Asymmetry in Gaze-Holding Impairment in Acute Unilateral Ischemic Cerebellar Lesions Critically Depends on the Involvement of the Caudal Vermis and the Dentate Nucleus.

Stabilizing the eyes in space when looking at a target is provided by a brainstem/cerebellar gaze-holding network, including the flocculus/paraflocculus complex (non-human primate studies) and the caudal vermis, biventer, and inferior semilunar lobule (human studies). Previous research suggests that acute lateralized cerebellar lesions preferentially lead to gaze-evoked nystagmus (GEN) on ipsilesional gaze. Here, we further characterize the effect of unilateral cerebellar lesions on gaze-holding and hypothesize that the side-specific magnitude of gaze-holding impairment depends on the lesion location. Nine patients (age range = 31-62 years) with acute/subacute (≤ 10 days old) MRI-confirmed unilateral cerebellar stroke were included. Horizontal gaze holding was quantified while looking at a slowly moving (0.5°/s) flashing target (gaze angle = ±40°). Asymmetry in eye-drift velocity was calculated and compared with the different MRI patterns of cerebellar lesions. Individual peak eye-drift velocities (range = 1.7-8.8°/s) occurred at the most eccentric eye positions (gaze angle = 28-38°). We found significantly asymmetric eye-drift velocity (EDV) in eight out of nine patients. The four patients with MRI-confirmed involvement of the caudal vermis and the dentate nucleus all presented with ipsilesionally-predominant EDV, while in the five patients with lesions restricted to the cerebellar hemisphere, EDV was stronger on contralesional gaze in three out of four found with an asymmetric EDV. Involvement of the caudal vermis and the dentate nucleus is critical for determining the directional GEN asymmetry in unilateral cerebellar lesions. Thus, our findings support the occurrence of GEN without floccular/parafloccular lesions and suggest that the EDV asymmetry in relation to the side of the lesion provides information about the involvement of specific structures.

Assessment of the anterior superior alveolar nerve and its impact on surgery of the lateral nasal wall.

BACKGROUND: The anterior superior alveolar nerve (ASAN) plays a major role in innervation of the lateral nasal wall. Its damage during nasal surgery can cause dental paraesthesia and numbness around the upper lip. METHODOLOGY: Retrospective evaluation of the computed tomographic (CT) scans of 50 consecutive patients analysing 100 sides. We measured the mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve, to the anterior superior alveolar canal and the anterior-posterior distance between the 'shoulder' of the inferior turbinate and the pyriform aperture. RESULTS: The mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve was 6.4 ± 2.33 mm, with no difference between sides The mean relative height of the shoulder in relation to the anterior superior alveolar nerve canal was 4.78 ± 2.31mm with no significant difference between the two sides. The anterior-posterior distance between the 'shoulder' of inferior turbinate and the pyriform aperture was 6.96± 2.28mm, with no significant difference between the two sides. CONCLUSIONS: We found the anterior superior alveolar nerve to be a constant landmark in the lateral nasal wall. Therefore, the course of the ASAN should be assessed on a CT scan when a surgical approach through the pyriform aperture or anterior medial wall of the maxillary sinus is planned.

Anterior maxillary wall and lacrimal duct relationship - CT analysis for prelacrimal access to the maxillary sinus.

BACKGROUND: The distance between the anterior wall of the maxillary sinus and the nasolacrimal duct shows a large individual variation. METHODOLOGY: To evaluate the feasibility of accessing the maxillary sinus through a prelacrimal window access (PLWA), a series of 100 paranasal CT scans from adult patients was analysed retrospectively. The distance between the anterior maxillary wall and the anterior border of the lacrimal duct (= prelacrimal window) were measured in 200 sides. RESULTS: A distance of more the 7 mm was found in 12.5% maxillary sinuses and would enable straight forward PLWA. A distance between smaller than 7mm and larger than 3mm was present in 56.5% of sinuses, and would make surgical access more demanding. In 31.5% of maxillary sinuses the distance was smaller than or equal to 3mm and in these patients this approach would be difficult without transecting the nasolacrimal duct. CONCLUSION: Only in 12.5% of sinuses a prelacrimal endoscopic access is readily feasible, while in 56.5% temporary tear sac dislocation is required and in 31.5% lacrimal sac dislocation is always needed along with a significant amount of bone removal to enable PLWA.

Brain metastases in gastro-oesophageal adenocarcinoma: insights into the role of the human epidermal growth factor receptor 2 (HER2).

BACKGROUND: Gastro-oesophageal adenocarcinomas rarely metastasize to the central nervous system (CNS). The role of the human epidermal growth factor receptor 2 (HER2) in patients with these cancers and CNS involvement is presently unknown. PATIENTS AND METHODS: A multicentre registry was established to collect data from patients with gastro-oesophageal adenocarcinomas and CNS involvement both retrospectively and prospectively. Inclusion in the study required a predefined clinical data set, a central neuro-radiological or histopathological confirmation of metastatic CNS involvement and central assessment of HER2 by immunohistochemistry (IHC) and in situ hybridisation (ISH). In addition, expression of E-cadherin and DNA mismatch repair (MMR) proteins were assessed by IHC. RESULTS: One hundred patients fulfilled the inclusion criteria. The population's median age was 59 years (interquartile range: 54-68), of which 85 (85%) were male. Twenty-five patients were of Asian and 75 of Caucasian origin. HER2 status was positive in 36% (95% CI: 26.6-46.2) of cases. Median time from initial diagnosis to the development of brain metastases (BMets) or leptomeningeal carcinomatosis (LC) was 9.9 months (95% CI: 8.5-15.0). Median overall survival from diagnosis was 16.9 months (95% CI: 14.0-20.7) and was not related to the HER2 status. E-cadherin loss was observed in 9% of cases and loss of expression in at least one DNA MMR proteins in 6%. CONCLUSIONS: The proportion of a positive HER2 status in patients with gastro-oesophageal adenocarcinoma and CNS involvement was higher than expected. The impact of anti-HER2 therapies should be studied prospectively.

Homozygous and compound heterozygous mutations in the ATP6V1B1 gene in patients with renal tubular acidosis and sensorineural hearing loss.

Distal renal tubular acidosis (dRTA) is characterized by the inability to excrete acid in the renal collecting ducts resulting in inappropriately alkaline urine and hyperchloremic (normal anion gap) metabolic acidosis in the context of a normal (or near-normal) glomerular filtration rate. Inborn dRTA can be due to autosomal dominant or recessive gene defects. Clinical symptoms vary from mild acidosis, incidental detection of kidney stones or renal tract calcification to severe findings such as failure to thrive, severe metabolic acidosis, and nephrocalcinosis. The majority of patients with recessive dRTA present with sensorineural hearing loss (SNHL). Few cases with abnormal widening of the vestibular aqueduct have been described with dRTA. Mutations in three different genes have been identified, namely SLC4A1, ATP6V1B1, and ATP6V0A4. Patients with mutations in the ATP6V1B1 proton pump subunit develop dRTA and in most of the cases sensorineural hearing loss early in childhood. We present two patients from two different and non-consanguineous families with dRTA and SNHL. Direct sequencing of the ATP6V1B1 gene revealed that one patient harbors two homozygous mutations and the other one is a compound heterozygous. To our knowledge, this is the first case in the literature describing homozygosity in the same dRTA gene on both alleles.

Intermittent intracranial condylar dislocation with minimal functional sequelae.

Degenerative changes of the temporomandibular joint (TMJ) present with a broad spectrum of morphological alterations. However, erosions leading to a glenoid fossa defect and condylar impingement of the temporal lobe are a rare finding. A 77-year-old female patient presented with limited mouth opening and pre-auricular pain during mastication on the left side. She denied any neurological dysfunction. Her medical history included poliomyelitis, multiple cancers, and osteonecrosis of the left tibial plateau. Computed tomography revealed advanced degeneration of both TMJs. On the left side, a glenoid fossa fragment was elevated towards the left middle cranial fossa. Real-time dynamic magnetic resonance imaging (MRI) showed repetitive intracranial condylar dislocation during mouth closure. She declined surgery and received instructions for self-management. At the 12-month follow-up, she reported resolution of the pain and normal masticatory function. A control MRI showed a stable radiographic appearance. This report illustrates that intermittent dislocation of the mandibular condyle into the middle cranial fossa can be successfully managed conservatively. The self-limiting nature of the TMJ degenerative joint disease, patient preference, and the patient's general health status require consideration when advising patients on the therapeutic strategy.

[Aberrant internal carotid artery as a cause of pulsatile tinnitus: a difficult diagnosis in MRI?]. / Aberrierende A. carotis interna als Ursache eines pulssynchronen Tinnitus : Schwierige Diagnose in der MRT?

We present the case of a 43-year-old patient with sensorineural hearing loss and the finding of an aberrant internal carotid artery in the left tympanic cavity that was causing pulsatile tinnitus. The aberrant vessel was initially invisible on magnetic resonance imaging (MRI) and was confirmed by high-resolution computed tomography and MR angiography (MRA). Recognition of an aberrant course of an internal carotid artery often requires a combination of MRI and MRA to establish the diagnosis and rule out other differential diagnoses.

[Palsy of CVI caused by ecchordosis physaliphora]. / N.-VI-Parese durch Ecchordosis physaliphora.

We report a case of symptomatic ecchordosis physaliphora (EP) in a 34-year-old woman who presented with progressive diplopia due to palsy of the left sixth cranial nerve. Repeated magnetic resonance imaging (MRI) disclosed typical characteristics of a congenital EP lesion with compression of the left abducens nerve presumably because of a secondary herniation of the arachnoid mater. We performed an augmenting combined recess resect procedure on the left eye. No progression of the lesion was observed over a period of 5 years. For differential diagnostics an EP has to be distinguished from skull base tumors, such as chordoma and chondrosarcoma.

Endovascular treatment of cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

Endovascular treatment by balloon angioplasty or intra-arterial papaverine infusion has been established as a valuable treatment option in patients with cerebral vasospasm refractory to maximal medical therapy. A summary of the indications, applications and limitations is provided for microcatheter guided selective papaverine infusion and transluminal balloon angioplasty in patients who sustain cerebral vasospasm following subarachnoid haemorrhage. Structured neuro-intensive and endovascular treatment of imminent vasospasm integrate papaverine administration and balloon angioplasty as complimentary rather than alternative techniques.

Gaze holding deficits discriminate early from late onset cerebellar degeneration.

The vestibulo-cerebellum calibrates the output of the inherently leaky brainstem neural velocity-to-position integrator to provide stable gaze holding. In healthy humans small-amplitude centrifugal nystagmus is present at extreme gaze-angles, with a non-linear relationship between eye-drift velocity and eye eccentricity. In cerebellar degeneration this calibration is impaired, resulting in pathological gaze-evoked nystagmus (GEN). For cerebellar dysfunction, increased eye drift may be present at any gaze angle (reflecting pure scaling of eye drift found in controls) or restricted to far-lateral gaze (reflecting changes in shape of the non-linear relationship) and resulting eyed-drift patterns could be related to specific disorders. We recorded horizontal eye positions in 21 patients with cerebellar neurodegeneration (gaze-angle = ±40°) and clinically confirmed GEN. Eye-drift velocity, linearity and symmetry of drift were determined. MR-images were assessed for cerebellar atrophy. In our patients, the relation between eye-drift velocity and gaze eccentricity was non-linear, yielding (compared to controls) significant GEN at gaze-eccentricities ≥20°. Pure scaling was most frequently observed (n = 10/18), followed by pure shape-changing (n = 4/18) and a mixed pattern (n = 4/18). Pure shape-changing patients were significantly (p = 0.001) younger at disease-onset compared to pure scaling patients. Atrophy centered around the superior/dorsal vermis, flocculus/paraflocculus and dentate nucleus and did not correlate with the specific drift behaviors observed. Eye drift in cerebellar degeneration varies in magnitude; however, it retains its non-linear properties. With different drift patterns being linked to age at disease-onset, we propose that the gaze-holding pattern (scaling vs. shape-changing) may discriminate early- from late-onset cerebellar degeneration. Whether this allows a distinction among specific cerebellar disorders remains to be determined.

Anterior spreader flap technique: A new minimally invasive method for stabilising and widening the nasal valve.

BACKGROUND: The 'anterior spreader flap' is a new minimally invasive technique, for the treatment of nasal valve insufficiency or stenosis. The aim of this study was to present our experience with a series of patients with nasal valve dysfunction corrected by the minimally invasive spreader flap technique. METHODOLOGY: We performed a retrospective review of our patients with nasal valve malfunction who underwent the anterior spreader flap between June 2010 and June 2013. The patients had to judge their symptoms of nasal obstruction pre- and 12 months post-operatively by the Nasal Obstruction and Septoplasty Effectiveness (NOSE) quality-of-life assessment scale. The difference between the pre- and post-operative evaluations of each group and between the groups was calculated, and it was statistically analysed. RESULTS: Forty-three patients were treated. In seven patients, the anterior spreader flap was performed as a single procedure (group F), in 15 patients the anterior spreader flap was combined with a septoplasty and a turbinoplasty (group FST), in 10 patients with a turbinoplasty (group FT) and in 11 with a septoplasty (group FS). All patients reported significant post-operative improvement in nasal breathing (p < 0.05). The mean improvement (diffNOSE) of all patients was 54.2 points. The 'FS' group and the 'FST' group showed best post-operative results, but there were no significant differences between the groups (p > 0.8). CONCLUSIONS: The anterior spreader flap is an effective and safe method for minimally invasive improvement of nasal breathing in patients with nasal valve dysfunction.

Carotid dissection with and without ischemic events: local symptoms and cerebral artery findings.

OBJECTIVE: To study whether spontaneous dissections of the cervical internal carotid artery dissection (ICAD) with and without ischemia of the brain or retina differ in the prevalence of vascular risk factors, local neurologic signs and symptoms, and stenoses and occlusions of the cerebral arteries. METHODS: The authors prospectively studied 181 consecutive patients with 200 ICAD. Diagnosis was based on ultrasonography and MRI or catheter angiography. Vascular risk factors, presenting local (headache, neck pain, Horner syndrome, pulsatile tinnitus, cranial nerve palsy on the side of the ICAD) and ischemic signs and symptoms, and ultrasonographic findings in the carotid and basal cerebral arteries were evaluated. RESULTS: ICAD with ischemic events (n = 145) had a higher prevalence of hypercholesterolemia (p < 0.05), >80% stenoses and occlusions of the ICA (p < 0.0001), and intracranial obstructions (p < 0.001). ICAD without ischemic events (n = 55) had a higher prevalence of Horner syndrome (p < 0.001), cranial nerve palsy (p < 0.01), and normal ICA findings (p < 0.0001). CONCLUSIONS: These data suggest that ICAD causing high-grade stenosis and occlusion are more likely to lead to intracranial obstructions and cerebral or retinal ischemic events. Conversely, ICAD without luminal narrowing cause more local signs and symptoms.

Acute and chronic neuroborreliosis with and without CNS involvement: a clinical, MRI, and HLA study of 27 cases.

Of the 96 serologically confirmed neuroborreliosis cases seen in our clinic between 1983 and 1988, 11 patients had mild to moderate and 4 patients had serious cerebral and/or spinal cord symptoms. Nine of these 15 patients with CNS involvement exhibited a primary chronic course of the illness. After high-dose intravenous therapy with penicillin, doxycycline or cefotaxime, given mostly in combination with cortisone, gradual recovery occurred with normalization of CSF findings characteristic of neuroborreliosis, and normalization of significantly elevated Borrelia burgdorferi IgG antibody titres in CSF and serum. Brain MRI and CT showed evidence of or were suggestive of vascular involvement which correlated with clinical symptoms in 11 of the 15 patients with CNS involvement. Brain MRI changes that were similar but much slighter in number and intensity were seen in 5 of 12 neuroborreliosis patients without clinical signs of CNS involvement (lymphocytic meningoradiculitis; Bannwarth's syndrome). The frequencies of the HLA-DR7 (75%), HLA-B44 (50%) and HLA-A29 (33%) antigens in 12 neuroborreliosis patients with clinical symptoms of CNS involvement were significantly different from the frequencies in 12 neuroborreliosis patients without CNS involvement and in 100 control subjects. Diagnostic criteria of active neuroborreliosis are proposed.

Transcranial color-coded Doppler sonography of intracranial aneurysms before and after endovascular occlusion with Guglielmi detachable coils.

BACKGROUND AND PURPOSE: Our purpose was to evaluate the ability of transcranial color-coded Doppler sonography (TCCD) to 1) identify Guglielmi detachable coils (GDCs) within intracranial aneurysms, 2) show endovascular aneurysmal occlusion and patency of parent and branch arteries, 3) determine the flow velocities within parent arteries and major branches before and after treatment, and 4) assess persistence of aneurysmal occlusion. METHODS: The sonographic appearance of GDCs was established experimentally by TCCD (2 to 2.5 MHz), which was then performed in 40 patients with 43 aneurysms occluded by GDCs. The patency of parent arteries and major branches was assessed qualitatively and compared with the immediate posttherapeutic angiographic appearance in every patient. Flow velocities were selectively measured and compared before and after treatment in 21 parent arteries and 24 major branches. Follow-up TCCD studies performed in 26 patients were compared with angiographic (16 cases) and MR angiographic (10 cases) findings for signs of recanalization of the treated aneurysms. RESULTS: The GDCs were identified experimentally and in the patients as hyperechoic structures of the size and shape, and in the location of, the treated aneurysm in 41 of 43 cases. TCCD in accordance with angiography showed a lack of flow in 42 aneurysms and the presence of flow signal in one large aneurysm. Patency of the parent artery was shown in 40 aneurysms and in all branches. Follow-up TCCD showed the coils unchanged in 23 of 26 cases. In three large aneurysms, TCCD indicated recanalization and reappearance of a flow signal separate from the parent artery. CONCLUSION: TCCD is a reliable, noninvasive means to assess parent artery and major branch patency and to reveal a lack of hemodynamic compromise in the vicinity of aneurysms after endovascular therapy. On follow-up examinations, TCCD was able to detect signs of aneurysmal recanalization.

Tributary venosinus occlusion and septic cavernous sinus thrombosis: CT and MR findings.

PURPOSE: In autopsy reports of patients who died of septic cavernous sinus thrombosis, tributary venosinus occlusion has been a common finding related to intracranial inflammatory complications. The purpose of this article is to illustrate the MR and CT appearance of septic cavernous sinus thrombosis and tributary venous occlusion. METHODS: Over a period of 7 years, eight patients with septic cavernous sinus thrombosis were examined by contrast-enhanced thin-section CT. The CT scans of these eight patients and those of 30 healthy control subjects were assessed independently and subjectively by two blinded readers to ascertain the presence, size, and density of areas of nonopacification within the cavernous sinus and the presence of filling defects and dilation of tributary veins and venous sinuses. In six subjects, MR images supplemented by a contrast-enhanced spoiled gradient-recalled acquisition in the steady state (SPGR) sequence were assessed with respect to the presence of filling defects, expansion, and signal abnormalities within the cavernous sinus and tributary veins and sinuses. The MR and CT findings were compared. RESULTS: The CT studies of the eight patients were consistently differentiated from those of the control subjects by the two readers. Contrast-enhanced CT findings in patients included areas of nonopacification that were present within the cavernous sinus bilaterally in six cases and unilaterally in two. The size of the filling defects exceeded 7 mm in 76% of thrombosed cavernous sinuses compared with 9% of control subjects. The mean density of filling defects in patients differed significantly from those in control subjects. Comparison of the MR and CT findings in six cases showed the contrast-enhanced SPGR sequence to be equivalent to CT with respect to delineation of filling defects. CONCLUSION: Contrast-enhanced high-resolution CT findings indicate that venosinus thrombosis associated with septic cavernous sinus thrombosis is not restricted to the superior ophthalmic vein and is more common than previously assumed. A contrast-enhanced SPGR MR sequence may be used as a reliable alternative to establish the diagnosis of cavernous sinus and tributary venosinus thrombosis.

Improvement of cerebral oxygenation patterns and metabolic validation of superselective intraarterial infusion of papaverine for the treatment of cerebral vasospasm.

OBJECT: The purpose of the present study was to assess cerebral oxygenation patterns and brain lactate concentration changes before, during, and after intraarterial infusion of papaverine with or without balloon angioplasty in patients with symptomatic vasospasm. METHODS: A total of 23 vascular territories were successfully treated in 10 patients. In three patients balloon angioplasty was performed before the papaverine infusion. Continuous monitoring of jugular bulb vein oxygen saturation with a fiberoptic catheter and blood sampling allowed the assessment of the cerebral arteriovenous oxygen and lactate differences. A significant and rapid improvement in jugular bulb oxygen saturation was observed in all cases, with critical values reflecting an improvement in cerebral oxygenation after endovascular treatment of vasospasm (p = 0.005). Lactate concentration in the jugular bulb normalized within 4 hours in all patients who had evidence of brain lactic acidosis before superselective intraarterial infusion of papaverine. Recurrence of abnormal metabolic and oxygenation patterns were observed in one case in which an optimal hypertension and hypervolemic therapy could not be achieved after the procedure. CONCLUSIONS: Improvement in cerebral oxygenation as well as prevention of cerebral lactic acidosis can be successfully achieved after intraarterial infusion of papaverine. Normalization of the oxygen supply after endovascular treatment has to be supported by optimal and well-monitored hypertension and hypervolemic hemodilution.

Latest techniques in head and neck CT angiography.

Continuous evolution of multi row CT is increasingly making CT angiography a viable imaging modality for assessment of the supraaortic and intracranial vessels as an anatomically and functionally coherent vascular system. Extended non-invasive examinations with reduced contrast volume have become feasible with the availability of 16 and 64 row MDCT scanners. Prerequisites to obtain high resolution CT angiographies of the head and neck vessels with superior detail include the administration of low contrast volume, high contrast density (400 mg I/ml) contrast media, adequate timing and data acquisition, optimal flow rate (4 ml/s) and saline flushing. Non-invasiveness, delineation of vessel calcification, virtual independence from hemodynamic conditions, and the ability to provide quantification without needing to correct for magnification are all attributes that favour CT angiography over digital subtraction angiography and to some extent even magnetic resonance angiography as an alternative non-invasive technique. CT angiography is established as a modality of choice for the assessment of patients with acute stroke and chronic steno-occlusive disease. CT angiography may indicate the presence of extra- or intracranial acute vessel occlusion and dissection, predisposing atherosclerotic steno-occlusive disease and thus indicate thrombo-embolism or local appositional thrombosis as the principle pathogenic factor. CT angiography is used to assess anatomy, and to depict the presence, location and extent of calcified and non-calcified plaque as a cause of high grade stenosis. Despite relatively limited sensitivity CT angiography is indicated for suspected or confirmed aneurysms that demand further verification of their presence, geometry, or relationship to parent artery branches and osseous anatomic landmarks. Low volume high density contrast media have substantially increased the ability of CT angiography to depict small aneurysms, small branches, and collateral vessels, and to recognize the residual lumen in vessels with high grade stenosis or conditions such as dissection or pseudo-occlusion. Superior detail high resolution CT angiography is thus a viable alternative to DSA, relegating the latter technique to endovascular treatment applications only.

[Malignant melanoma of the meninges--MR and CT diagnosis]. / Maligne Melanome der Meningen--MR- und CT-Diagnostik.

Malignant melanoma of the meninges is a rare neoplasm derived from melanocytes of the cranial or spinal meninges. Histologically classified as grade IV tumours, malignant melanoma may present either as a diffuse meningeal neoplasm, first described by Virchow in 1859, or as a circumscribed tumour attached to the meninges. Although diagnosis is rarely established prior to surgery or autopsy, MR and CT may provide indispensable information probably leading to earlier diagnosis. In 4 patients, diagnosis of a primary meningeal melanoma was based on MR and CT findings and histology. Histology was obtained in 3 cases by surgery, in one patient by autopsy and showed a melanotic and an amelanotic malignant melanoma in 2 patients each. Autopsy was carried out in 3 cases after survival of 4, 5, and 18 months; in a single case, the follow-up period is almost 3 years.

[Tinnitus and its radiological diagnosis and therapy]. / Ohrgeräusche und ihre radiologische Diagnostik und Therapie.

Tinnitus is a familiar symptom in diseases of the central nervous system. Its aetiology being of a varied nature, the type of tinnitus is a pointer to the pathoanatomic findings that are responsible for the disease. The causes of tinnitus are often found in the borderline areas between various neighbouring disciplines, such as otology, neurology and neurosurgery, whereas the final identification of the real causes is mainly within the scope of radiological diagnosis, in which computed tomography and superselective angiography play an essential role. In addition to arteriovenous fistulas near the petrous bone and glomus tumours, which are well known, there are a few other aetiologies of pulse-synchronous tinnitus that are being discussed in this paper. In recent years there has been substantial therapeutical progress owing to the introduction of new techniques and the development of improved materials for embolisation in interventional neuroradiology. Their application is discussed in connection with various patient groups.