We report a case of  a 34-year-old female with a history of metastatic ovarian cancer on chemotherapy with FOLFOX who presented with of altered mental status (AMS) and seizures. Levetiracetam was initiated and she was admitted to the hospital. Patient notably had intermittent dilated non-reactive left pupil. MRI brain did not reveal any acute pathology or abnormal enhancement. Lumbar puncture (LP) was done and showed an elevated ICP >55 cm H2O, normal protein and significantly low glucose (18 mg/dl). CSF analysis was negative for infectious workup and was positive for cytology with concern for metastatic adenocarcinoma. She had an external ventricular drain placed and had fluctuating ICPs. Her hospital course was complicated with worsening mental status and electrographic seizures for which lacosamide and phenytoin were introduced. She had ventriculo-peritoneal (VP) shunt placement due to fluctuating ICPs. She continued to have worsening mental status and decline in respiratory status. She was eventually made comfort care and deceased.

A mismatch in clinical and radiological picture was seen in this patient who had objective evidence of raised ICP with AMS and pupillary abnormalities however normal neuro imaging.

There should be a high suspicion of raised ICP secondary to LC in a patient with malignancy and focal neurological deficits even with normal neuro imaging. Caution should be maintained with LP as this can lead to herniation.