Pulsatile tinnitus with a dural arterio-venous fistula diagnosed by computed tomography-angiography

Abstract

A 43 year-old female patient suffered the sudden onset of pulsatile tinnitus in the left ear 2 months ago. The tinnitus did not subside spontaneously and remained unchanged. The patient had no history of head trauma or surgery of the head and neck. The character of the tinnitus was pulsatile, and it was synchronous with the heart beat. Audiologic examinations were performed and all of the results were normal. Computed tomography with angiography was performed and evidence of an arterio-venous fistula (AVF) was found. 4-vessel angiography was performed to confirm the dural AVF between the external carotid artery and sigmoid sinus. Embolization of the feeder-vessels was done under a fluoroscope and 70% of the fistula flow was controlled after embolization and the tinnitus totally subsided during the embolization.

Keywords: Angiography; Arteriovenous fistula; Embolization; Pulsatile tinnitus; Therapeutic.

Fig. 1

Pre-embolization computed tomography angiography shows signs of dural arteriovenous fistula at transverse-sigmoid sinus and occipital artery. A: Shaggy appearance of sigmoid sinus (white arrow). B: Focal stenosis of left transverse-sigmoid junction (white arrow). C: Multiple bony channels at left occipital area (white arrow). D: Prominent vascular structures along left tentorial margin (white arrow). E: Dilated left occipital artery (white arrow).

Fig. 2

Angiographic findings of arterial phase of left external carotid artery before and after embolization with N-butylcyanoacrylate. 1st row is finding of pre-embolization, 2nd row intra-embolization, and 3rd row post-embolization. A: Coronal view of 1st feeder from occipital artery. B: Coronal view of 2nd feeder from occipital artery. C: Sagittal view of 3rd feeder from occipital artery. D: Sagittal view of 4th feeder from occipital artery. E: Sagittal view of 5th feeder from middle meningeal artery. F: 6th feeder from proximal portion of superficial temporal artery. Minimal blood flow to the sigmoid sinus through small collaterals of occipital artery is still visible in post-embolization.