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Images in Neurology |

Multiple Cranial Neuropathies Evolving Over a Decade From Occult Perineural Basal Cell Carcinoma

William A. Fletcher, MD, FRCPC; Mohammed Almekhlafi, MD, FRCPC; Roland N. Auer, MD, PhD, FRCPC
Arch Neurol. 2012;69(1):134-135. doi:10.1001/archneurol.2011.1064.
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A 69-year-old man was referred with a 3-month history of diplopia and left ptosis. During the previous 7 years, he had progressive loss of left trigeminal and facial nerve function, initially affecting the upper trigeminal branches and culminating in complete hemifacial anesthesia and paralysis. No cause had been found despite repeated neurological assessments and 3 magnetic resonance imaging scans. Neuro-ophthalmological examination showed a new left oculomotor nerve palsy. He denied prior health issues but specific questioning about skin cancer prompted review of pathological records, which revealed that a basal cell carcinoma had been excised from his forehead 4 years before the onset of neurological symptoms.

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Figure 1. T1-weighted magnetic resonance images with gadolinium. Coronal views show thickening and enhancement of the left ophthalmic (arrowhead) and maxillary (white arrow) nerves and wasting of the masseter and pterygoid muscles (black arrows) (A) as well as thickening of the left mandibular nerve (arrow) (B). Axial views show enhancement of the left facial nerve (arrows) in its tympanic (C) and mastoid (D) segments.

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Figure 2. Skin biopsy and mandibular nerve biopsy specimens. A, The original skin biopsy shows invasive basal cell carcinoma (hematoxylin-eosin; scale bar indicates 2000 μm). B, Carcinoma cells outline and infiltrate nerve fascicles (hematoxylin-eosin; scale bar indicates 300 μm). C, Higher magnification shows perineural invasion by individual tumor cells (hematoxylin-eosin; scale bar indicates 50 μm). D, Immunocytochemistry (Ki67 staining) shows perineural single-file distribution (scale bar indicates 200 μm).

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