To report a case of hemorrhagic metastatic melanoma presenting as hypertensive intracerebral hemorrhage (ICH) in a patient with a history of cutaneous melanoma, presumably in remission, whose clinical deterioration markedly preceded imaging findings.

Fulminant cerebral edema secondary to occult metastatic disease is rare and can result in catastrophic neurological decline despite minimal radiographic progression.

A 53-year-old man with hypertension and a remote history of cutaneous melanoma of the posterior neck (diagnosed 2 years prior and treated with wide-margin excision and adjuvant immunotherapy) presented with acute onset headache, nausea and vomiting. He was hypertensive with an initial blood pressure of 191/122 mmHg. CT head revealed a right parieto-occipital ICH with mild intraventricular extension. MRI brain with contrast showed a 1.3 cm nodular enhancing focus within the ICH. CT chest/abdomen/pelvis demonstrated multiple pulmonary nodules. Patient was admitted to the ICU for close monitoring and blood pressure management. He was transferred to the inpatient floor on day 3 of admission. Within 24 hours, he developed ipsilateral pupillary dilation, bilateral leg weakness, and altered mental status requiring intubation and mechanical ventilation. Within an hour, he rapidly lost all brainstem reflexes. CT revealed only modest hemorrhage progression and minimal ventricular enlargement. EEG revealed diffuse background suppression. Despite rapid hyperosmolar therapy, steroids, and ventilatory management, he progressed to brain death. Autopsy revealed metastatic melanoma in the right parieto-occipital lobe with subarachnoid and intraventricular hemorrhage, marked cerebral edema with transtentorial herniation, diffuse hypoxic-ischemic injury, and leptomeningeal involvement consistent with meningeal carcinomatosis.

Fulminant cerebral edema from occult metastatic melanoma can cause rapid neurological decline outpacing radiologic progression. This delay in imaging findings can pose a challenge to prompt treatment. In atypical hemorrhagic strokes, particularly in patients with a remote history of malignancy, the possibility of underlying tumor and fulminant cerebral edema should be considered early.