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Background: Dural venous sinus thrombosis (DVST) is an increasingly recognized cause of a wide array of neurological symptoms, with outcomes that range from complete recovery to death. Approximately 23% of patients with DVST will worsen after initial presentation, as a result of restricted venous outflow and venous hypertension, but early identification of this subset is challenging. A venous collateral scale (VCS) that grades alternative drainage routes may improve prediction of clinical deterioration.Methods: From our institutional database, we identified patients with documented DVST on dedicated venous imaging (MR, CT or catheter angiography) from January 2010 to July 2016. Patients were excluded for thrombosis related to arteriovenous fistulae. The VCS (Table) was created and scores were determined from cerebrovascular venous imaging at presentation by two reviewers blinded to subsequent imaging and clinical data.Results: Among 28 patients that met criteria, median age was 42 (IQR 24-57) and 50% (14/28) were female. Presentation symptoms included intracranial hemorrhage in 40% (11/28) and headache without hemorrhage in 18% (5/28). Transverse sinus occlusion was present in 68% (19/28), and superior sagittal sinus occlusion in 39% (11/28). 82% (23/28) of patients were treated with anticoagulation, and 18% (5/28) with endovascular thrombectomy. New hemorrhage or expansion of initial hemorrhage occurred in 21% (6/28). In-hospital mortality occurred in 18% (5/28). VCS was 0 in 18% (5/28), 1 in 39% (11/28), and 2 in 46% (12/28). Lower VCS was significantly associated with development of new hemorrhage or expansion of initial hemorrhage (62% vs. 0%, VCS 0-1 vs. 2, p<0.01). VCS demonstrated excellent discrimination for in-hospital clinical worsening (C-statistic 0.85).Conclusions: The type and quality of venous collaterals influence outcome in DVST. VCS helps identify patients who are likely to deteriorate and may need additional early interventions.