The empty delta sign: frequency and significance in 76 cases of dural sinus thrombosis

The presence of the empty delta sign on contrast material-enhanced computed tomographic (CT) scans of the brain is considered pathognomonic of sagittal sinus thrombosis (SST); however, a valid explanation for its appearance is lacking, despite several hypotheses. To determine the frequency of the sign and its prognostic significance, 76 reported cases (112 CT manifestations) of SST and SST-related intracranial sinovenous occlusive disease were reviewed. Ten CT signs related to both disease processes were reported; the empty delta sign was the most frequently reported sign (28.6%) of SST. Patients with hemorrhagic infarction and/or the empty delta sign on CT scans had the poorest prognosis. A case illustrative of the empty delta sign is described in which there was engorgement of endothelial- and nonendothelial-lined spaces in the dura mater with hemorrhagic rupture into the dural leaf. The empty delta sign can probably be explained on the basis of the rich dural venous collateral circulation, consisting primarily of lateral lacunae, a vascular mesh (dural cavernous spaces), and meningeal venous tributaries.