A case of spontaneous intracerebral haemorrhage (midbrain and thalamic, with intraventricular extension) as the first presentation of an anaplastic astrocytoma is presented. Multiple CT scans and cerebral angiography failed to identify any vascular or neoplastic cause for the haemorrhage, and a presumptive diagnosis of hypertensive haemorrhage was made. Shunting of hydrocephalus was followed by early clinical improvement. However, delayed progressive deterioration necessitated MRI scan, which demonstrated a mass lesion in the basal ganglia and midbrain. This was subsequently found to be anaplastic astrocytoma on biopsy. The literature regarding this uncommon presentation of spontaneous intracerebral haemorrhage from an occult brain tumour is reviewed. The need for investigation and close follow-up of presumed hypertensive haemorrhage is emphasised by this case.