Correspondence (reply): In Reply

We would also have liked to write that it is possible to establish the diagnosis of dural arteriovenous fistula—and, above all, to reliably exclude its presence—with minimally invasive diagnostic methods. Several papers demonstrate these efforts to find a non-invasive screening technique (1– 3). MRI is insufficient and even MRA often provides only subtle and indirect signs. It is to the credit of our colleague Prof. Arning that all fistulas diagnosed using ultrasonography could be confirmed using DSA. However, he cannot provide information about the sensitivity of ultrasonography. But this would be of interest when looking at a screening method.

An ultrasound scan performed by a skilled practitioner represents a helpful complementary technique prior to DSA, because, if positive, it increases the probability of detecting a fistula. This can help the patient to decide to actually undergo DSA. However, it is not possible to exclude a fistula requiring treatment based on the evidence provided by ultrasonography. As an example, we like to highlight one of our patients, recently diagnosed by us using DSA with a dural fistula from a branch of the ascending pharyngeal artery which caused a pulsatile tinnitus. Doppler ultrasonography was – unsurprisingly – unremarkable. Prof. Arning's concept “DSA only in case of abnormal ultrasound findings“ gives rise to the critical question, how many fistulas have gone undetected in his department.

Based on the data from the literature and our own experiences, we cannot move away from our recommendation: DSA has unfortunately to remain the gold standard.