Abstract
We report a case of a 72-year-old male who presented to the hospital with a chief complaint of diplopia in the setting of a recent onset of urinary incontinence and right-sided back pain. He was subsequently diagnosed with prostate cancer, notably metastasizing to the right sphenoid bone, causing impingement of the oculomotor nerve. Our case is unique in that the patient's initial presentation of prostate cancer was oculomotor nerve palsy with subsequent histologic analysis of the primary tumor showing both small cell neuroendocrine carcinoma along with adenocarcinoma. Also, the initial routine stroke protocol MRI and computed tomography angiography (CTA) missed the lesion, while gadolinium-enhanced targeted MRI revealed lesions in both the spine and the orbit. This case emphasizes the need for enhanced contrast as well as focused imaging in patients presenting with diplopia with a negative initial workup for stroke. Ptosis can be a sign of metastasis from other cancers and it is important to have a broad differential including metastatic disease in patients' presenting with similar symptoms and negative initial workup who may otherwise be at risk of cancer.