{
  "abstract": "A man in his 50s presented with a 2-week history of progressively worsening headache, dizziness and unsteadiness. Asymptomatic bradycardia (30–50 bpm), intermittent sinus arrest and elevated systolic blood pressure were observed. Aside from these abnormal vital signs, physical and neurological examinations were unremarkable, and brain CT revealed no abnormalities. Within 1 month of symptom onset, the patient developed confusion, which gradually progressed. Cardiac evaluation undertaken during the work-up for the patient’s confusion revealed no abnormalities other than the previously observed heart rate variations. Brain MRI demonstrated multiple sulcal hyperintensities (SHI) on fluid-attenuated inversion recovery (FLAIR) ( figure 1a, b) in the absence of signal changes in diffusion-weighted imaging, initially raising concern for subarachnoid haemorrhage. No signal changes were observed in the brain parenchyma adjacent to the SHI. Emergent cerebral angiography revealed no evidence of intracranial aneurysms and ruled out subarachnoid hemorrhage (SAH). Lumbar puncture showed elevated opening pressure (>300 mm H₂O) with mild pleocytosis. Infectious work-up, including testing for tuberculosis, yielded unremarkable results. Additionally, autoimmune screening, including for IgG4-related disease, revealed no significant findings. Abnormal pachymeningeal contrast enhancement was later detected on gadolinium-enhanced MRI (figure 1c). Elevated cerebrospinal fluid (CSF) carcinoembryonic antigen levels were subsequently identified, and CSF cytology suggested signet ring cell carcinoma. Ultimately, whole-body contrast-enhanced CT and comprehensive gastrointestinal endoscopy confirmed leptomeningeal carcinomatosis of unknown origin. After lumbar puncture and glycerol administration, the patient’s blood pressure and bradycardia showed mild improvement, and he regained consciousness and was able to communicate. His headache also decreased in intensity but persisted as a residual symptom.",
  "authors": [
    {
      "affiliations": [
        "Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan"
      ],
      "name": "Miharuka Yokosaki"
    },
    {
      "affiliations": [
        "Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan",
        "Epilepsy Center, Hiroshima University Hospital, Hiroshima, Japan"
      ],
      "name": "Shuichiro Neshige"
    },
    {
      "affiliations": [
        "Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan",
        "Epilepsy Center, Hiroshima University Hospital, Hiroshima, Japan"
      ],
      "name": "Hirofumi Maruyama"
    }
  ],
  "title": "Leptomeningeal carcinomatosis presenting with multiple sulcal FLAIR hyperintensities and incomplete Cushing’s triad",
  "uid": "0b901b6c-d6df-5811-b75c-f89f3eeb885b"
}