Asymptomatic Metastatic Renal Cell Carcinoma Presenting as Acute Intracerebral Hemorrhage in a Geriatric Patient

The complex association between acute neurological events and underlying malignancies presents significant challenges for clinicians, especially in elderly patients where manifestations can be atypical. Intracerebral hemorrhages (ICHs), commonly linked to hypertension, may obscure the presence of serious underlying conditions such as renal cell carcinoma (RCC), which can delay diagnosis and timely intervention. Although late-stage presentations are usually those accompanied by systemic symptoms, including weight loss, fatigue, and hematuria, most patients, particularly older people, present with very little until the late stages of their disease. We describe, in this report, a case of a 70-year-old man presenting as a 1-day onset unconsciousness with acute-onset hemiplegia. He showed an almost gross impairment of consciousness. He was graded as 6 according to the Glasgow Coma Scale. There was also marked hypertension in his initial evaluation. The computed tomography scan of his head showed a large ICH that corresponded with a hypertensive bleed. Due to mass effect and deteriorated neurological condition, the patient was intubated and put on mechanical ventilation. This, after stabilization, underwent emergency craniotomy with improvement postoperatively in neurological status. The histopathology examination of the evacuated clot had metastatic RCC. On imaging, abdominal studies showed a large hypervascular renal mass, no urinary symptom, and this is within consistent documentation on review with previous documentation. However, many will express that such is rare for this disease RCC, especially as aged population often presents atypically. This case puts emphasis on the need for adequate assessment and interdisciplinary management in patients presenting with acute neurological symptoms. It reminds us of the necessity for routine histopathological examination of evacuated hematomas to uncover hidden malignancies and to facilitate both neurological and oncological management strategies.