Pulsatile Tinnitus from a Dural Arteriovenous Fistula

Abstract

A 50-year-old woman presented with headaches and left pulsatile tinnitus that she first noticed several months before. The tinnitus had been increasing in intensity, was now constant, and often caused the patient to awaken from sleep. There was no antecedent history of trauma. No visual changes were associated with the headaches.Examination disclosed no apparent cutaneous abnormalities. No neurologic deficits were present. A bruit could be heard that was loudest over the left occiput. Laboratory data were normal.Radiographic evaluation included computed tomography and magnetic resonance imaging of the head; results were normal. Angiography demonstrated a vascular malformation in the region of the left transverse sinus. Numerous meningeal arteries from both the internal and external carotid arteries were feeding the malformation. Rapid shunting of blood to the venous side was apparent in the left transverse sinus. The nidus of the malformation appeared to lie in the walls of the sinus. The findings were characteristic of a dural arteriovenous fistula.

Pulsatile tinnitus —a review of 84 patients

“…Therefore the causes of pulsatile tinnitus are multiple. They include systemic disorders with high cardiac output (anaemia, thyrotoxicosis, valvular heart disease) [9, 111, circumscribed vascular variations [ 1,8,19,20,25,27,28,37,49], arteriovenous malformations, dural arteriovenous fistulas [2,3,10,12,13,23,24,34,38,42,55,58] or arterial wall diseases causing stenosis such as dissections, fibromuscular displasias or atherosclerosis [7, 16-18, 30, 33, 35, 44, 50, 56], skull base tumours [26,36,48, 511, intracranial hypertension [31,32,45,46] and rare diseases such as Paget's disease [14] or histiocytosis X of the petrous bone [5].…”

“…None of these investigations showed an abnormality that could explain pulsatile tinnitus. [58] Dural arteriovenous fistula [2,13,23,24,34,38,55] Carotid cavernous fistula [42] Aneurysm of the ICA [3,12] Fibromuscular dysplasia of the ICA [ 17,56] Dissection of the ICA [33,50] Atherosclerosis [7,16,30,44] Occlusion of the contralateral CCA [35] Vascular anomalies of the ear [8,20,28,49] Vascular compression of the VIII nerve [27,37] Migraine [52] Jugular bulb anomalies [1,391 Abnormal condylar and mastoid emissary veins [19,25] Glomus tumor [26,36,48] Paget's disease [14] Cavernous haemangioma [51] Histiocytosis X [5] Intracranial hypertenison of various causes [14,31,32,45,46] Anaemia, high cardiac output [9,11] Palatal myoclonus [4,22] Abnormally paten...…”

Value of DSA in the Diagnostic Workup of Pulsatile Tinnitus

“…The vascular genesis of PT can be separated into arterial or venous pathologies. Frequent vascular pathologies of PT are dural arteriovenous fistula (dAVF), arteriovenous malformations (AVM), sigmoid sinus diverticulum, carotid-cavernous fistulae or ICA stenosis [ 5 , 6 ]. Frequent nonvascular causes of PT are paraganglioma, intracranial hypertension or systemic disorders e.g.…”

Pulsatile Tinnitus: Differential Diagnosis and Radiological Work-Up

“…Vascular causes include arterial or venous vascular pathologies, such as dural arteriovenous fistula (dAVF), arteriovenous malformation (AVM), aneurysm, internal carotid artery stenosis or dissection, congenital vascular variants, transverse sinus stenosis, or increased cardiac output [4, 5]. Non-vascular etiologies of pulsatile tinnitus include neoplasm like paraganglioma, osseous pathology, idiopathic intracranial hypertension, and systemic disorders such as anemia [6–8].…”