Perfusion imaging abnormalities in acute cerebral venous sinus thrombosis: A case series

The clinical value of perfusion imaging in arterial ischemic stroke is well established, but its interpretation in cerebral venous sinus thrombosis (CVST) remains less clearly defined. We present a case series of five patients with acute CVST who demonstrated perfusion abnormalities on initial CT perfusion (CTP) or MR perfusion (MRP). The observed findings demonstrated a spectrum of venous hemodynamic patterns. Several patients showed delayed transit metrics, including increased MTT or Tmax, with preserved or increased CBV, suggesting venous congestion or vasogenic edema rather than arterial-type ischemic penumbra. In contrast, one patient demonstrated delayed transit with decreased CBV and CBF, suggesting more advanced venous infarction or tissue-level perfusion failure. One additional patient demonstrated hyperperfusion in a non-territorial distribution, most compatible with ictal or peri-ictal hyperemia rather than a primary venous congestion pattern. Four patients had favorable neurological recovery, whereas one patient had a poor short-term outcome likely driven primarily by large baseline hemorrhage. These cases highlight that perfusion abnormalities in CVST should be interpreted differently from arterial stroke and may be most useful when stratified into venous congestion, venous infarction, and seizure-related hyperperfusion patterns.