Transverse sinus dominance predicts outcome after venous sinus stenting for pulsatile tinnitus

OBJECTIVES: Venous sinus stenting (VSS) is highly effective for pulsatile tinnitus (PT), yet up to 20% of patients experience incomplete relief. We aimed to investigate whether transverse sinus dominance could serve as a non-invasive imaging biomarker for clinical risk stratification. MATERIALS AND METHODS: Preoperative transverse sinuses were classified into balanced or non-balanced dominance via qualitative visual assessment on CTV/MRV. The primary endpoint was an unfavorable outcome (residual tinnitus, defined as postoperative tinnitus handicap inventory (THI) > 16) at 3-month follow-up. Multivariable analysis utilized Firth's penalized logistic regression to account for zero-event cells. RESULTS: This retrospective study included 58 consecutive patients who underwent VSS for unilateral venous PT. Overall, 49 patients (84.5%) achieved a favorable outcome. Transverse sinus dominance was strongly associated with clinical efficacy: all 9 unfavorable outcomes occurred in patients with non-balanced dominance (9/38, 23.7%), whereas balanced dominance yielded a 0% unfavorable outcomes (0/20) (Absolute Risk Difference: 23.7%; p = 0.021). Following adjustment, non-balanced dominance remained a robust independent risk factor for an unfavorable outcome, whereas the trans-stenotic pressure gradients (TPG) showed no significant association. Conversely, the absolute reduction in THI was independently associated with higher preoperative THI (p < 0.001) and female sex (p = 0.045). CONCLUSION: Balanced transverse sinus dominance is associated with a significantly lower risk of residual tinnitus after VSS. Preoperative evaluation of sinus dominance offers a practical approach for patient risk stratification and expectation management. KEY POINTS: Question Balanced transverse sinus dominance is strongly associated with complete symptom resolution after venous sinus stenting. Findings Non-balanced dominance carries a 23.7% risk of residual low-grade pulsatile tinnitus despite successful stenting. Clinical relevance Preoperative evaluation of sinus dominance serves as a practical, non-invasive imaging biomarker for clinical risk stratification.