BACKGROUND Methanol can cause many acute complications when ingested, either intentionally or accidentally. One rare complication is cerebral hemorrhage, which can present with focal neurologic deficits, decreased consciousness, and fixed, dilated pupils. With vigilant monitoring of patients in the acute period of toxicity, rapid identification, and initiation of treatment, outcomes can potentially be improved in these patients. CASE REPORT We present a case of a 42-year-old man who presented after ingestion of windshield wiper fluid. Initial symptoms started with fatigue and altered mental status, but he quickly developed abdominal pain and became obtunded. CT initially showed no acute hemorrhage or other pathology, but on day 2, despite receiving fomepizole, bicarbonate, and dialysis, the patient became hypotensive and showed loss of cranial nerve reflexes, and repeated CT head scans showed acute intracranial hemorrhage with mass effect. CONCLUSIONS Although the exact mechanism of intracranial hemorrhage and necrosis following methanol intoxication remains uncertain, we know beyond doubt that it can progress rapidly and lead to severe and irreversible complications, so identifying and treating it immediately is essential. In this case, methanol ingestion was known on presentation, antidote and renal replacement therapy were initiated within hours of ingestion, yet our patient still suffered fatal brain hemorrhage. Important warning signs of acute hemorrhage include loss of cranial nerve reflexes and decrease in consciousness, so these findings warrant further evaluation and prompt neuroimaging, especially in high-risk patients like the one in this report.