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Background Cerebral venous sinus thrombosis (CVST) is a rare and heterogeneous form of stroke characterized by variable clinical trajectories and evolving venous hemodynamics. Although systemic anticoagulation remains the standard of care, a subset of patients deteriorate despite treatment and may require escalation to endovascular therapy. Early physiologic markers that contextualize disease severity and clinical evolution remain poorly defined. Computed tomography perfusion (CTP), widely used in arterial stroke triage, has not been well characterized in CVST. We sought to describe perfusion imaging findings in CVST and explore how baseline CTP abnormalities relate to management pathways, imaging evolution, and functional outcomes.Methods We performed a retrospective analysis of patients with radiographically confirmed CVST who underwent baseline CTP imaging between January 2024 and October 2025 at two high-volume tertiary stroke centers. Patients were stratified by the presence or absence of baseline CTP abnormalities. Management strategies, including medical therapy alone or escalation to endovascular intervention, were recorded. Imaging outcomes were defined as partial or complete recanalization on follow-up venous imaging when available. Functional outcomes were assessed using modified Rankin Scale (mRS) scores at baseline, early post-treatment, and 3-month follow-up.Results Thirty-seven patients met inclusion criteria, of whom 27 (73.0%) demonstrated baseline CTP abnormalities. Overall, 15 patients (40.5%) underwent endovascular intervention. Among patients with CTP abnormalities, 12/27 (44.4%) underwent intervention compared with 3/10 (30.0%) without perfusion abnormalities. Imaging improvement occurred across management strategies, including 8/12 patients with CTP abnormalities who underwent intervention and 8/15 managed medically. All patients without CTP abnormalities who underwent intervention demonstrated imaging improvement. Early post-treatment disability was greatest among patients undergoing endovascular intervention irrespective of perfusion phenotype, while patients without perfusion abnormalities managed medically demonstrated the lowest early disability. At 3-month follow-up, functional outcomes were generally favorable across groups, with variability by both perfusion status and management pathway. Seven patients experienced complications, all of whom demonstrated baseline perfusion abnormalities.Conclusions Baseline CTP abnormalities were common in this multicenter CVST cohort and were associated with heterogeneous management pathways and clinical trajectories. Perfusion findings evolved over time and frequently improved following treatment, suggesting that CTP may provide additional physiologic context beyond anatomic venous imaging alone. These findings support further investigation of CTP as a hypothesis-generating tool for risk stratification and for informing future studies of patient selection in CVST management.Disclosures A. Suri: None. Y. Vays: None. V. Jaikumar: None. T. Morioka: None.