Sigmoid Sinus Wall Reconstruction for Venous Pulsatile Tinnitus: A Critical Review of Surgical Outcomes, Hemodynamic Evidence, and Pressure-Associated Findings

Background/Objectives: To critically evaluate the evidence on sigmoid sinus wall reconstruction (SSWR) for venous pulsatile tinnitus (PT), with emphasis on outcome durability, objective hemodynamic assessment, pressure-associated findings, and safety. Methods: A critical review with a structured literature search and reporting informed by PRISMA 2020 was performed using PubMed/MEDLINE and backward citation searching. Embase, Scopus, and the Cochrane Library were used to identify contextual secondary reviews and to cross-check the primary-study set. A descriptive study-level appraisal addressed design, cohort size, follow-up, outcome objectivity, hemodynamic measurements, and complication reporting. The manuscript is presented as a critical review because no prospective registration or formal risk-of-bias assessment was undertaken. Results: Thirty-four records were identified, two duplicates were removed, and 32 records were screened; 10 studies were included in the qualitative synthesis. These comprised dedicated SSWR/resurfacing outcome cohorts and clinical, imaging, or pressure/hemodynamic studies, with some studies contributing to more than one domain. The cohorts were small, heterogeneous, and predominantly retrospective, and only one cohort had mean follow-up exceeding 5 years. In that cohort, complete PT elimination was reported in 24/37 ears (64.9%), with significant partial improvement in 10 additional ears, yielding an initial satisfactory response in 34/37 ears (91.9%); after recurrence was considered, the source authors reported long-term success in 31/37 ears (83.8%). IIH (3/35), papilledema (5/35), and venous sinus stenting (2/35) were reported separately during follow-up and were not combined into a composite prevalence. Objective pre- and postoperative intracranial pressure or venous hemodynamic measurements were sparse, and complication reporting was inconsistent. Conclusions: This critical review suggests symptomatic benefit from SSWR in selected patients but finds insufficient evidence to determine whether the procedure normalizes intracranial pressure, corrects upstream venous hemodynamics, prevents recurrence, or modifies long-term disease. Comparative treatment recommendations cannot be supported. Prospective multicenter studies with standardized objective, patient-reported, and safety outcomes are required.