Immune thrombocytopenic purpura (ITP) is traditionally considered a bleeding disorder; however, thrombotic events are increasingly recognized, particularly in patients treated with thrombopoietin receptor agonists (TPO-RAs). Cerebral venous thrombosis (CVT) is a rare but serious complication in this setting. We report a 40-year-old woman with chronic ITP and elevated antiphospholipid antibody (aPL) IgG who developed headache, vomiting, and blurred vision. MRI demonstrated a left parieto-occipital hemorrhagic infarct and CT venography confirmed thrombosis of a parasagittal cortical vein. Despite therapeutic anticoagulation, malignant cerebral edema necessitated emergency decompressive craniectomy under general anesthesia. The patient improved neurologically and was discharged ambulant with support. This case highlights the complex interplay between ITP, TPO-RA therapy, aPL, and CVT, and underscores key perioperative challenges.