19th July 2023

A 67-year-old woman presents with left-sided weakness which has been present for the last 7 hours.

A 67-year-old woman presents with left-sided weakness which has been present for the last 7 hours. On examination, you note a dense left-sided hemiparesis and a palpable mass in the left upper quadrant of the abdomen. She doesn’t like going to the doctor and has no formal diagnoses in her past medical history. She does tell you that she often feels very itchy and this is worse after she’s had a bath.

Blood results:

• Haemoglobin 193g/l (115-165g/l)
• Haematocrit 0.58 l/l (0.37-0.47l/l)
• Mean cell volume 77fl (80-100fl)
• White cell count 12.3 x 10⁹/l (3.6-11.0 x 10⁹/l)
• A CT head confirms a right-sided ischaemic stroke.

What is the most likely cause?

Select the SINGLE most appropriate option from the list below. Select ONE option only.