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Coronavirus disease 2019 (COVID-19) is a novel infection of which we still have much to learn. Microvascular and macrovascular complications are increasingly recognised as being among the drivers of morbidity and mortality in patients with this condition. Here we present a case of a woman with COVID-19 who suffered massive and bilateral middle cerebral artery strokes, which presented as reduced consciousness several days into admission. Clinicians need to be aware of possible causes of reduced consciousness in COVID-19 patients, particularly as delirium appears to be a common complication, and revisit working diagnoses if the clinical picture does not fully fit. Studies into both anticoagulation and the management of stroke in the context of COVID-19 are urgently needed to help inform future practice., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

A 72-year-old man was brought to the emergency department with acute onset confusion and haemoptysis. Chest X-ray showed a possible lung mass, while CT head showed a fluid-filled, space-occupying lesion (SOL) in the right frontal lobe of the brain. MRI head indicated that this SOL had spilt its contents into the subarachnoid and intraventricular spaces. Due to a fluctuating Glasgow Coma Scale (GCS), the patient underwent emergency debulking. Macroscopically, a frail-walled cystic tumour filled with straw-coloured fluid was noted; histology confirmed metastasis from a primary lung adenocarcinoma. Whole brain radiotherapy was given, with a view to commence systemic therapy. The patient, however, deteriorated and unfortunately passed away a few weeks after completing radiotherapy. This patient presented with leptomeningeal metastasis as the first presentation of a lung adenocarcinoma, and had a highly unusual mechanism by which leptomeningeal spread had occurred, with metastatic brain tumour spilling its contents into the meningeal spaces., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)