Cerebral venous sinus thrombosis (CVST) is an emergent diagnosis frequently missed on standard brain imaging in the ED, with studies reporting miss rates up to 30–73% on noncontrast CT alone. Diagnostic delays average 4–10 days from initial presentation in confirmed cases. CTV and MRV both have very high sensitivity for detection of CVST.

When to Suspect CVST

1. Unexplained focal neurologic deficits: Hemiparesis, aphasia, or new seizures without corresponding arterial infarct, mass effect, or hemorrhage on noncontrast CT/CTA.
2. Signs of increased ICP without mass lesions or traumatic findings
3. Hypercoagulable states: OCP use, malignancy, peripartum status, thrombophilia 
4. High risk CT findings: 
   1. Skull fracture traversing a dural sinus (SSS, transverse)
   2. Empty delta sign
   3. Atypical hemorrhage patterns:
      1. Multifocal cortical subarachnoid hemorrhage (especially posterior-predominant).
      2. Nontraumatic-appearing cortical SAH or bilateral thalamic hemorrhages.
      3. Hemorrhagic venous infarcts (“thumbprint edema”).

Summary: Consider adding CTV in patients with strong thrombotic risk factors, atypical/multifocal hemorrhage patterns, or focal deficits unexplained by CT/CTA.

References

1. Ferro, J. M., Bousser, M. G., Canhão, P., Coutinho, J. M., Crassard, I., Dentali, F., di Minno, M., Maino, A., Martinelli, I., Masuhr, F., de Sousa, D. A., Stam, J., & European Stroke Organization (2017). European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology. European stroke journal, 2(3), 195–221. https://doi.org/10.1177/2396987317719364
2. Saposnik, G., Bushnell, C., Coutinho, J. M., Field, T. S., Furie, K. L., Galadanci, N., Kam, W., Kirkham, F. C., McNair, N. D., Singhal, A. B., Thijs, V., Yang, V. X. D., & American Heart Association Stroke Council; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; and Council on Hypertension (2024). Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association. Stroke, 55(3), e77–e90. https://doi.org/10.1161/STR.0000000000000456