Anticoagulation in the Treatment of Pulsatile Tinnitus Caused by Internal Jugular Vein Stenosis: A Rare Case Report

Abstract

Background: Anticoagulation is considered as a first line treatment of pulsatile tinnitus caused by internal jugular vein thrombosis. We present a case of non-thrombotic internal jugular vein occlusion which responded to Apixaban (Eliquis) therapy. Case Presentation: A 54-year-old female with no significant past medical history presented with debilitating pulsatile tinnitus for two months. Her symptoms included inability to sleep, lower appetite, and intense pressure and throbbing in the face and ears. She described it as a ‘whooshing sound’ exacerbated in the supine position. She admitted to occasional episodes of neck throbbing and forceful heart beat over the years and had undergone multiple workups including Echocardiograms and Holter monitoring, with no apparent abnormalities. The recent workup, including coagulation studies, Computed Tomography (CT) scans and Magnetic Resonance Imaging (MRI) of the head and neck, yielded negative findings. However, a CT angiogram revealed an isolated non-thrombotic occlusion of the most proximal aspect of the left Internal Jugular Vein (IJV), with extensive occipital and sub occipital collateral flow. She had been taking antihypertensive and diuretic medications without much effect. She was then prescribed anticoagulation therapy initially with IV enoxaparin (30 milligrams for two weeks) and then oral Apixaban (5 milligrams b.i.d.). Eliquis 5 milligrams bid was continued for 8 months and tapered down to 2.5 milligrams bid for 4 months to completely off in 12 months. Her symptoms improved after eight weeks and were completely gone within a year. Repeat MR angiography showed improved flow in the jugular venous system. Conclusions: A trial of anticoagulation is warranted and can be beneficial in patients with non-thrombotic internal jugular vein occlusion causing pulsatile tinnitus refractory to other treatments.