BACKGROUND: The gold standard for the diagnosis and detailed evaluation of spinal dural arteriovenous fistula (SDAVF) is a digital subtraction angiography (DSA). However, this procedure is time-consuming and effortful. A time-resolved contrast enhanced 4D magnetic resonance angiography (4D-MRA) can be used to increase the diagnostic accuracy of spinal magnetic resonance imaging for the detection and localization of a SDAVF. The goal of this study is to assess the diagnostic accuracy of 4D-MRA for the detection and localization of a SDAVF in comparison to DSA based on a systematic review of the literature. METHODS: We performed a systematic review and meta-analysis on the diagnostic accuracy of 4D-MRA compared to DSA. Literature was reviewed from the PubMed, Cochrane, and EMBASE databases. RESULTS: In comparison with DSA, the pooled sensitivity of MRA was 98.2% (95% confidence interval [CI] 91.5%-99.6%), with a pooled specificity of 88.2% (95% CI 57.5%-97.6%) for the diagnosis of SDAVFs. The side and level of the SDAVFs were correct in 91% (95% CI: 86%-94%) and 76% (95% CI: 71%-80%), respectively. CONCLUSIONS: Current literature indicates that 4D-MRA has a high sensitivity and specificity for the detection and localization of a SDAVF. It can serve to guide DSA to shorten the procedural time, reduce the risk of complications, and decrease patient discomfort.