To highlight the varying presentations of leptomeningeal carcinomatosis in the presence of negative imaging or other diagnostic studies.

Our patient presented with over ten instances of episodic attacks described as tonic stiffening, anisocoria, dizziness, unresponsiveness, tinnitus and falls. He was recently diagnosed with non-metastatic esophageal cancer three months prior to presentation. His workup included MRI brain with and without contrast that was significant for abnormal enhancement in the right vertebral artery and a chronic right cerebellar infarct. Lumbar puncture, including cytology, was unremarkable. He suffered one of these episodes while hospitalized and unfortunately it proved to be fatal, as he became bradycardic and suffered a cardiac arrest.

Autopsy revealed diffuse leptomeningeal neoplastic involvement of the cerebrum, cerebellum, midbrain and brainstem. There was evidence of tumor invasion into the right vertebral artery wall and cranial nerves V, VII, VIII, IX, X, and XII, as well as multiple levels of autonomic ganglia and dorsal root ganglia. Histology was consistent with metastatic esophageal carcinoma. 

The etiology of his episodes was thought to be multifactorial, with transient episodes of increased intracranial pressure secondary to diffuse leptomeningeal involvement and direct invasion of tumor, leading to similar pathophysiology as an otolithic crisis.

Leptomeningeal carcinomatosis should be on the differential diagnosis for any patient with a history of cancer presenting with neurological deficits.