Fig. 7—

74-year-old woman with new nocturnal pulsatile tinnitus (case 7; same patient as in Fig. 1).

A, Time-of-flight MRA image shows left-sided marginal sinus fistula presenting with focal signal intensity (arrow) in region of left jugular foramen.

B, Arterial spin-labeling perfusion image shows bilateral areas of high signal intensity in jugular foramen extending anteriorly toward inferior petrosal sinuses, which is reflux pathway responsible for pressurizing cavernous sinuses from marginal sinus (arrows).

C, Anteroposterior left external carotid injection digital subtraction angiogram shows extensive marginal sinus fistula supplied by several branches, including stylomastoid artery (solid black arrow) and branches of ascending pharyngeal artery (dashed black arrow). Fistula drainage refluxes via both inferior petrosal sinuses, mirroring appearance (white arrows) in B.