Problem Epistaxis is a common symptom among middle aged and old aged population especially when they suffer from hypertension or on antiplatelet therapy for coronary artery disease. When such patient present with epistaxis, it is customary to attribute their bleeding to their comorbidity. Clival tumors are extremely rare in the spectrum of skull base tumors. Metastasis into the Clivus is even rarer. Clival metastasis can occur from a variety of primaries and can sometimes occur in a setting of an occult primary. In such cases, their detection would exclusively depend on the symptoms at the clival region. Method Case report. Case We report of a middle-aged male with a known history of cardiac disease who presented with epistaxis. His epistaxis was initially attributed to the use of antiplatelet therapy. However, due to persistent symptoms radiology was done which revealed a clival lesion. A transsphenoidal biopsy was taken which came out to be metastatic adenocarcinoma. Conclusion We discuss this case due to its atypical presentation, the technique of transsphenoidal biopsy and review of the literature. Highlights ? Metastasis to clivus is rare and clival metastasis presenting as epistaxis is even rarer. ? In the absence of evident primary tumor, the initial diagnosis of clival metastasis becomes almost impossible. ? Trans sphenoidal clival biopsy will have to be done to confirm the diagnosis. ? The present case presents the difficulties and challenges while facing a case of clival metastasis with occult primary.
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