Dural Arteriovenous Fistulas Secondary to Intracranial Pulsatile Tinnitus: Reported Cases and Review of Literature

Introduction: Dural arteriovenous fistulas are lesions involving the dura and the epidural space. Not uncommon manifest only as headache and pulsatile tinnitus, diagnosed after complications as hemorrhage, neurological deficits, or seizures.

Related Cases: Case 1. A 42-year-old female patient presented with pulsatile tinnitus left ear and headache 11 years ago. She had normal otoscopy but an intense systolic murmur on auscultation of the parotid region and the left mastoid with normal immittance and audiometry. Angiography showed ectasia of the carotid system on the left, and prominence on the left venous system. Cerebral angiography showed the presence of dural fistula with multiple feeder arteries, involving the entire left sigmoid sinus, with signs of cerebral venous hypertension. Case 2. A 69-year-old female patient presented with pulsatile tinnitus left and headache 6 months ago. At the left mastoid examination, she had a normal otoscopy but systolic murmur. Audiometry and impedance showed left sensorineural hearing loss in acute moderate intensity. Cerebral angiography showed dural fistula to the sigmoid left sinus with reflux into cortical veins and signs of cerebral venous hypertension. Patients were treated by endovascular approach for arterial road, with injection of Onyx 18 with complete remission of pulsatile tinnitus.

Conclusion: Dural fistulas are intriguing lesions that may have variable clinical manifestations. Pulsatile tinnitus could be main symptom, highlighting the importance of auscultation with a stethoscope mastoid and parotid examination in these patients. Indication of treatment should be individualized for each patient.

Keywords: Arteriovenous fistulas, tinnitus.