A man in his mid-40s presented to hospital with confusion, headache and feeling generally unwell. He had had a total resection of a grade IV astrocytic glioma 1 year prior. Initial observations, blood tests and CT head scan were unremarkable for acute features to explain the patient’s presentation. However, an MRI head scan on this admission demonstrated a clear communicating hydrocephalus with new abnormal leptomeningeal enhancement, consistent with leptomeningeal metastatic infiltration by glioma. Lumbar puncture cytology and biochemistry supported this interpretation. As a small district general hospital in rural Wales, we discuss the experience of diagnosis and coordination of specialist input from a multidisciplinary team. We share the challenges of managing leptomeningeal disease in the COVID-19 pandemic, in the context of the additional risks this presents with chemotherapy-induced immunosuppression.