J Korean Neurosurg Soc.  2020 Jul;63(4):532-538. 10.3340/jkns.2019.0233.

Endovascular Treatment of Traumatic Arteriovenous Fistula in Young Adults with Pulsatile Tinnitus

• Kim HS
• Song JH
• Oh JK
• Ahn JH
• Kim JH
• Chang IB

• KMID: 2504648
• DOI: http://doi.org/10.3340/jkns.2019.0233

Abstract

Traumatic arteriovenous fistulas (AVFs) involving the external carotid artery are exceedingly rare in young adults. Since an AVF is the most common life-threatening cause for pulsatile tinnitus (PT), meticulous evaluation and treatment of patients with PT is crucial. Here, we present two traumatic AVF cases treated with coil embolization leading to no residual fistulous connections followed by an immediate and complete resolution of PT. A 20-year-old man developed left ear tinnitus three months after a traumatic brain injury involving the right temporal bone fracture. Cerebral angiography demonstrated an enlarged left middle meningeal artery (MMA) and a fistular point at the posterior branch of the MMA draining to the middle meningeal vein (MMV) and the left pterygoid plexus, suggesting an AVF. Another 18-year-old girl developed left tinnitus, left exophthalmos, and conjunctival injection 6 months after a traffic accident involving no demonstrable abnormal findings in the radiologic exam. Magnetic resonance angiography demonstrated a markedly dilated left MMA draining to the MMV, left cavernous sinus, and left superior ophthalmic vein. In both cases, coil embolization was performed with total obliteration of the fistular point.

Keyword

Arteriovenous fistula; Embolization; Tinnitus; Meningeal artery

Figure

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  Fig. 1. A 20-year-old man developed pulsatile tinnitus on his left ear 3 months after head trauma. A : Facial CT demonstrates longitudinal fractures on right temporal bone and hemorrhage in right middle ear (arrows). B : Brain MRA demonstrates dilatation of left MMA (arrow). C : Brain CT angio demonstrates fistulous connection between left external carotid artery and left pterygoid plexus suggestive of AVF (arrow). D : Transfemoral cerebral angiography demonstrates fistular point between left MMA and MMV (arrow). CT : computed tomography, MRA : magnetic resonance angiography, MMA : middle meningeal artery, AVF : arteriovenous fistula, MMV : middle meningeal vein.

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  Fig. 2. Fistular point is selected with microcatheter (arrow). B : Coil embolization is being done with platinum coil (arrow). C : Total obliteration of fistular point (arrow) is achieved and no visible early venous drainage into middle meningeal vein and pterygoid plexus is confirmed. D : Control angiography shows total obliteration of fistular point (arrow) and arteriovenous fistula is disappeared.

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  Fig. 3. An 18-year-old girl developed pulsatile tinnitus on left ear 6 months after head trauma. A : Brain CT demonstrates left exophthalmos (arrow). Brain MRA demonstrates dilatation of left MMA (B, arrow) and left MMV (C, arrow) and left cavernous sinus (D, arrow). CT : computed tomography, MRA : magnetic resonance angiography, MMA : middle meningeal artery, MMV : middle meningeal vein.

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  Fig. 4. Transfemoral cerebral angiography was performed. A : Arteriovenous fistula between left MMA and MMV (arrow) draining to left cavernous sinus and superior ophthalmic vein is observed. B and C : Coil embolization is being done with platinum coil (arrow). D : Control angiography shows total obliteration of fistular point (arrow) and no residual venous drainage is found. MMA : middle meningeal artery, MMV : middle meningeal vein.

Reference

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