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Niger J Clin Pract. 2019 Oct;22(10):1430-1434. doi: 10.4103/njcp.njcp_128_19.

Is there any association between jugular venous reflux and nonpulsatile subjective tinnitus? A preliminary study of four-dimensional magnetic resonance angiography.

Author information

Department of Medical Imaging, Vocational School of Health Sciences, Acibadem University, Istanbul, Turkey.
Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.
Department of Emergency Medicine, School of Medicine, Acibadem University, Istanbul, Turkey.
Department of Biostatistics and Medical Informatics, School of Medicine, Halic University, Istanbul, Turkey.
Department of Otorhinolaryngology, Acibadem Taksim Hospital, Istanbul, Turkey.
Department of Radiology, Istanbul GATA Sultan Abdulhamid Han Hospital, Istanbul, Turkey.
Private Practice Clinician, Istanbul, Turkey.
Department of Radiology, School of Medicine, Trakya University, Edirne, Turkey.



To demonstrate whether there is an association between jugular venous reflux and nonpulsatile subjective tinnitus (NST) using real-time four-dimensional magnetic resonance imaging (MRI) angiography.

Materials and Methods:

Patients with unilateral NST who underwent contrast-enhanced MRI with a special protocol were included in the study. Thick slab dynamic maximum intensity projection images were obtained including interleaved stochastic trajectories (TWIST)-MRI examination. All patients were requested to perform Valsalva maneuver during the sequence. Jugular venous reflux grading was performed as follows: absence of reflux or if reflux does not reach the base of the skull: grade 0; if reflux reaches the jugular bulb, but no intracranial contrast is observed: grade 1; and if reflux extends into the intracranial cortical veins and/or the cavernous sinus above the jugular bulb: Grade 2.


A total number of 30 patients, 23 male and 7 female, were included in the study. Jugular venous reflux was not identified (Grade 0) in 20 patients. Grade 1 reflux was determined in 7 cases and Grade 2 reflux was observed in 3 cases. Notably, only patients with Grade 2 reflux described worsening of their tinnitus symptoms during the examination and their daily activities as well.


NST might also be associated with hemodynamic problems of the venous system and the MRI protocol starting with TWIST accompanied with Valsalva maneuver is not well-known, yet seems to be a feasible and beneficial method to detect potential jugular venous reflux in NST patients.


Four-dimensional magnetic resonance-angiography; TWIST; Valsalva maneuver; magnetic resonance imaging; tinnitus; venous reflux


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