Case Presentation A 69-year-old female presented for elective lumbar decompressive laminectomies and L5-S1 lumbosacral joint fusion after failing conservative management for chronic lumbago. The procedure was successful and the patient was discharged after a brief uneventful hospital course. One week later, the patient returned with sepsis secondary to surgical wound infection. She developed severe headaches and subsequent imaging revealed isolated left parietal cortical vein thrombosis with concomitant subarachnoid and subdural hemorrhage in addition to dural enhancement, suggestive of CSF leak. In light of the active hemorrhage and the superficial nature of the cortical venous thrombosis, anticoagulation was decided against. One week later, she returned with encephalopathy, seizures, and six episodes of emesis. Imaging revealed left parietal subarachnoid hemorrhage and acute parenchymal hemorrhage in the left parietal lobe with a thrombosed left parietal cortical vein and partial thrombosis of the superior sagittal sinus. Considering the previous decision against anticoagulation, risk vs benefits at this juncture lent towards heparin despite active subarachnoid hemorrhage and acute intraparenchymal hemorrhage.

Discussion The ambiguous presentation of CCVT makes for a challenging diagnosis, especially as a direct or indirect postoperative complication, thereby requiring both a skilled clinician and early detection to improve patient outcomes. Headache has been described as the most common of CCVT symptoms. In a systematic review of 325 cases, headaches were most common (46.8%) while seizures were third most common (42.5%) (Song et al. 2021). Magnetic resonance modalities are also a crucial element to the diagnosis of CCVT with T2 weighted sequencing being the most sensitive (97.4% ) (Linn et al. 2010). Though imaging is imperative in making a definitive diagnosis, having a high index of suspicion for CCVT and weighing risks vs benefits of treatment is required to prevent catastrophic outcomes as can occur with thrombotic extension and further complications.

Conclusion Clinical decision making of risks versus benefits of anticoagulation in the setting of isolated cortical venous thrombosis associated with intraparenchymal hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage.Professional Practice Gap(s) A professional practice gap is the difference between actual and ideal knowledge, competence, performance and/or patient outcomes. When there is a gap between what the professional is doing or accomplishing compared to what is ’achievable on the basis of current professional knowledge,’ there is a professional practice gap.

The present case describes an intricate hospital course of a patient who initially presented for elective lumbar spine surgery that developed numerous rare complications including surgical site CNS infection, sepsis, subarachnoid and intraparenchymal hemorrhage with CSF leak, and cerebral cortical venous thrombosis. While current data supports anticoagulation even with present SAH, isolated superficial cortical thrombosis is rare and further studies are required for determination of risks and benefits of anticoagulation in this setting.

Disclosures S. Nittala: None. J. Prosapio: None. M. Wilson: None. P. Youssef: None.