**4. Clinical presentation**

Patients with DAVFs may be discovered incidentally and be totally asymptomatic. However, if symptoms are present, they can range widely from mild to fatal in severe cases. The site of DAVF and the direction of the venous drainage (anterograde or retrograde) are two of the factors that will determine the nature of symptoms [17].

Benign symptoms like headache and pulsatile tinnitus present when DAVF drains into dural sinus in an anterograde pattern without CVD. Aggressive symptoms of pseudotumor cerebri, papilledema and dementia present when DAVF drains in a retrograde pattern leading to an increase in the intracranial pressure, hence the severe presentation [11].

According to location, ophthalmic symptoms like chemosis, exophthalmos, double vision and low visual acuity occur if the DAVF is located in the cavernous sinus because the ophthalmic venous drainage may get compromised with subsequent increase in the intraocular pressure and periorbital edema [13]. Ear symptoms like pulsatile tinnitus and retroauricular pain present if DAVF involves transverse and sigmoid sinuses. Pulsatile tinnitus can be heard over the mastoid area with auscultation [16].

Tentorial and anterior cranial fossa DAVFs usually present with hemorrhage because both can obtain retrograde CVD. Exophthalmos and chemosis are also present in cases of anterior cranial fossa DAVFs if they obtain cavernous sinus drainage [11].

In severe cases, patients suffer from intracranial hemorrhage and neurological deficits like seizures, parkinsonism, and cerebellar symptoms [15].

Other presentations include brainstem infarction and cervical myelopathy if DAVF is located around the brainstem. Also, these lesions can cause cranial neuropathy because of the compression on cranial nerves [13].
