Acute dural venous sinus injuries: Imaging and challenges

Dural venous sinus injury (DVSI) can occur after traumatic brain injury and lead to impaired cerebral venous outflow through extrinsic compression, intraluminal thrombosis, or mixed mechanisms. It can progress to a sinus tear or transection with hemorrhage. On noncontrast-enhanced head CT, DVSI may be subtle and can be confounded by adjacent fractures, extra-axial blood products, and filling defects such as arachnoid granulations. Although the reported incidence of severe head injury is 1-4%, modern trauma imaging has revealed a substantially higher burden of DVSI and dural venous sinus thrombosis (DVST) in patients with skull base and calvarial fractures, particularly when fractures cross or overlie major sinuses or the jugular bulb. This narrative review focuses on acute post-traumatic dural venous sinus injury and synthesizes current knowledge on the angiographic anatomy. We also highlight the strengths and limitations of CT venography (CTV), MR venography (MRV), and adjunctive digital subtraction angiography in detecting DVSI, differentiating intraluminal thrombus from extrinsic compression, and characterizing collateral pathways. Finally, we review management strategies, including neurosurgical decompression for mechanically compressed sinuses, the non-standardized use of systemic anticoagulation for DVST in the presence of a hemorrhage, and the role of detailed venographic mapping for operative planning. Timely recognition of these injuries and their complications, guided by a systematic venographic approach, is essential for mechanism-based management that may reduce the risk of serious sequelae including venous infarction.