Radiology · Medical Literature
Letter to the editor re: Sathya A, Nguyen TN, Klein P, et al. Endovascular vs surgical treatment of sigmoid sinus diverticulum causing pulsatile tinnitus: A systematic review. Interv Neuroradiol. 2024 Mar 22:15910199241231325.
Abstract
Letter to the Editor re: Sathya A, Nguyen TN, Klein P, et al. Endovascular vs surgical treatment of sigmoid sinus diverticulum causing pulsatile tinnitus: A systematic review. Interv Neuroradiol. 2024 Mar 22:15910199241231325.
Clinical relevance
Does endovascular treatment (EVT) or surgical treatment (transmastoid sinus wall reconstruction) produce superior efficacy and safety outcomes in patients with sigmoid sinus diverticulum (SSD) causing pulsatile tinnitus, and what methodological or clinical concerns does the Sathya et al. 2024 systematic review raise that warrant further scrutiny? __SNAPSHOT__ {"studyDesign":"Letter to the Editor — critical commentary on a previously published systematic review (Sathya et al., Interv Neuroradiol, 2024 Mar 22:15910199241231325); not a primary study or independent systematic review","setting":"Not reported; correspondence responding to a multi-institutional systematic review conducted at Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA","sampleSize":"Not reported for the Letter itself; the index systematic review (Sathya et al. 2024) identified 38 articles from 539 initial publications after screening, covering endovascular and surgical treatment cohorts","population":"Patients with imaging-confirmed sigmoid sinus diverticulum (SSD) causing pulsatile tinnitus (PT); the underlying systematic review included studies published between January 1, 2000 and January 31, 2023","intervention":"Endovascular treatment (EVT) of SSD, including coil embolization, stenting, and stent-assisted coiling techniques","comparator":"Surgical treatment of SSD, principally transmastoid extraluminal sinus wall reconstruction (as described by Eisenman and others)","primaryOutcome":"Not formally defined in the Letter; the index systematic review assessed resolution or improvement of pulsatile tinnitus and procedural complication rates between EVT and surgical approaches","followUp":"Not reported in the Letter; the index systematic review did not mandate a minimum follow-up duration across included studies","fundingSource":"Not reported"}
Key findings
This submission is a Letter to the Editor responding to the Sathya et al. 2024 systematic review, which concluded that EVT appears more effective and safer than surgical treatment for SSD-associated pulsatile tinnitus but acknowledged that large comparative studies are lacking. The Letter (Eisenman, Ghandi, Hsieh et al.) is available only as a correspondence item without a structured abstract; specific quantitative findings, p-values, confidence intervals, or effect sizes attributable to the Letter itself are not reported. The index systematic review on which the Letter comments found that EVT in patients with pulsatile tinnitus and venous diverticulum 'appears more effective and safer than surgical treatment, but large studies are lacking' and that 'studies directly comparing endovascular and surgical treatment are needed.' Eisenman — who is a recognized surgical authority in this field, having described standardized transmastoid sinus wall reconstruction — and co-authors likely contest methodological or interpretive aspects of the Sathya et al. conclusions. The specific arguments, any re-analyzed data, and any independently calculated metrics presented in the Letter are not accessible from the available abstract, which contains no quantitative content. No NNT, NNH, absolute risk differences, or relative effect sizes are reportable from the Letter alone.
Practice implications
IMPORTANT CAVEAT: Only the PMID metadata, journal, authors, and title are available for this Letter; no abstract text was retrievable. All interpretation below is therefore necessarily limited to contextual inference from the known published literature and the index article being critiqued. The Letter should be read in its entirety before drawing any clinical conclusions. Contextually, the debate it enters is clinically significant: SSD is an increasingly recognized, treatable cause of pulsatile tinnitus, and the optimal treatment modality remains genuinely uncertain. The Sathya et al. 2024 systematic review was constrained to descriptive statistics across predominantly small case series and case reports, without head-to-head randomized or prospective comparative data. Eisenman's group has published extensively on surgical outcomes, reporting complete PT resolution in up to 90–95% of appropriately selected surgical patients (Eisenman et al., Laryngoscope 2018), suggesting that the systematic review's apparent EVT advantage may reflect patient selection, reporting bias, or heterogeneity across included studies rather than a true superiority signal. The findings of the index review apply to a population that is predominantly female, often of childbearing age, frequently with elevated BMI, and with associated conditions such as idiopathic intracranial hypertension (IIH) and transverse sinus stenosis — subgroups whose optimal management may differ substantially. Patients with concurrent IIH, venous stenosis, or isolated dehiscence without diverticulum were not separately analyzed in ways that allow confident subgroup-specific treatment guidance. Practice should not change on the basis of this Letter or the index systematic review alone; the letter likely reinforces the conclusion that prospective comparative trials are urgently needed. __LIMITATIONS__ 1. Only a Letter to the Editor is being summarized; no structured abstract, methods, results, or data tables are available — all interpretation is context-dependent inference. 2. The index systematic review (Sathya et al. 2024) itself was limited to descriptive statistics without formal meta-analysis, pooled effect estimates, or risk-of-bias-adjusted comparisons, drawing primarily from case reports and small case series. 3. No randomized controlled trials or prospective head-to-head comparative studies of EVT vs. surgery for SSD exist in the literature to date, making any superiority claim of either modality preliminary. 4. Heterogeneity across included surgical and endovascular series (differing patient selection criteria, operator experience, outcome definitions, and follow-up durations) severely limits cross-modal comparisons. 5. Publication bias favoring positive outcomes is a known and unaddressed confound in both EVT and surgical case series. 6. Concurrent comorbidities — particularly IIH, transverse sinus stenosis, and sigmoid sinus dehiscence without frank diverticulum — were variably reported and may substantially confound treatment outcome comparisons. 7. Long-term durability data for EVT (recurrence, device-related complications, need for antiplatelet therapy) are sparse compared to the longer surgical track record. 8. Generalizability is uncertain across surgical volumes, institutional expertise, and geographic patient populations. 9. Funding source for the Letter is not reported. __BOTTOM_LINE_CATEGORY__ low_certainty __BOTTOM_LINE__ This is a Letter to the Editor critiquing a 2024 systematic review that provisionally favored endovascular over surgical treatment for sigmoid sinus diverticulum-associated pulsatile tinnitus; no independent quantitative findings are reported in the Letter itself, and only the full text can reveal its specific arguments. The index systematic review was based entirely on low-quality evidence (case reports and small series without comparative controls), and no definitive conclusion about EVT versus surgical superiority can yet be drawn. Clinicians should continue individualized decision-making based on patient anatomy, comorbidities (especially IIH and transverse sinus stenosis), institutional expertise, and patient preference, while awaiting prospective comparative data.