Background: Anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs) present unique treatment challenges due to their complex angioarchitecture and high risk of hemorrhage. Recent advancements in endovascular techniques have highlighted the potential of transarterial embolization in managing these fistulas.

Objective: The purpose of this study is to evaluate the clinical and angiographic outcomes of transarterial embolization (TAE) as a first-line treatment for ACF DAVFs over a twenty-year period.

Methods: From March 200 to September 2021, a total of 54 patients harboring ACF DAVFs underwent TAE as a first-line approach at our institution. The clinical presentation, angiographic features, procedure-related complications, clinical outcomes, and angiographic results were analyzed retrospectively.

Results: Among 54 ACF DAVF treated, there were 48 males and 6 females, with a mean age of 52.5 (52.5 ± 13.0) years. Intracranial hemorrhage (51.9%, 28/54) was the most common symptom. A total of 57 embolization attempts were performed. 85.2% (46/54) achieved complete angiographic occlusion immediately post-TAE. Complications occurred in 3.7% (2/54) of patients. 97.6% (41/42) experienced symptom improvement or stabilization during clinical follow-up. Radiological follow-up showed that 85.0% (34/40) maintained complete fistula occlusion. Angiographic recurrence occurred in one (2.5%, 1/40,) patient without any symptoms.

Conclusions: TAE for ACF DAVFs demonstrates a high rate of complete occlusion with an acceptable safety profile. Further comparative studies with other treatment approaches are recommended to validate these findings.