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Introduction Transverse sinus stenosis (TSS) is a significant contributor to pulsatile tinnitus (PT) due to the proximity of inner ear structures within the temporal bone. Clinical management typically involves venous stenting to restore physiological venous outflow, with treatment decisions predominantly guided by invasive manometry.Aim of Study This study employs image-based blood flow simulations to non-invasively estimate the trans-stenotic pressure drop and analyze unstable flow fluctuations that may contribute to PT.Method Four TSS patients with PT symptoms underwent a multimodal imaging protocol, including 3D rotational angiography, magnetic resonance venography and flow measurements using quantitative magnetic resonance angiography, in addition to invasive manometry. Image-based blood flow simulations using patient-specific boundary conditions were performed. A regular-fidelity computational fluid dynamics (CFD) setup was used to calculate pressure gradients across the stenosis, as well as wall shear stress (WSS) and vorticity. High-frequency flow fluctuations were further analyzed using a high-fidelity CFD configuration.Abstract A26 Figure 1Results Regular-fidelity simulations reproduced patient-specific pressure drops with a minimal error of 7.30% (absolute deviation: 0.35 mmHg). Hemodynamic analysis at the temporal bone revealed increased WSS (47% ± 22%) and vorticity (41% ± 19%) compared to the contralateral side of the sinus. High-fidelity simulations identified pronounced high-frequency fluctuations, particularly during peak systole, in the flow near the sigmoid plate.Conclusion This study successfully reconstructed clinically relevant pressure drops non-invasively. Hemodynamic factors potentially inducing PT were identified, including elevated shear stress and high-frequency flow instabilities.Conflict of Interest No