This case reports a rare occurrence of urothelial carcinoma (UC) brain metastasis, emphasizing vigilance when neurological symptoms manifest in UC patients.

Urothelial carcinomas (UC) are the sixth-most common type of malignancy in developed countries, composed of bladder cancers (90-95%) and upper tract urothelial carcinomas (UTUC)(5-10%). UTUC have a peak incidence in individuals aged 70-90 years old, and are twice as common among men. Although UC can metastasize to any organ, the most common metastatic sites include lymph nodes, liver, lung, bone, and peritoneum. There are 98,000-170,000 cases of brain metastases each year, but brain metastases with a urothelial origin are a particularly rare occurrence, especially in the absence of other metastatic sites. Single lesions are more common than multiple metastases in UC patients with brain involvement. The most common locations for brain metastases are the frontal lobe, followed by the temporal and parietal lobes. While cases of UC metastases to the brain are rare, the prognosis is poor.

A 76-year-old female with a history of localized UTUC who completed 2 cycles of neoadjuvant ddMVAC followed by left nephroureterectomy, with final pathology ypT3N0. Three years later she presented with aphasia and right-sided weakness. Imaging revealed the presence of multiple metastatic lesions in the left frontal subcortical white matter. A brain biopsy confirmed the metastatic carcinoma, staining results were positive for GATA-3, p63 and p40, compatible with patient's known history of urothelial primary. The initial treatment plan was to perform outpatient gamma-knife procedure; however, patient suffered a basilar occlusion and underwent thrombectomy with partial re-perfusion. Due to clinical deterioration patient was transitioned to hospice.

This case emphasizes the importance of considering distant brain metastasis from urothelial carcinoma in patients with neurological symptoms and UC history. Despite its rarity, early identification and treatment are crucial due to the uniformly poor prognosis.