Male 51-year-old patient without systemic or otological disease, complained of tinnitus of pulsatile nature on the left, synchronous with heartbeat, which had started 9 months before and hindered his professional performance (administrative assistant) and resulted in marked anxiety. The patient had taken antidepressants, anxiolitic and vasoactive drugs prescribed by the neurology, without any response. ENT physical examination presented normal otoscopy and the patient had past history of septoplasty two years before the onset of tinnitus. Neurological examination had no significant findings.
Pure tone audiometry - mild decrease in high frequencies (3000Hz 30 dB; 4000Hz 35 dB; 6000Hz 40 dB) bilaterally.
Brainstem evoked potential did not evidence any abnormalities.
Nuclear Magnetic Resonance of the head, with gadolinium- isolated focus of reduced signal in T1 and elevated in T2, not impregnated by the contrast medium in the left frontal radial crown, suggestive of cerebral lacuna. Basilar artery was elongated and tortuous, describing anterior-lateral loop on the left under the pons.
Head angioresonance - brain images in T2 showed hyperintense focus on left radial crown, which may correspond to small area of gliosis or lacuna infarction. Tortuous vertebral-basilar transition towards the pontine-cerebellum angle cistern on the left (Figure 2).
We conducted the following complementary tests: 
In both neuroimaging studies the other head and vascular structures were normal.
After excluding the hypothesis of surgical treatment, we prescribed clonazepam 2mg/day associated with propranolol 20mg TID, which made tinnitus more tolerable to the patient.