[2026-08-11] Diagnostic Performance of Superior Ophthalmic Vein Doppler Ultrasonography for Carotid-Cavernous Fistula and Cavernous Sinus Dural Arteriovenous Fistula

Mungkorn Apirakkan; Massupa Krisem; Ekachat Chanthanaphak

doi:10.33165/rmj.2027.e280317

Authors

Mungkorn Apirakkan Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand https://orcid.org/0000-0002-9823-3480
Massupa Krisem Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Ekachat Chanthanaphak Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand https://orcid.org/0000-0002-1838-647X

DOI:

https://doi.org/10.33165/rmj.2027.e280317

Keywords:

Superior ophthalmic vein, Doppler ultrasound, Carotid–cavernous fistula, Dural arteriovenous fistula, Intraocular pressure

Abstract

Background: Carotid-cavernous fistula (CCF) and cavernous sinus dural arteriovenous fistula (dAVF) often present with ocular symptoms and may increase intraocular pressure (IOP). Cerebral angiography is the reference standard; however, noninvasive tools are needed to support diagnostic triage and treatment decision-making.

Objectives: To evaluate the diagnostic performance of superior ophthalmic vein (SOV) Doppler ultrasonography (DUS) for CCF/cavernous dAVF, to compare its performance with magnetic resonance angiography (MRA), and to assess the relationship between Doppler parameters and elevated IOP.

Methods: This retrospective diagnostic accuracy study included 67 eyes from 51 patients who underwent SOV DUS and cerebral digital subtraction angiography for suspected CCF/cavernous dAVF. Analyses were performed at the eye level. Diagnostic performance of DUS, MRA, and an either-positive combined strategy was calculated using cerebral angiography as the reference standard. Doppler parameters, clinical features, and IOP were analyzed, and receiver operating characteristic analysis was used to evaluate the ability of the resistive index (RI) to identify elevated IOP (≥ 20 mmHg).

Results: Cerebral angiography confirmed fistulas in 59/67 eyes (88.1%). DUS had a sensitivity of 72.9% (95% CI, 60.4%-82.6%) and specificity of 75.0% (95% CI, 40.9%-92.9%), whereas MRA had a sensitivity of 79.7% (95% CI, 67.7%-88.0%) and specificity of 87.5% (95% CI, 52.9%-97.8%). The combined DUS-or-MRA strategy increased sensitivity to 81.4% (95% CI, 69.6%-89.3%). RI showed limited discrimination for elevated IOP, with an area under the curve of 0.65 (95% CI, 0.46-0.79). At an RI cutoff of 0.62, sensitivity was 46.4% and specificity was 84.2%.

Conclusions: SOV DUS demonstrated moderate diagnostic performance for CCF/cavernous dAVF and may complement MRA in clinical triage. However, a negative DUS finding does not exclude the condition. RI should be interpreted as a supportive Doppler parameter rather than a standalone marker of elevated IOP.

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