Soldato
Autoruns, Rootkit Revealer et al? And then there's non direct approaches like listening to what your computer is telling you. Is it running slow? Are apps randomly crashing with no obvious pattern? Has your bandwidth suddenly taken a severe drop? Is the Event Viewer full of suspicious activity? If any of these suspicions seem founded then it takes 5 minutes to boot into a Recovery Console prompt and take a peep at your System32 folder for any strange looking .sys files. Even the most advanced rootkits can't hide themselves if you don't boot from the OS on which they're installed
All great, useful tools. However, how long are you willing to wait and monitor whether that random application crash was benign or not? Do you trust what process explorer is telling you? If I take the machine offline do I really want to trust my knowledge of the system32 folder or would it just be easier and more convenient to run an offline scan?
You can get away without using antivirus software but that doesn't preclude it from being useful in some instances.
Generally though if a virus is sophisticated enough then no tool, and certainly not some poxy "anti virus", will be able to detect it. Just look at the Iranians. I'm sure they were running AV on their nuke lab computers but it didn't save them did it?
And if we're talking about the same piece of malware, part of it's propagation method was using code signed by Microsoft so relying on image verification wouldn't have worked for them either.