Recurrent Syncope Caused by a Dural Arteriovenous Fistula: A Case Report and Review of the Literature.

BACKGROUND Dural arteriovenous fistulas (DAVFs) are pathologic vascular connections that shunt dural arterial flow directly to dural venous drainage. Only a few isolated case reports describe syncope on presentation. We report the first case of DAVF causing recurrent, progressive syncope in an otherwise asymptomatic patient. CASE REPORT A female in her late 20s presented with a 9-year history of syncopal episodes and was found to have a DAVF. Syncopal episodes were exacerbated by positional changes, strenuous activity and emotional stressors. Symptoms occurred upon wakening and lasted for 2 to 3 hours before she was able to regain functionality. Physical examination revealed no abnormalities. Magnetic resonance imaging of the brain showed no irregularities. Magnetic resonance angiography revealed abnormal serpiginous structures in the left jugular foramen which communicated with the ascending pharyngeal branch of the left external carotid artery. Cerebral angiogram disclosed a left jugular bulb DAVF supplied by the left ascending pharyngeal and left occipital arteries. The DAVF was successfully managed by progressive endovascular embolization with coils and Onyx 34. On clinical follow-up evaluation, the patient had no further episodes of dizziness or syncope. CONCLUSION We present an atypical case of DAVF in a patient presenting with recurrent syncope. Only 4 cases of DAVF causing syncope have been reported, all in combination with other neurological symptoms. In comparison, we report a unique case of DAVF presenting solely with recurrent syncope, a previously undocumented finding in the literature. Our case adds to other reports of nonspecific DAVF presentations and highlights the importance of considering this etiology.