Clival metastasis from a gastrointestinal adenocarcinoma causing multiple cranial neuropathies

A 78-year-old man with a history of benign prostatic hyperplasia presented with double vision, facial pain, altered taste and headache for 7 weeks. Neurological exam was notable for palsies of the right V, VI, VII and XII cranial nerves. An expansive clival mass and multiple lesions in the vertebra were found on MRI. Radionuclide studies showed extensive tumour burden in his liver and peritoneum. His serologies showed normal carcinoembryonic antigen and carbohydrate antigen 19-9 levels and modestly elevated prostate-specific antigen, which was a red herring. Biopsy of his omentum was consistent with metastatic adenocarcinoma with immunostaining indicating an upper gastrointestinal primary tumour. The patient underwent several cycles of radiation therapy, but ultimately elected to pursue hospice care. This case demonstrates the presentation of multiple cranial neuropathies from a clival mass and an unusual primary source from an upper gastrointestinal tumour.