In September 2008, a 43-year-old woman presented to the Emergency Department at Frenchay Hospital with a 3-month history of back pain, right hip and knee pain, right leg weakness, constipation and urine incontinence, altered sensation in the limbs, and visual disturbance with flashing lights in the left eye. Two weeks prior to this admission she was seen at Frenchay Hospital with cauda equina symptoms. She has had an MRI of the spine, which showed a disc prolapse but did not explain the symptoms. The patient was discharged. However, her pain continued to worsen, and sensation changes progressed across the whole of the perianal region. She was unable to sit down for 8 weeks due to pain on flexion and started using a stick as her right leg was weak. On examination she had a decreased sensation in the perianal area. Neurological examination of the upper limbs revealed a slight numbness of the radial side of the forearm. Neurological examination of the lower limbs revealed the following: reduced power in the right hip flexion (1/5) and extension (2/5), the power in the left leg was 4/5, absent reflexes in both legs, reduced sensation in the right medial aspect of the distal right calf dorsum of the foot sole and the lateral dorsum of the left foot and the sole of the left foot. On examination of her visual fields, she demonstrated a loss of outer vision in her left eye. CT and MRI of the head showed metastases in the right parietal occipital region, together with some smaller metastases associated with the dura and skull base. MRI of the spine revealed fairly diffuse infiltrating nodules in the nerve roots of the lumbosacral plexus. Her performance status was 3 due to progressive leg weakness. The diagnosis was meningeal carcinomatosis with brain metastasis from breast cancer. No other signs of metastatic breast cancer were seen on CT at this point. A year prior to presentation, she had been diagnosed with 4 × 3 cm grade 3 triple-negative invasive ductal carcinoma treated with 6 cycles of neoadjuvant TAC chemotherapy followed by wide local excision and axillary node clearance. None of the 10 lymph nodes showed viable cancer. She had also completed radiotherapy to her left breast in May 2008. The patient was transferred to our centre and started on inpatient IT methotrexate 12.5 mg with oral capecitabine. The first 4 cycles of IT methotrexate were administered twice weekly due to deteriorating symptoms, as her left leg become weak as well. Her vision improved after 1 cycle of treatment. Other neurological symptoms improved after 3 cycles. From that point on she received weekly IT methotrexate. The 6th cycle was delayed by a week due to urosepsis and opioid toxicity. Cerebrospinal fluid was sent for analysis by cytospin before each IT treatment. She was discharged on capecitabine (1 week on and 1 week off at a 75% dose) before cycle 7 of IT methotrexate. A further cycle of IT methotrexate was not given as she was readmitted with pyrexia and pain in her lower abdomen, perianal area, and shouting/burning pains down the leg. She did not require any antibiotics, and the pain was controlled with analgesia. Her symptoms improved and she received cycle 8 of IT methotrexate as inpatient. In total, she received 8 cycles of IT methotrexate, and her neurological symptoms have improved. Malignant cells were still present in the cerebrospinal fluid. MRI of the head and spine after IT chemotherapy combined with capecitabine showed good response to therapy with disappearance of some of the smaller metastatic lesions and a significant reduction in the size of the larger lesions in the brain, but the spine lesions within the theca were more prominent, suggesting progressive disease. She was referred for craniospinal radiotherapy and started 10 days after her last IT treatment. She received 36 Gy in 20 fractions over 4 weeks. MRI of the head/spine after radiotherapy showed significant improvement in the appearances of both intracerebral and ependymal metastases. In April 2009, MRI of the head showed further involution of cerebral metastases. The posterior fossa and right frontal metastases were essentially invisible, while the right occipital metastases in the lobe showed further involution. There was no convincing focal meningeal mass. She was treated with carboplatin 6 months after completion of craniospinal radiotherapy to prevent recurrence of meningeal disease. She completed 4 cycles of carboplatin between 21/05/2009 and 10/09/2009. In 2011, she had recurrent solitary right occipital metastasis, which was treated with stereotactic radiotherapy. In 2012, MRI showed increasing occipital abnormality with oedema, which was surgically excised and proved to be radiation necrosis only, with no viable tumour. In 2013, MRI showed no new disease, only post-surgical changes. It has been 8 years since she first presented with neurological symptoms. Currently, the patient is in complete clinical and radiological remission and has recently been discharged from our clinic.