Patients with pulsatile tinnitus could present a diagnostic challenge to the treating physician. Pulsatile tinnitus could be the first presenting complaint in patients with dural arteriovenous fistula or other serious conditions. Recent advances in non-invasive radiological technology revolutionized the diagnosis and management of patients presenting with pulsatile tinnitus. The purpose of this presentation is to define and review potential etiologies in patients with pulsatile tinnitus and to present an update on the radiological work up and treatment modalities available.