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Neurology & Stroke

Case Report Volume 8 Issue 1

Spontaneous Intracranial Dural Arteriovenous Fistula in the Differential Diagnosis of Pulsatile Tinnitus

Joseph Bruno Bidin Brooks,1 Mateus Reghin Neto,2 Guilherme Lopes da Silveira,3 Rodrigo André Oliveira,3 Eduardo de Almeida Guimarães Nogueira,4 Marcos Vinícius de Queiroz,4 Victor Perez Meireles de Souza,4 Celso Luis Silva de Oliveira,5 Juarez Harding,5 Fábio Prosdocimi6

1Department of Neurology, Department of Function and Structure; UNIMES- Universidade Metropolitana de Santos, Brazil
2Institute of Neurological Sciences, Hospital Beneficencia Portuguesa de Sao Paulo, Brazil
3Clínica Mega Imagem, Brazil
4UNIMES- Universidade Metropolitana de Santos, Brazil
5Department of Neurology, Irmandade Santa Casa Misericórdia de Santos, Brazil
6Department of Function and Structure, UNIMES- Universidade Metropolitana de Santos, Brazil

Correspondence: Joseph Bruno Bidin Brooks, Irmandade Santa Casa de Misericórdia de Santos, Avenida Claudio Luiz da Costa 5, Santos, São Paulo, Brazil, 1175-9, Tel +55-13-32020600

Received: September 12, 2017 | Published: February 15, 2018

Citation: Brooks JBB, Neto MR, Silveira GLD, Oliveira RA, Nogueira EAG et al. (2018) Spontaneous Intracranial Dural Arteriovenous Fistula in the Differential Diagnosis of Pulsatile Tinnitus. J Neurol Stroke 8(1): 00280. DOI: 10.15406/jnsk.2018.08.00280

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Pulsatile tinnitus, Arteriovenous fistula, Case report


Tinnitus is defined as the perception of a sound in the absence of a corresponding external source. According to the heart beat synchronization, it can present as Pulsatile Tinnitus (PT) and non-pulsatile Tinnitus (NPT). PT is difficult to diagnose, especially when otoscopy is normal, since the underlying etiology is not always clinically identifiable. Arteriovenous dural fistulas are rare abnormal connections between arteries and veins, corresponding to 10-15% of cerebral vascular malformations, and may initially manifest as PT.1,2


The report of this case was submitted and approved by the ethics committee of the Metropolitan University of Santos.

Case presentation

A 37-year-old man presented with a sudden onset, holocranial headache and left pulsatile tinnitus. The auscultation of the lateral portion of the neck identified a systolic murmur, more intense in the left mastoid region. Otoscopy, fundoscopy, clinical and laboratory examination were normal. History of trauma investigation was negative. Magnetic resonance imaging of the brain, angioresonance and digital subtraction angiography of intracranial vessels confirmed the presence of a dural arteriovenous fistula (Figure 1). The arterial vascular supply was made by cavernous branches of the left internal carotid artery and transverse branches of the left occipital artery, in addition to numerous dural branches from arteries of the contralateral carotid system. The venous drainage was precocious and towards the left transverse and sigmoid sinus into the internal jugular vein and suboccipital plexus in the same topography. The congenital abnormalities in the vascular anatomy of the cerebral arteriovenous transition are the main etiological cause imputed in this case. The patient underwent endovascular treatment with selective arterial embolization with occlusion of the fistulous path and satisfactory results.

Figure 1 A) Brain MRI (left), B) Angioresonance of intracranial vessels (middle) and C) Digital subtraction angiography (right) shows a complex dural arteriovenous fistula.


The presentation of this case alerts the possibility of spontaneous intracranial dural arteriovenous fistula in the differential diagnosis of pulsatile tinnitus. Attention to this clinical–radiologic correlation may help physicians make correct diagnoses and appropriate treatment.



Conflicts of interest



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