Invited commentary

Abstract

In this randomized prospective trial, Dr Angiletta and colleagues have shown that perioperative Dexamethasone (DEX) administration reduces the incidence of clinically apparent, temporary, carotid endarterectomy (CEA) associated cranial nerve (CN) dysfunction from 5.7% to 2.3% (P = .009). This benefit was achieved with no adverse effects attributable to the steroid. Interestingly, DEX administration had no effect on the incidence of permanent CN dysfunction in this study. The authors'conclusion that temporary CN dysfunction is often related to operative trauma induced perineural inflammation, which is mitigated by DEX treatment, is both novel and plausible. That DEX administration has no effect on the incidence of permanent CN dysfunction suggests that such injuries are the result of direct nerve trauma (transection or crush) not ameliorated by steroid pre-treatment. Two questions regarding the role of steroids in cranial nerve dysfunction remain unanswered by this study. First, in formulating their hypothesis and experimental design, the authors were influenced by the previously well-described beneficial effects of steroids in spinal cord injury patients. Their conviction that steroids were likely to be beneficial led the authors to a study design mandating postoperative steroid administration to all patients who showed signs of postoperative CN dysfunction. Since all patients with postoperative CN dysfunction were treated with steroids, the influence of postoperative steroids on recovery rate or in converting potentially permanent dysfunction to temporary dysfunction cannot be determined. Perhaps a better design would have included a secondary randomization of those with postoperative CN dysfunction to either no additional treatment or a 1-week course of DEX. Alternatively, the authors might now initiate a follow-up study testing the effects of postoperative DEX on recovery in patients with post-CEA CN dysfunction. However, given the low incidence of CEA-associated CN dysfunction, the number of subjects required to achieve a statistically robust study would be prohibitive in a single institution study. Second, the optimal dose and dosing regimen cannot be determined from this study. It is possible that a single lower pre-incisional steroid dose might be just as effective as the authors' regimen of six doses of 8 mg of DEX (1 hour prior to CEA, 6 and 12 hours post-CEA, every 12 hours on postoperative day #1, and once on the morning of postoperative day #2). This interesting and provocative study shows that the incidence of CEA-associated CN dysfunction can be markedly reduced with steroid pre-treatment with no adverse effects. Confirmatory studies elucidating the influence of postoperative steroids on the course of CN dysfunction and establishing the most practical and effective dosing regimen are now required. Dexamethasone minimizes the risk of cranial nerve injury during CEAJournal of Vascular SurgeryVol. 49Issue 1PreviewThe incidence of cranial and cervical nerve injury during carotid endarterectomy (CEA) ranges from less than 7.6% to more than 50%. Lesions are mainly due to surgical maneuvers such as traction, compression, tissue electrocoagulation, clamping, and extensive dissections. The use of dexamethasone (DEX) and its beneficial effects in spinal cord injuries have already been described. We investigated whether DEX could also be beneficial to minimize the incidence of cranial and cervical nerve injury during CEA. Full-Text PDF Open Archive