Dural Metastasis without Subdural Hematoma or Subdural Fluid Collection in a Patient with Signet Ring Cell Gastric Adenocarcinoma

Patient: Female, 39-year-old Final Diagnosis: Dural metastasis in signet ring cell gastric adenocarcinoma Symptoms: Confusion • generalized seizure • headache Medication: — Clinical Procedure: — Specialty: General and Internal Medicine • Oncology OBJECTIVE: Unusual clinical course BACKGROUND: Signet ring cell (SRC) gastric adenocarcinoma is an aggressive histotype associated with poor prognosis, especially in advanced gastric cancer. Dural metastasis is rarely described in the literature, and clinical manifestations are generally related to subdural hematoma. Here we present a case of advanced SRC gastric cancer with dural neoplastic involvement in the absence of subdural hematoma or subdural fluid collection. CASE REPORT: A 39-year-old woman presented with multiple episodes of confusion and headache. She had a history of SRC gastric adenocarcinoma that had been treated with neoadjuvant chemotherapy and total gastrectomy without evidence of disease relapse at follow-up. During hospitalization, she experienced persistent drowsiness and frequent generalized seizures that were nonresponsive to antiepileptic drugs. Brain computed tomography showed a dural right parafalcine nodular lesion suggestive of metastasis, and an SRC presence was detected in a cerebrospinal fluid sample. Cerebral magnetic resonance imaging showed isolated diffuse dural neoplastic involvement without evidence of subdural hematoma or subdural fluid collection. We considered palliative treatment with intrathecal chemotherapy, but it was not carried out because of clinical worsening and subsequent death. CONCLUSIONS: In the very few case reports in the literature, dural metastasis in advanced gastric cancer is mainly associated with subdural hematoma. In our case, the absence of any subdural effusion, which is an even rarer condition, along with an unusual clinical presentation dominated by generalized seizures represented a diagnostic challenge. Given the aggressive course of the disease, a rapid diagnosis could allow a faster specific treatment to relieve a patient’s symptoms.