Meningocele, a Protective Finding in Patient with Pulsatile Tinnitus and Brain Imaging Features Suggesting PTCS

Pulsatile tinnitus is a diagnostically challenging and commonly subjective symptom. It is a sensation of whooshing, whistling, humming that is unilateral or bilateral and is synchronized with heart beat. Origin may be arterial, arteriovenous or venous. It frequently resolves with distal pressure over the ipsilateral jugular vein. In pseudotumor cerebri syndrome (PTCS) origin of pulsatile tinnitus is likely venous due to turbulent flow through narrowed transverse venous sinus. Patients with PTCS typically present with headaches (90%) and transient visual obscurations (70%). Many patients have transverse sinus stenosis as result of chronic elevation of intracranial pressure which in turn leads to fibrosis resulting in narrowed appearance of dural sinus on venous imaging. Patients with PTCS can have abnormal findings on MRI including empty sella, transverse sinus stenosis, widened optic nerve sheath, and posterior globe flattening of orbits. In addition high intracranial pressure (ICP) can lead to spontaneous meningoceles, which could become a source of CSF leak.