A 49-year-old woman with a history of gastric bypass and menorrhagia presented with transient left arm weakness and right eye blindness, preceded by central vision loss that resolved spontaneously. The examination was normal. Laboratory studies revealed leukocytosis (15,600/μL), anemia (hemoglobin 7.4 g/dL), and marked thrombocytosis (1,074,000/μL) with giant platelets on smear. CT angiography demonstrated a 6-mm non-obstructive embolus at the right carotid bifurcation. With no vascular risk factors or identifiable embolic sources, hematologic evaluation was pursued. Platelet-pheresis was performed and complicated by a right femoral peri-catheter thrombus, for which she was started on apixaban for three months. Hydroxyurea was initiated for the elevated platelet count. Her hospitalization was further complicated by severe menorrhagia due to uterine fibroids requiring multiple transfusions. Molecular testing for JAK2, CALR, and MPL mutations was negative, and thrombophilia workup was unremarkable. Thrombocytosis was attributed to iron-deficiency anemia from chronic blood loss, representing a paradoxical state of bleeding and thrombosis. At follow-up, her platelet count had normalized, and hemoglobin improved after treating her iron-deficiency anemia. The patient was started on clopidogrel for secondary stroke prevention.