A patient developed dysarthria and was found to have fibrous dysplasia of the clivus accompanied by cranial nerve impingement, particularly the hypoglossal canal. The dysarthria progressed to more severe bulbar dysfunction and a subsequent diagnosis of amyotrophic lateral sclerosis. This case highlights a discussion of the potential influences of focal lesions on the site of symptom onset in this neurodegenerative disease.A 41-year-old right-handed man presented with dysarthria, dysphagia, and weight loss. Examination initially showed mild tongue atrophy with fasciculations and dysarthria but no significant limb weakness or upper motor neuron findings. The patient underwent magnetic resonance imaging (MRI) of the brain that revealed a mass in the clivus with potential impingement on cranial nerves IX-XII ( Figure 1). Biopsy of this mass was consistent with fibrous dysplasia without evidence of malignancy, and resection was not performed. Over the next year, he developed slowly progressing dysarthria and dysphagia accompanied by dyspnea with mild exertion. This was followed by right upper limb weakness. He never developed diplopia, sensory symptoms, or bowel or bladder incontinence. His family history was notable for a maternal first cousin who died at 50 years of age from amyotrophic lateral sclerosis (ALS) with an initial presentation of difficulty with ambulation. Neither of the patient's parents had similar symptoms.Neurological examination 1 year after the onset of symptoms showed an intact mental status. His speech was profoundly dysarthric, but his language was fluent. Cranial nerve exam was notable for bifacial weakness. His tongue was atrophic with fasciculations bilaterally. Motor examination showed weakness of neck flexion and asymmetric weakness in the upper limbs. Specifically, MRC grade for neck flexion strength was 4; deltoids were 4+ right and 5 left; biceps were 4+ bilaterally; triceps were 4 right and 4+ left; wrist extensors were 4 bilaterally; intrinsic muscles of the hand were 5 on the right and 5 on the left; thumb flexion was 4 bilaterally; hip flexion was 5 bilaterally; leg extension was 5 bilaterally; foot dorsiflexion and plantar flexion were 5 bilaterally. Deep tendon reflexes: jaw jerk was slightly increased. Biceps reflexes were 3 bilaterally; triceps were 2 bilaterally; patellar reflexes were 3 bilaterally. He had crossed adductors. Ankle jerk reflexes were 2 bilaterally. His plantar response was flexor. He had reduced tone in the upper limbs. This was accompanied by atrophy of both upper limbs, most notably in deltoid muscles. He had fasciculations in the cervical paraspinous muscles, trapezius, multiple muscles in the arms, and the quadriceps muscles bilaterally. Sensory examination was intact. Coordination was intact to finger-nosefinger and heel-to-shin testing. He did not have a Romberg sign, and gait exam demonstrated normal toe-heel and tandem gait.Laboratory analysis consisted of a normal cerebrospinal fluid analysis. Cervical spine MRI demonstrated mild cervical spondylosis. ...