Thrombocytosis is frequently encountered as an incidental laboratory finding since isolated thrombocytosis is often asymptomatic. Even though thrombocytosis is benign and self-limiting in most cases, it can at times result in thrombosis or hemorrhage. The most common type of thrombocytosis is reactive (secondary) thrombocytosis and can be due to infections, trauma, surgery, or occult malignancy. Since thrombocytosis is a known risk factor for thrombosis, it is commonly a concern for ischemic stroke and myocardial infarction. Much less common are hemorrhagic events associated with thrombocytosis. Studies have shown that when hemorrhage is present in patients with thrombocytosis, it is most often seen in the setting of chronic myelogenous leukemia and essential thrombocythemia. In essential thrombocythemia, the overall risk of bleeding and thrombosis is 0.33% per patient-year and 6.6% per patient-year, respectively. In the general population, the risk of bleeding and thrombosis is 0% and 1.2%, respectively. The present study is a case report of an 83-year-old man who presented to the emergency department with hypertension and headache, who was then found to have significant thrombocytosis (platelets >1,000×10(9)/L) and acute right intraventricular hemorrhage without any signs of neurological deficits, or evidence of vascular malformations or mass. We present this case report for review and discussion of some of the challenges and considerations associated with the management of such patients.