Contrast enhancement of the vertebral body marrow may be seen secondary to collateral venous blood flow via the vertebral venous plexus in the setting of superior vena cava obstruction. We report a 48-year-old woman presenting with bilateral brachiocephalic vein obstruction and multilevel thoracic spine hyperdensities as seen on venous-phase CT angiography (CTA), initially concerning for sclerotic neoplastic lesions. A contrast-enhanced CT of the neck obtained 1 day prior to the chest CTA did not demonstrate any osseous abnormality, and inspection of the chest CTA demonstrated filling of perivertebral venous collateral vessels. The abnormal vertebral body enhancement was therefore feltsecondary to retrograde collateral venous flow via the basivertebral venous plexus in the setting of functional SVC obstruction. Vertebral body enhancement should be considered in patients with thoracic central venous obstruction when enhancement or apparent sclerosis of the vertebral bodies is seen on CTA.