A 58-year-old male presented with continuous left-sided tinnitus for 30 years without hearing loss. He described tinnitus as a constant rhythmic sound that synchronized with his heartbeat. Three years before the presentation, the patient was experiencing worsening vertigo. Vertigo was not affected by positional changes but was sometimes accompanied by nausea and vomiting, lasting for hours. The patient claimed that the symptoms affected his quality of life (QoL) with a Tinnitus Handicap Inventory (THI) score of 70.
There were no focal neurological deficits. Audiological examinations showed that his peripheral hearing was normal. MRI showed no abnormalities, yet time-of-flight MRA (TOFMRA) showed a dilated vessel from the left external carotid artery (ECA) branch on the left temporal region [Figure 1a]. Due to the typical symptoms of vascular lesion and a dilated vessel, concern was raised for a potential DAVF, and we continued with six-vessel cerebral DSA plus ECA branches injection.
A routine six-vessel angiography revealed no abnormal findings in the arterial phase. However, injection of the left ECA confirmed the presence of a Borden/Cognard Type I dural fistula in the left middle cranial fossa with a feeder from the internal maxillary artery through the accessories branch of the meningeal artery, with venous ectasia with a size of 4.8 mm x 8.2 mm [Figure 1b and 1c]. The diagnosis of DAVF, fed by the left ECA and draining into the left inferior petrosal sinus [Figure 1d], was therefore made.
Due to the severity of tinnitus and the dizziness impacting the patient's QoL, we performed a superselective embolization using the Seldinger technique through transfemoral access. The Magic microcatheter 1.5-F was positioned as close as DAVF [Figure 2a]. N-butyl-2-cyanoacrylate (n-BCA) and iodized oil (Lipiodol) with a concentration of 1:1 50% were chosen as liquid embolic agents because it was a slow-flow DAVF [Figure 2b]. Post-embolization angiogram showed no more fistula and patent flow of the artery branches [Figure 2c]. During the 1-week follow-up, vertigo and PT were completely resolved with a THI score of 8. We considered performing TOF-MRA in the 6-month follow-up.