LAUSR

We were very interested to read the analysis by Sanchez et al of the largest cohort study of anterior cranial fossa dural arteriovenous fistulas (ACF DAVFs). In this study, 60 cases of ACF DAVFs from 12 centers between 1990 and 2017 in the CONDOR database are included. Fiftythree of the 60 cases (88.8%) received treatment. The majority of the patients underwent microsurgery (66%, 35/53) or endovascular surgery (32%, 17/53). All those who received microsurgery as their first line of treatment had their ACF DAVFs completely removed. Only 53% (9/17) of patients who received an endovascular approach as firstline treatment achieved angiographic cure. Complications were lower in patients treated with microsurgery (6%, 2/35) compared with endovascular treatment (12%, 2/17). At an average of 75 days after endovascular treatment, 18% (2/11) of ACF DAVFs had angiographic recurrence. This article also goes into great detail about the clinical presentation and angioarchitecture of ACF DAVFs, which is a significant contribution to the literature. However, surgery is far more traumatic, necessitates a longer hospital stay and may expose patients to unnecessary risks. CONDOR contains 27 years of data, with data collection beginning in 1990. As a result, endovascular approaches include a wide range of techniques and devices. Recent advances in endovascular catheters, liquid embolic agents and endovascular techniques may result in a higher rate of successful embolizations, changing the conclusion that “Most ACFdAVFs should be managed with microsurgery”. In our unpublished study, 40 patients received transarterial embolization (TAE) as a firstline treatment. The complete occlusion rate for exclusive TAE was 86.8% (33/38). The ophthalmic artery, the middle meningeal artery and the sphenopalatine arteries were the most commonly used arterial access routes for complete embolization. Complications occurred in one patient (2.5%, 1/40) (retinal ischemia). There has been no recurrence of the fistulas based on imaging followup. The findings show higher obliteration rates as well as lower complication and recurrence rates than in previous studies with TAE exclusively. 3 We concluded that endovascular treatment is also a good option for ACF DAVFs. Microsurgery should be used as an adjunct or as a remedial measure. We thank the authors for introducing the largest cohort of ACF DAVFs to the readers.