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Small cell lung cancer (SCLC) is predominantly seen in smokers and is neuroendocrine tumor that comprises about 15 percent of all lung cancers. Usually present as metastatic disease on initial presentation. Brain is a common metastatic site. We present a unique presentation of small cell lung cancer presenting as hemorrhagic cystic brain lesions. CASE PRESENTATION: 62 years old male heavy smoker presented to the ER for the complains of recurrent falls, headaches and general weakness. Patient and family states he has multiple falls in last few days and also fell in primary care office and was sent to ER. No trauma history or head injury with the falls. Patient also complains of headaches and losing weight. He has lost several pounds over few weeks. Headaches were defined as generalized constant headaches. On arrival his vitals were stable. No significant findings of physical exam. His CT brain showed thick walled large cystic lesion in the right frontal lobe, left temporal lobe Posterior fossa and left cerebellar hemisphere concerning for metastatic lesions. He had MRI done which showed multiple enhancing cystic lesions with hemorrhagic components. He underwent further work up with CT chest/abdomen and pelvis. CT chest showed mediastinal lymphadenopathy but no other significant findings, CT abdomen and pelvis were negative. He underwent Bronchoscopy with EBUS with biopsy of lymph nodes. Pathology results showed poorly differentiated cancer most consistent with small cell lung cancer.

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