Presentation
Pulsatile tinnitus.
Patient Data
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Bilateral subcortical and periventricular white matter T2 hyperintensity without evidence of restricted diffusion, in keeping with chronic small vessel ischemic change. Further chronic ischemic change within the brainstem. Chronic left frontal lobe cortical infarct.
High signal within the left cavernous sinus on MRA, similar to the adjacent internal carotid artery. High signal within the dilated left superior ophthalmic vein representing arterialized retrograde flow. This is in keeping with a left caroticocavernous fistula. Flow related artifact within the cavernous sinus with no evidence of cavernous sinus thrombosis.
Additionally, there are enlarged external carotid branches (occipital and posterior auricular) on the left feeding a left transverse sinus dural arteriovenous fistula.
Case Discussion
Pulsatile or buzzing tinnitus is a typical symptom experienced by patients due to the turbulent flow within the fistula.
Direct caroticocavernous fistulas are often secondary to trauma, which may be recent or old. This patient had a history of falls.
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