannulation, trauma, surgery or
irradiation [4]. External compression by an elongated styloid
process has also been reported [5]. The clinical presentation
of this condition is highly variable, ranging from insidious to
symptomatic, such as headaches, dizziness, pulsatile tinnitus,
visual impairment, sleep disturbance, and neck discomfort
or pain. Standard diagnostic criteria are not available, and
current diagnosis largely depends on a combination of imaging
modalities [6]. Hence, investigating the IJV, whether occlusion
or stenosis, is critical to minimize misdiagnoses and better
understand its etiology.
Venous outflow mainly occurs through the internal jugular
system in a supine position, making it more challenging to be
diagnosed with noninvasive diagnostic modalities. In addition,
gravity affects cerebral venous system output. Studies indicate
jugular vein collapse in an upright position, with cerebral venous
drainage occurring through the vertebral venous system instead
[7]. In this case, we report left jugular vein occlusion presenting
as pulsatile tinnitus in the supine position. Fewer case reports
of IJV stenosis associated with pulsatile tinnitus and other
symptoms have been reported [8,9].

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Thank you again, very interesting!