Non-stenotic dominant oblique occipital sinus causing dehiscent duplication of the jugular bulb: imaging diagnosis and novel endovascular management with stenting.

BACKGROUND: This study investigates a rare cause of pulsatile tinnitus related to a dehiscent duplication of the jugular bulb associated with a non-stenotic dominant oblique occipital sinus. We report a series of treated patients and describe a novel radiological feature-the 'playing card heart sign'.

METHODS: In this retrospective single-center study, four patients presenting with venous pulsatile tinnitus due to five dehiscent jugular bulb duplications associated with a non-stenotic dominant oblique occipital sinus were included between January 2023 and September 2024. Clinical assessment included symptom onset, body mass index, and Tinnitus Handicap Inventory score. High-resolution temporal bone CT scans and cerebral venous imaging were used to identify anatomical anomalies. Patients with a significant clinical impact underwent endovascular stenting. Outcomes were assessed at follow-up.

RESULTS: The mean patient age was 41.9 years, with a median body mass index of 27.4 kg/m². Tinnitus was unilateral in three patients and alternating in one. Imaging revealed a bony dehiscence overlying a duplicated jugular bulb, ipsilateral to a non-stenotic dominant oblique occipital sinus, with no venous pressure gradient. Stenting (n=5) led to complete resolution of tinnitus in all patients, with a median follow-up of 15 months and no reported complications.

CONCLUSIONS: Jugular bulb duplication with dehiscence, associated with a non-stenotic dominant oblique occipital sinus, represents an under-recognized cause of pulsatile tinnitus. This condition can be effectively treated with stenting. Identification of the 'playing card heart sign' on imaging is key for accurate diagnosis and management.