Cranial nerve injury is associated with dual antiplatelet therapy use and cervical hematoma after carotid endarterectomy

Abstract

To determine predictors of cranial nerve injury (CNI) after carotid endarterectomy (CEA). Consecutive CEAs performed over a 5-year period were enrolled in this study. Outcomes analyzed included 30-day major adverse event rate (composite of stroke, death, and myocardial infarction), death, stroke, disabling stroke, myocardial infarction, cervical hematoma and CNI rate, reoperation, and hospital readmission at 30days. There were 1258 CEAs were included in the study, 1168 (93%) were performed using an eversion technique. Patients with symptoms comprised 27% of the cohort (n= 340). At 30days, there were no deaths, 23 major adverse events (1.8%), 11 strokes (0.9%: nine minor, two major), 12 myocardial infarctions (0.9%), 41 cervical hematomas (3.3%), 9reoperations (0.7%) and 10 hospital readmissions (0.8%). Median duration of stay was 1day (interquartile range, 1-2days). CNI rate at discharge was 2.3% (n= 29). Two patients (9%) had more than one cranial nerve affected. The marginal mandibular branch of the facial nerve was most frequently involved (n= 16; 52%), followed by the hypoglossal (n= 9; 29%), the vagus (n= 4; 13%), and the spinal accessory nerve (n= 2; 6%). Horner's syndrome, consistent with an injury to the cervical sympathetic chain, occurred in 13 patients (1%) who had a true cranial nerve affected as well. The vast majority (94%) of these CNIs and all Horner's syndrome neurapraxias were transient; only the two accessory lesions persisted at their follow-up visit (median, 32months; range, 8-72 months). Significant predictors for CNI included diabetes (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.0-6.2; P= .048), cervical hematoma (OR, 41.7; 95% CI, 13.8-125.4; P< .001), and dual antiplatelet therapy (OR, 4.4; 95% CI, 1.7-11.4; P=.002). CNI is predominantly a transient complication, but is associated significantly with dual antiplatelet therapy use and the occurrence of a postoperative cervical hematoma. Scrupulous attention to hemostasis might reduce the incidence of CNI.