Suicidal Ideation in a Severe Case of NonPulsatile Tinnitus Caused by a Dural Arteriovenous Fistula

Abstract Pulsatile tinnitus is often the initial presentation of a dural arteriovenous fistula, so a high index of suspicion is needed to avoid misdiagnoses and possible fatal consequences. Although pulsatile tinnitus commonly originates from a vascular malformation and non-pulsatile tinnitus from a neurodegenerative one, pulsatile and non-pulsatile presentations can result from other underlying pathologies. If a vascular pathology causes a non-pulsatile complaint that cannot be heard by the examiner or detected clinically or radiologically, it is bound to be misdiagnosed as central tinnitus. Herein, we report a rare presentation of a dural arteriovenous fistulas contributing to subjective, non-pulsatile tinnitus. The 50-year-old male patient in this case presented with 2 years of tinnitus, refractory to several treatment approaches that eventually lead to suicidal ideation. Magnetic resonance imaging of the head, magnetic resonance angiography of the head and neck, and computerized tomography scan of the temporal bone did not reveal any acute pathology. Cerebral angiogram revealed a dural arterio-venous malformation in the left sigmoid and transverse sinus. The patient was treated with transarterial Onyx18 embolization of the dural arterio-venous malformation. His symptoms resolved by 50% following treatment and by 80% at 6-month reevaluation. Dural arteriovenous fistulas are rare vascular malformations that, if left untreated, have fatal complications. These vascular malformations may not be detected by physical examination or audiometric evaluation alone. In the absence of neurologic deficits and retrograde leptomeningeal or cortical venous drainage, selective angiographic embolization appears to be an efficient and low-risk modality for symptomatic treatment.