Gemistocytic astrocytoma mimicking hypertensive haemorrhage

Gemistocytic astrocytoma is a rare variant of diffuse astrocytoma, characterized by a high proportion of gemistocytic cells, which exhibit aggressive behaviour and an increased risk of malignant transformation. Its clinical and radiological presentation can be misleading, especially when it mimics other intracerebral pathologies, such as hypertensive intracerebral haemorrhage (ICH). Differentiating between a primary hemorrhagic event and a hemorrhagic tumour remains a significant diagnostic challenge. We report the case of a 56-year-old male with no prior medical history who presented with sudden-onset right-sided hemiparesis and severe speech disturbances. Initial neuroimaging revealed a deep intraparenchymal hematoma in the left internal capsule, and lenticular nucleus, strongly suggestive of a hypertensive hemorrhagic stroke. Despite intensive medical management, the patient’s condition deteriorated, prompting further imaging studies, which raised suspicion of an underlying neoplastic process. Subsequent MRI findings indicated features atypical for a purely hemorrhagic lesion, necessitating neurosurgical intervention for definitive diagnosis. The patient underwent a left fronto-temporo-parietal craniotomy, during which a tumour-like mass was encountered and completely resected. Histopathological analysis confirmed the diagnosis of gemistocytic astrocytoma. Postoperatively, the patient showed gradual neurological improvement, though residual deficits persisted. This case highlights the complexity of differentiating a gemistocytic astrocytoma from a spontaneous hypertensive haemorrhage, particularly in patients without a prior oncological history. While intracerebral haemorrhage is commonly associated with chronic hypertension, intratumoral haemorrhage remains an important differential diagnosis, especially when imaging findings suggest a mass effect, perilesional oedema, or progressive neurological deterioration despite optimal medical therapy. MRI characteristics, such as hyperintense T2-weighted and FLAIR signals, can provide critical clues, but histopathological confirmation remains the gold standard. Gemistocytic astrocytomas, though rare, should be considered in cases of unexplained intracerebral haemorrhage, particularly when imaging findings or clinical progression are atypical. This case underscores the importance of a multidisciplinary approach involving neurology, neuroradiology, and neurosurgery to ensure timely diagnosis and appropriate management. A high index of suspicion is crucial to prevent delays in the recognition and treatment of hemorrhagic brain tumours, which can significantly impact patient outcomes.