Neurosurgery 2009 Dec;65(6):E1208-9; discussion E1209
Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, Toronto, Canada.
Objective: This is the first report of an aggressive dural arteriovenous fistula presenting with rhinorrhea. It demonstrates the importance of recognizing increased intracranial pressure, and its underlying cause, as the predisposing factor to a spontaneous cerebrospinal fluid leak because this carries implications for management.
Clinical Presentation: Ten years after minor trauma and directly after an intercontinental flight, a 43-year-old woman presented with rhinorrhea. Right-sided pulsatile tinnitus had been present for the past 9 years. Imaging demonstrated an intracranial dural arteriovenous fistula of the right transverse sinus with cortical venous reflux. Magnetic resonance imaging findings indicated long-standing increased intracranial pressure.
Intervention: The fistula was treated by endovascular means, using both transvenous and transarterial approaches, which led to immediate relief of the tinnitus and resolution of the rhinorrhea within 4 days.
Conclusion: A dural arteriovenous fistula should be included in the differential diagnosis of underlying causes of increased intracranial pressure when examining a patient with a cerebrospinal fluid leak. Treatment of the fistula should precede attempts to treat the rhinorrhea, especially if the fistula has cortical venous reflux.