To present a case of cerebral venous thrombosis (CVT) masquerading as acute arterial stroke. To review the imaging features of CVT seen on acute CT stroke imaging. To consider and routinely look for signs of CVT, particularly when there is discordance between clinical signs, CT perfusion (CTP) abnormalities and CT arterial (CTA) imaging.

CVT encompasses both thrombosis of the cortical or deep cerebral veins and dural venous sinuses.1,2 It is an uncommon cause of stroke, accounting for 0.5-1% of all adult population strokes.1,3 Contemporary stroke treatment emphasizes time to intervention as a major determinant of patient outcomes. The diagnosis of CVT is challenging owing to its rarity, varied clinical presentation and often subtle radiological features. These factors combined with the time critical nature of stroke, may lead to CVT being overlooked on initial rapid CT stroke imaging (NCCT/CTA/CTP)...

Non-contrast CT (NCCT) Direct signs “Filled delta” sign: hyper-attenuating dural venous sinus.4 Dense vessel or “cord” sign: linear/serpiginous, hyper-attenuating deep/cortical vein/s.5 Indirect signs Cerebral oedema resulting in gyral swelling, sulcal effacement, and hypodensity. Intracerebral haemorrhage. Dural thickening/enhancement of the falx and/or tentorium secondary to venous stasis and hyperaemia.6[Fig 1][Fig 2] CT whole brain perfusion (CTP) Perfusion abnormalities that do not correspond to a particular arterial territory, and/or that do conform to a typical venous drainage territory.[Fig 3] Contrast enhanced CT Direct signs “Empty delta” sign:...

Erroneous attribution of CVT related changes to an arterial cause is a potential pitfall of NCCT/CTA/CTP interpretation. The use of automated CTP outputs should be used in conjunction with careful review of NCCT and CTA to ensure imaging concordance. Knowledge of, and routinely checking for, the radiological features of CVT seen on acute CT stroke imaging protocols can help radiologists and stroke physicians expedite diagnosis, avoid treatment complications and improve patient outcome.

T. Skalina: Nothing to disclose B. Travers: Nothing to disclose R. Grimley: Nothing to disclose S. Dupre: Nothing to disclose

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