Multiple cranial nerve palsies due to perineural invasion.

A 69-year-old man presented with a recent history of painless diplopia and left eye conjunctival injection. He had a cutaneous adenosquamous carcinoma removed from the left forehead 3 years before. The examination showed complete left ophthalmoplegia, exophthalmos, ptosis, and ipsilateral V1 hypoesthesia. Brain MRI revealed thickening and contrast enhancement of the external wall of the left cavernous sinus (figure 1). Because of skin cancer history, biopsy specimens of the previously resected tumor were reassessed, exhibiting neoplastic perineural spread (figure 2). Cavernous sinus invasion due to centripetal perineural spread from a supposedly removed skin cancer has been previously reported.1,2