脑静脉血栓形成（cerebral venous thrombosis，CVT）是少见但可治疗的脑血管急症，累及硬脑膜静脉窦、皮质静脉或深静脉系统。其临床表现异质性强，可仅表现为头痛，也可出现癫痫、局灶性神经功能缺损、颅内压增高、意识障碍甚至脑疝[1-3]。CVT漏诊、误诊和延迟诊断的本质，是低临床警觉性、不典型表现、风险因素采集不足、影像路径不完整和系统流程缺陷共同作用的结果。

1. 头痛相关情境

新发、持续性、进行性加重或性质明显不同于既往的头痛，尤其伴恶心、呕吐、视物模糊、复视、短暂黑矇、卧位加重、屏气或咳嗽加重时，应考虑CVT。孤立头痛不能因神经系统查体正常而轻易排除CVT[7]。

2. 神经系统事件

成人首次癫痫、局灶起始癫痫、癫痫后持续神经功能缺损，以及头痛伴偏瘫、失语、意识障碍、精神行为异常或脑神经受累，均应进入CVT鉴别诊断。

3. 高危人群

4. 影像提示

非典型脑出血、出血性梗死、跨动脉供血区病灶、双侧丘脑或基底节病变、皮质下水肿、蛛网膜下腔出血但动脉瘤证据不足、年轻患者不明原因脑出血，均应追加静脉系统影像。

影像报告应系统评估上矢状窦、直窦、横窦、乙状窦、深静脉系统、皮质静脉和颈内静脉近端。重点观察静脉窦充盈缺损、窦腔扩张、异常高密度、异常强化、静脉性水肿、出血性梗死及脑疝风险。

需特别警惕以下误判来源：横窦发育不良、静脉窦不对称、蛛网膜颗粒、窦内隔、慢血流、时间飞跃法（time-of-flight，TOF）MRV流动伪影，以及慢性血栓再通。若脑实质病灶不符合动脉供血区，应主动寻找静脉源性病变证据[11-13]。

CVT急性期治疗以抗凝为基础，目的在于防止血栓延展、促进再通和控制高凝状态。CVT相关颅内出血通常并非抗凝的绝对禁忌，需结合病情综合判断[2,3]。严重病例若出现神经功能恶化、脑疝风险、血栓进展或抗凝失败，应早期讨论血管内治疗或外科减压[1,15]。

病因处理同样重要。感染性CVT需抗感染并控制感染源；含雌激素避孕药相关CVT应停用相关药物；妊娠和产褥期患者需产科联合管理；抗磷脂综合征相关CVT影响长期抗凝策略；疫苗诱导免疫性血栓性血小板减少症相关CVT则需特殊抗凝和免疫治疗策略[2,4]。

CVT应被视为“少见、易误诊、但可治疗”的脑血管急症。孤立头痛、视乳头水肿、成人首次癫痫、妊娠产褥期、口服避孕药、头颈部感染和不典型脑出血，是最需要提高警觉的场景。D-二聚体阴性和平扫CT阴性均不能可靠排除CVT。疑似病例应尽早完成CTV或增强MRV；怀疑皮质静脉血栓时应补充SWI或GRE。减少漏诊的关键，不仅在于医生个人经验，更在于标准化触发规则、结构化影像报告、复诊预警、多学科协作和质量改进闭环。

[1] Saposnik G, Bushnell C, Coutinho JM, et al. Diagnosis and management of cerebral venous thrombosis: a scientific statement from the American Heart Association[J]. Stroke, 2024, 55(3): e77-e90. DOI: 10.1161/STR.0000000000000456.

[2] Field TS, Lindsay MP, Wein T, et al. Canadian Stroke Best Practice Recommendations, 7th Edition: Cerebral Venous Thrombosis, 2024[J]. Can J Neurol Sci, 2024: 1-57. DOI: 10.1017/cjn.2024.269.

[3] Ferro JM, Bousser MG, Canhão P, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis: endorsed by the European Academy of Neurology[J]. Eur J Neurol, 2017, 24(10): 1203-1213. DOI: 10.1111/ene.13381.

[4] 国家卫生健康委员会办公厅. 脑血管病防治指南（2024年版）[S]. 北京: 国家卫生健康委员会, 2024.

[5] 中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国颅内静脉血栓形成诊断和治疗指南2019[J]. 中华神经科杂志, 2020, 53(9): 648-663. DOI: 10.3760/cma.j.cn113694-20200225-00113.

[6] Silvis SM, de Sousa DA, Ferro JM, et al. Cerebral venous thrombosis[J]. Nat Rev Neurol, 2017, 13(9): 555-565. DOI: 10.1038/nrneurol.2017.104.

[7] Bakradze E, Shu L, Henninger N, et al. Delayed diagnosis in cerebral venous thrombosis: associated factors and clinical outcomes[J]. J Am Heart Assoc, 2023, 12(19): e030421. DOI: 10.1161/JAHA.123.030421.

[8] Liberman AL, Gialdini G, Bakradze E, et al. Misdiagnosis of cerebral vein thrombosis in the emergency department[J]. Stroke, 2018, 49(6): 1504-1506. DOI: 10.1161/STROKEAHA.118.021058.

[9] Ferro JM, Canhão P, Stam J, et al. Delay in the diagnosis of cerebral vein and dural sinus thrombosis: influence on outcome[J]. Stroke, 2009, 40(9): 3133-3138. DOI: 10.1161/STROKEAHA.109.553891.

[10] Heldner MR, Zuurbier SM, Li B, et al. Prediction of cerebral venous thrombosis with a new clinical score and D-dimer levels[J]. Neurology, 2020, 95(7): e898-e909. DOI: 10.1212/WNL.0000000000009998.

[11] van Dam LF, van Walderveen MAA, Kroft LJM, et al. Current imaging modalities for diagnosing cerebral vein thrombosis: a critical review[J]. Thromb Res, 2020, 189: 132-139. DOI: 10.1016/j.thromres.2020.03.011.

[12] Buyck PJ, Zuurbier SM, Garcia-Esperon C, et al. Diagnostic accuracy of noncontrast CT imaging markers in cerebral venous thrombosis[J]. Neurology, 2019, 92(8): e841-e851. DOI: 10.1212/WNL.0000000000006959.

[13] Pannell JS, Wintermark M, Gilligan LA, et al. ACR Appropriateness Criteria® Cerebrovascular Diseases[J]. J Am Coll Radiol, 2024, 21(6S): S112-S142. DOI: 10.1016/j.jacr.2024.02.014.

[14] Ferro JM, Coutinho JM, Dentali F, et al. Safety and efficacy of dabigatran etexilate vs dose-adjusted warfarin in patients with cerebral venous thrombosis: a randomized clinical trial[J]. JAMA Neurol, 2019, 76(12): 1457-1465. DOI: 10.1001/jamaneurol.2019.2764.

[15] Coutinho JM, Zuurbier SM, Bousser MG, et al. Effect of endovascular treatment with medical management vs standard care on severe cerebral venous thrombosis: the TO-ACT randomized clinical trial[J]. JAMA Neurol, 2020, 77(8): 966-973. DOI: 10.1001/jamaneurol.2020.1022.