Sixth Cranial Nerve Palsy and Craniocervical Junction Instability due to Metastatic Urothelial Bladder Carcinoma

Abstract

Metastases involving the clivus and craniocervical junction (CCJ) are extremely rare. Skull base involvement can result in cranial nerve palsies, while an extensive CCJ involvement can lead to spinal instability. We describe an unusual case of clival and CCJ metastases presenting with VI cranial nerve palsy and neck pain secondary to CCJ instability from metastatic bladder urothelial carcinoma. The patient was first treated with an endoscopic endonasal approach to the clivus for decompression of the VI cranial nerve and then with occipitocervical fixation and fusion to treat CCJ instability. At the 6-month follow-up, the patient experienced complete recovery of VI cranial nerve palsy. To the best of our knowledge, the simultaneous involvement of the clivus and the CCJ due to metastatic bladder carcinoma has never been reported in the literature. Another peculiarity of this case was the presence of both VI cranial nerve deficit and spinal instability. For this reason, the choice of treatment and timing were challenging. In fact, in case of no neurological deficit and spinal stability, palliative chemo- and radiotherapy are usually indicated. In our patient, the presence of progressive diplopia due to VI cranial nerve palsy required an emergent surgical decompression. In this scenario, the extended endoscopic endonasal approach was chosen as a minimally invasive approach to decompress the VI cranial nerve. Posterior occipitocervical stabilization is highly effective in avoiding patient’s neck pain and spinal instability, representing the approach of choice.

Bladder Carcinoma With Solitary Skull Metastasis: A Rare Presentation in a Middle-Aged Female

“…The cancer can also spread to distant sites via the vertebral venous system, bypassing the major caval system [7].…”

Solitary Calvarial Metastasis As the First Presentation of Urothelial Bladder Cancer

“…Ogunyemi et al reported the case of a 62-year-old patient with metastases of transitional cell carcinoma of the bladder to the sphenoid and cavernous sinus [4]. Nasi et al presented the case of a 70-year-old man with metastases of urothelial carcinoma to the clivus and craniocervical junction [6]. Saldanha et al reported the case of an 80-year-old man with metastases of anaplastic carcinoma of the bladder to the left petrous temporal bone [7].…”

“…Bladder cancer typically spreads to the bone hematogenously. Hematogenous spread of bladder cancer can result from tumor infiltration into the vesical or prostatic venous plexuses and can bypass the major caval system to cause distant metastasis through the vertebral venous system [6].…”