A 50-year-old woman presented with a 2-month history of Lhermitte sign, progressive gait and limb ataxia, weakness, and urinary hesitancy. Seven years ago, she had squamous cell tongue carcinoma that was treated with a partial resection and radiotherapy, which resulted in complete remission. A physical examination revealed pyramidal weakness, hypertonia, and hyperreflexia in the upper and lower extremities. Magnetic resonance imaging of the spine revealed a contrast-enhancing, cervical spinal cord hyperintensity (Figure 1A and B). Magnetic resonance imaging scans of the brain at that time were unremarkable (Figure 2A and B). Despite short-lived transient improvement of symptoms with high-dose steroid therapy, administered for possible transverse myelitis, the patient's neurological condition continued to deteriorate. Five months later, magnetic resonance imaging revealed enlargement of the cervical cord lesion (Figure 1C and D) and new, extensive, contrast-enhancing periventricular hyperintensity (Figure 2C and D). A biopsy of the periventricular region revealed a high-grade anaplastic astrocytoma, consistent with a primary intramedullary spinal cord astrocytoma with brain metastases. The patient's condition continued to deteriorate, and eventually she succumbed to respiratory compromise.