Chronic pulsatile tinnitus and continuous vertigo due to very delayed diagnosis of single slow-flow dural arteriovenous

Tinnitus and vertigo are classic symptoms of inner ear disease. Dural arteriovenous fistulas (DAVF) are a rare type of acquired intracranial vascular malformation whose symptoms mimic inner ear disease, but what distinguishes it from other tinnitus is the characteristic of DAVF is pulsatile and heartbeat-synchronous. We present a 58-year-old male with chronic left-sided pulsatile tinnitus (PT) for 30 years and continuous vertigo for 3 years that took numerous consultations to establish a diagnosis after the onset of symptoms. Delay in diagnosis is caused by normal magnetic resonance imaging and an unrecognized subtle mass in the left temporal region by time-of-flight magnetic resonance angiography (TOF-MRA) at the screening test. As we know, TOF-MRA could not provide a clear picture to establish a slow-flow DAVF. Cerebral angiography, a gold standard diagnostic, revealed a Borden/ Cognard Type I single slow-flow DAVF in the left temporal region. The patient was treated with superselective transarterial embolization. After 1 week of follow-up, the symptoms of vertigo and PT were completely resolved.