Incidence Of Cranial Nerve Injury Research Articles

Traumatic Cranial Nerve Injuries – An Institutional Experience

IntroductionRoad Traffic accidents (RTA) in India are the sixth among the leading cause of death. The cranial nerves serve several essential functions. Loss of these functions can adversely affect the quality of life. This study was conducted to assess the incidence of Cranial Nerve Injury (CNI), radiological and clinical patterns and to ascertain the significant and often debilitating effect of CNI in otherwise non-life threatening Traumatic Brain Injuries. MethodologyThis prospective study was conducted in the Department of Neurosurgery, SRIHER between April 2019 and September 2021. A total of 62 patients among the 402 patients with TBI had CNI. Patients with GCS <9 were excluded from the study. ResultsThree fourth of the patients belonged to the 21–50 age group (n = 301) and 78 % of the study population were men (n = 313). Patients with cranial nerve injuries, ear bleed and nasal bleed occurred in a higher proportion compared to patients without CNI −58 %(n = 36) vs 15 %(n = 60). Forty Two of the 62 patients with CNI had an associated skull base fracture, the incidence of which was considerably high compared to those without CNI (68 % vs 23 %). The average GOS for patients with TBI and CNI was worse than for those with TBI without CNI in our study group (2.64 vs 1.43). ConclusionPatients with TBI with CNI often tend to be younger and have a poor outcome. Early identification with aggressive neuro-rehabilitation may improve the outcome.

Examining the Incidence of Cranial Nerve Injuries in Patients with Mild Traumatic Brain Injury at a Tertiary Healthcare Centre

Examining the Incidence of Cranial Nerve Injuries in Patients with Mild Traumatic Brain Injury at a Tertiary Healthcare Centre

Role of mini access during carotid endarterectomy: a prospective observational study.

Data from literature confirmed the non-trivial risk associated with carotid revascularization. The purpose of this study is to evaluate carotid endarterectomy (CEA) via a mini-invasive access (3-6 cm longitudinal) incision as a viable alternative to the traditional access via a cutaneous incision (˃6 cm) in terms of nerve sparing and neck pain/disability for patients. We performed a prospective, observational, cohort study on 796 consecutive patients who underwent CEAs. A number of 730 patients was included in the final analysis. Patients entered in two different cohorts: CEA with 3-6 cm incision was performed in N.=398 (Group A); CEA with>6 cm incision was performed in N.=398 (Group B). Entire data set is available from 382 in group A and 348 in group B. Adverse events were recorded at 30 days, 3 and 6 months after surgery. The primary purpose of this study was to identify the incidence of cranial nerve injuries and related pain (by Northwick Park Neck Pain Questionnaire [NPq]) in both groups. Differences between groups were exploratory, only, and considered significative for P≤0.05. Secondary objectives were: death, major and minor stroke, transient ischemic attack (TIA), myocardial infarction (MI) and main duration of operation. The cumulative incidence of transient deficit of peripheral nerve in group A was 1.7% at 30 days and 19.4% in group B (RR: 0.10, 95% CI 0.07-0.1, P=0.0001) suggesting a possible benefit from mini-skin incision on nerve injuries reduction. Cranial nerve permanent injuries were identified in 0.17% of mini-incision group and 0.23% of standard group. Exploratory comparison did not demonstrate significative differences between the groups (RR: 0.72, 95% CI 0.19-2.71, P=0.63). The median NPq postoperative score was 40% in GROUP A and 79% in GROUP B (exploratory difference 39%, 95% CI 32.22-45.20%, P=0.0001, χ2: 114.007). At 6 months, NPq was 20% and 42%, respectively; exploratory differences were still present. The need to prolong the mini-incision in GROUP A to preserve the surgical outcome was 1.3%, only. According to these results the mini skin incision allows a sufficient vessels exposure for dissection, endarterectomy, reconstruction of carotid artery and shunt positioning, minimizing surgical invasiveness, decreasing the incidence of temporary cervical nerve dysfunction and improving the aesthetic result with significative less pain suffered by the patients. Transverse cervical and great auricular nerves sparing decreased postoperative hypo-paresthesia in the neck, improving patient's satisfaction. These data suggest that this procedure can be considered safe. Exploratory analysis suggested that it could possibly be considered a safety alternative to standard carotid endarterectomy. A randomized controlled trial is ongoing for definitive conclusions.

Artificial Intelligence-Based MRI in Diagnosis of Injury of Cranial Nerves of Premature Infant and Its Correlation with Inflammation of Placenta.

The study focused on the effects of artificial intelligence algorithms in magnetic resonance imaging (MRI) for diagnosing cranial nerve inflammation of placenta and the correlation between cranial nerve injury with placental inflammation was explored. The subjects were selected from 132 premature infants in the hospital. According to the pathological examination of placenta, 81 cases with chorioamnionitis were taken as the experimental group and 51 cases without chorioamnionitis were taken as the control group. The incidence of cranial nerve injury in different groups of premature infants was analyzed by MRI diagnosis based on the principal component analysis (PCA) artificial intelligence algorithm, so as to analyze the correlation between cranial nerve injury and placental inflammation in premature infants. It was found that when the PCA artificial intelligence algorithm was incorporated into MRI examination of cranial nerve injury of premature infant, the A (accuracy), P (precision), R (recall), and F1 values under the PCA algorithm were 92%, 93.75%, 90%, and 92.87%, respectively. The A, P, R, and F1 of the control group were 54%, 54.1%, 52%, and 53.03%, respectively; there were statistically significant differences between the two groups, P < 0.05. As for the correlation of placental inflammation and cranial nerve injury, the positive detection rate of the experimental group was 53.09%, and the positive detection rate of the control group was 15.69%, and the difference was statistically significant, P < 0.05. In conclusion, the PCA artificial intelligence algorithm has high effectiveness and high accuracy in auxiliary diagnosis of premature brain nerve injury, and placental inflammation greatly increases the chance of premature infant suffering from brain nerve injury.

The Efficacy and Safety of

Objective: Microvascular decompression (MVD) surgery has been accepted as a minimally invasive surgical modality for the treatment of hemifacial spasm (HFS). However, the size of the bone window does not match the concept of minimally invasive. This study is aimed at evaluating the efficacy and safety of <2 cm micro-keyhole MVD.Methods: A total of 148 patients with HFS diagnosed in the First Affiliated Hospital of Chongqing Medical University from January 1, 2019, to July 1, 2020, who underwent MVD in the neurosurgery department of the hospital were collected. Surgery was performed by a retrosigmoid keyhole approach with the bone hole diameter <2 cm, which was named micro-keyhole MVD. The efficacy and safety of the micro-keyhole MVD were evaluated by statistical analysis of the efficacy of the micro-keyhole MVD and the incidence of postoperative complications.Results: The effect of micro-keyhole MVD was satisfying (cure or partial remission) in 97.2% (n = 144). The failure and recurrence rates were 2.7% (n = 4) and 0.6% (n = 1), respectively. Among them, immediate facial palsy, delayed facial palsy, hearing loss, and cerebrospinal fluid (CSF) leakage were found in 0.6% (n = 1), 8.1% (n = 12), 4.7% (n = 7), and 1.3% (n = 2). Only one patient developed cerebellar infarction, which was complicated by “moyamoya disease.” The micro-keyhole MVD in the treatment of HFS can achieve a high remission rate and reduce the incidence of surgical complications.Conclusion: Micro-keyhole MVD is a safe and effective minimally invasive treatment for HFS. This technique does not increase the incidence of cranial nerve injury. Meanwhile, it reduces the incidence of CSF leakage and hearing loss (HL).

A Prospective Study on the Incidence and Outcome of Cranial Nerve Injuries in Patients with Traumatic Brain Injuries

Abstract Background Posttraumatic cranial nerve injuries are not uncommon and can occur by shearing forces, rapid acceleration/deceleration, or injury to the skull base. The incidence of cranial nerve injury in craniocerebral trauma varies between 5 and 23 percent in various literature. Methodology A prospective study was conducted on the incidence and outcome of cranial nerve injuries (CNI) in 256 consecutive cases of traumatic brain injuries (TBI). Patients over the age of 5 years with a follow-up of 6 months in the period from September 2017 to November 2018 in our institution were sampled. Results A total of 256 patients were included in our study. The incidence of CNI in TBI patients was 14.8% (38 patients). Facial nerve was the most common cranial nerve to be involved, followed by olfactory nerve and vestibulocochlear nerve. Cranial nerve injury was more common in patients with severe head injury (p &lt; 0.005), younger age group, associated base of skull fractures (p &lt; 0.001), and facial fractures (p &lt; 0.005). Twenty-eight patients (73.7%) had a delayed presentation of CNI (p &lt; 0.001). Of the 73.6% patients who recovered, 16 (42%) patients had partial recovery, while 12 (31%) patients had complete recovery. Younger age group (p &lt; 0.05) and delayed onset of deficit (p &lt; 0.001) were associated with significant better outcome. Conclusions CNI are a major cause of morbidity in TBI patients. All patients admitted with TBI should be examined meticulously for CNI on follow-up.

Outcomes after Transverse-Incision 'Mini' Carotid Endarterectomy and Patch-Plasty.

PurposeTraditional exposure for carotid endarterectomy (CEA) involves making a longitudinal incision parallel to the anterior border of the sternocleidomastoid. Such incisions can be painful, aesthetically displeasing, and associated with a high incidence of cranial nerve injury (CNI). This study describes the outcomes of CEA performed through small (<5 cm long), transversely oriented incisions located directly over the carotid bifurcation, as identified by color-enhanced Duplex ultrasound.Materials and MethodsPatient demographics and operative data were collected retrospectively from an in-house database of consecutive vascular patients undergoing CEA with a small transversely oriented incision for both symptomatic and asymptomatic carotid artery stenoses.ResultsA total of 52 consecutive patients underwent CEA between 2012 and 2016 (median age, 73.5 years; interquartile range, 67–80.3; male/female ratio, 40:12). CEA was performed under regional/local anesthesia (LA) in 48 (92.3%) patients, with 4 (7.7%) being performed under general anesthesia. One patient under LA experienced neurological dysfunction intraoperatively (manifesting as an inability to count out loud) that resolved with insertion of shunt. One patient experienced a transient neurological event (expressive dysphasia) within the immediate postoperative period, which resolved within 6 hours. No in-hospital death or perioperative major adverse cardiovascular events were noted. No persistent CNIs nor bleeding complications necessitating re-exploration were reported. Follow-up data were available for a median period of 3.1 years and for all patients. Three patients experienced strokes following discharge (2 strokes contralateral to and 1 transient ischemic attack ipsilateral to the operated side).ConclusionSmall, transversely orientated incisions, hidden within a neck skin crease can be safely performed in the majority of patients undergoing CEA.

Carotid endarterectomy in patients with high plaque

BackgroundDifficult cephalad exposure during carotid endarterectomy in patients with high plaque (HP) may lead to increased incidence of complications after carotid endarterectomy. We report on our experience of carotid endarterectomy in patients with HP. MethodsThis is a retrospective review of 1,233 consecutive patients who underwent carotid endarterectomy by a single surgeon at 2 teaching hospitals between January 1989 to December 2018. Group A consisted of patients with HP (n = 100) diagnosed by computed tomography angiography of the neck in 90, catheter-based arteriography in 8, and an unexpected finding during carotid endarterectomy in 2 patients. Group B consisted of 1,133 consecutive carotid endarterectomies with plaque ending in Zone 1 non-high plaque (nHP). ResultsBoth groups were similar in age (70.9 ± 8.7 vs 70.3 ± 9.1, P = .53). There was a preponderance of male patients in the HP group (78.0% vs 66.1%, P = .02). Associated risk factors, including coronary artery disease, hypertension, diabetes, chronic obstructive pulmonary disease, and hyperlipidemia, were similar in both groups. Indications for carotid endarterectomy in HP patients include recent stroke (<8 weeks) in 15 patients (15.0%), transient ischemic attack in 23 patients (23.0%), and asymptomatic in 62 patients (62.0%). Three patients (3.0%) with HP required shunt placement compared with 10.9% in the nHP group (P = .009). Completion carotid arteriogram was performed in 6 patients. Perioperative stroke and mortality were similar in both groups. The incidence of cranial nerve injury was higher in the HP group. ConclusionMost patients with HP can be diagnosed with computed tomography angiography of the neck or catheter-based arteriography. Shunt requirement in patients with HP is significantly lower than in the nHP group. Perioperative stroke and mortality in patients with HP undergoing carotid endarterectomy is similar to the nHP group; however, there is a higher incidence of permanent cranial nerve injury. Carotid artery stenting should be considered in cases in which carotid endarterectomy may be challenging, such as in patients with HP. Overall, our results demonstrate that carotid endarterectomy can be safely performed in patients with HP, however, at an increased risk of permanent cranial nerve injury.

Anatomic criteria determining high-risk carotid surgery patients.

Based on randomized trials, carotid endarterectomy (CEA) is the standard procedure for patients with a 50-99% symptomatic carotid stenosis and carefully selected patients with an asymptomatic high-grade carotid stenosis. Carotid artery stenting (CAS) is a technical alternative for patients with a high surgical risk or difficult anatomic conditions (e.g., recurrent stenosis). This study aims to provide an overview of anatomic factors associated with a higher risk of CEA complications. The current literature was analyzed using a hierarchical approach. Firstly, carotid guidelines published between 2010 and 2015 and their recommendations or statements concerning anatomic risks for CEA were examined. Secondly, the retrieved full-text articles of the cited literature were assessed in detail. Thirdly, we searched the MEDLINE databank using the key words "recurrent stenosis" OR "high carotid bifurcation" OR "irradiation" OR "tracheostomy" OR "neck dissection" OR "contralateral paralysis of the recurrent laryngeal nerve" AND "carotid endarterectomy" OR "carotid surgery". Finally, the available data were summarized, as was information on each defined anatomic risk factor for CEA complications. The whole analysis is descriptive; no statistics were used. No evidence was found for a higher incidence of cranial nerve injuries after carotid surgery due to a high carotid lesion. CEA can be performed if the carotid stenosis is accessible by ultrasound. Restenosis and irradiation were not associated with a higher risk of stroke or death, but were associated with a higher incidence of cranial nerve injuries. No literature is available on the influence of neck dissection, contralateral paralysis of the recurrent nerve, or tracheostomy on the CEA surgical risk. Anatomic criteria determining high-risk carotid surgery patients have been defined as high or low carotid stenosis, restenosis after CEA, previous radical neck dissection or cervical irradiation, contralateral laryngeal nerve palsy, and tracheostomy. Most of the defined criteria are based on expert opinion. Therefore, individual treatment based on carotid imaging and the local skin and soft tissue conditions is recommended.

Eversion Versus Conventional Carotid Endarterectomy: Both Winners

Despite ample evidence that carotid endarterectomy (CEA) reduces the relative risk of stroke, there is scant analysis of the surgical technique. CEA with patch angioplasty (c-CEA) and eversion CEA (e-CEA) have similar stroke and mortality rates, but some studies suggest that e-CEA has a higher incidence of cranial nerve injury and hypertension. The purpose of this study was to determine if there is a difference in the outcome of CEA based on operative technique. From 2009 to 2012, all patients who had CEA in our institution were identified with Current Procedural Terminology and International Classification of Diseases-9th Revision codes. Continuous variables were analyzed by the Wilcoxon rank sum test. Categoric variables were assessed as percentages and analyzed by the Pearson χ2 test statistic. Univariate Cox regression analysis was used to describe the characteristics of each group and operative conditions. Multivariate logistic regression models controlled for age, gender, and comorbidities analyzed predictors of 30-day and 1-year blood pressure changes. A total of 242 patients (60% male) underwent CEA (187 c-CEA, 37 e-CEA). Mean age was 69.7 years, and 60% had asymptomatic carotid disease. Between groups, there were no statistically significant differences in comorbidities (hypertension, diabetes, hyperlipidemia, peripheral arterial disease, myocardial infarction, smoking) or postoperative outcomes. There was no difference in preoperative or postoperative blood pressures in each group, and neither group experienced an increased degree of hypertension postoperatively. Based on regression modeling, surgical technique was not predictive of postoperative hypertension (P = .36). Contrary to prior reports on short-term increases in blood pressure, there are no long-term blood pressure differences in patients undergoing e-CEA vs c-CEA. Both operative techniques provide equally good outcomes with minimal risk to cranial nerves and baroreceptor function.TableOutcomes of patch angioplasty carotid endarterectomy (c-CEA) vs eversion carotid endarterectomy (e-CEA)c-CEA (n = 187)e-CEA (n = 37)PGeneral anesthesia96%46%.00Intraoperative shunt use89%24%.00Postoperative stroke2%3%.801 year mortality0.5%0%.66Cranial nerve injury2.1%2.7%.08Mean blood pressure Preoperative142/71136/70.23 2 weeks postoperative134/74137/69.45 1 year postoperative137/74140/72.45Antihypertensive medications Preoperative21.8.44 1 year postoperative1.82.1.46 Open table in a new tab

Incidence, outcomes, and effect on quality of life of cranial nerve injury in the Carotid Revascularization Endarterectomy versus Stenting Trial

Cranial nerve injury (CNI) is the most common neurologic complication of carotid endarterectomy (CEA) and can cause significant chronic disability. Data from prior randomized trials are limited and provide no health-related quality of life (HRQOL) outcomes specific to CNI. Incidence of CNIs and their outcomes for patients in the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) were examined to identify factors predictive of CNI and their impact on HRQOL. Incidence of CNIs, baseline and procedural characteristics, outcomes, and HRQOL scores were evaluated in the 1151 patients randomized to CEA and undergoing surgery ≤30 days. Patients with CNI were identified and classified using case report forms, adverse event data, and clinical notes. Baseline and procedural characteristics were compared using descriptive statistics. Clinical outcomes at 1 and 12 months were analyzed. All data were adjudicated by two neurologists and a vascular surgeon. HRQOL was evaluated using the Medical Outcomes Short-Form 36 (SF-36) Health Survey to assess general health and Likert scales for disease-specific outcomes at 2 weeks, 4 weeks, and 12 months after CEA. The effect of CNI on SF-36 subscales was evaluated using random effects growth curve models, and Likert scale data were compared by ordinal logistic regression. CNI was identified in 53 patients (4.6%). Cranial nerves injured were VII (30.2%), XII (24.5%), and IX/X (41.5%), and 3.8% had Horner syndrome. CNI occurred in 52 of 1040 patients (5.0%) receiving general anesthesia and in one of 111 patients (0.9%) operated on under local anesthesia (P = .05). No other predictive baseline or procedural factors were identified. Deficits resolved in 18 patients (34%) at 1 month and in 42 of 52 patients (80.8%) by 1 year. One patient died before the 1-year follow-up visit. The HRQOL evaluation showed no statistical difference between groups with and without CNI at any interval. By Likert scale analysis, the group with CNI showed a significant difference in the difficulty eating/swallowing parameter at 2 and 4 weeks (P < .001) but not at 1 year. In CREST, CNI occurred in 4.6% of patients undergoing CEA, with 34% resolution at 30 days and 80.8% at 1 year. The incidence of CNI was significantly higher in patients undergoing general anesthesia. CNI had a small and transient effect on HRQOL, negatively affecting only difficulty eating/swallowing at 2 and 4 weeks but not at 1 year. On the basis of these findings, we conclude that CNI is not a trivial consequence of CEA but rarely results in significant long-term disability.

Complete transposition of carotid bifurcation: can it be an additional risk factor of injury to the cranial nerves during carotid endarterectomy?

The internal carotid artery (ICA) usually, lies posterolaterally to the external carotid artery (ECA). Sometimes a complete carotid transposition can occur, with the ECA in a lateral position and the ICA on the medial side can occur. Our study evaluated the significance and impact that this anomaly may have on cranial nerve injuries. From January 2008 to November 2010, 296 patients underwent 360 consecutive primary carotid endarterectomy (CEA) procedures. During carotid isolation, we detected an unexpected lateral position of the ECA in 11 cases (3.6%). χ(2) analysis and the Student's t-test were used to compare the incidence of cranial nerve injuries between the 11 patients with the lateral ECA who underwent CEA (group A) and 11 randomized patients with a normal bifurcation (group B). Statistical significance was inferred at χ(2)>3.84 and P<0.05. A statistical difference in the incidence of superior laryngeal nerve paralysis was detected between groups A and B (18.1%, 2/11 in group A vs. 0%, 0/11 in group B; χ(2)>3.84; P<0.05). No differences in incidence of injury were detected for the other cranial nerves. A very meticulous mobilization of the ECA and ICA is needed to perform CEA, but superior laryngeal nerve injury can occur despite the use of a safe and meticulous surgical technique.

Inferior alveolar nerve injury with laryngeal mask airway: a case report.

IntroductionThe incidence of damage to the individual cranial nerves and their branches associated with laryngeal mask airway use is low; there have been case reports of damage to the lingual nerve, hypoglossal nerve and recurrent laryngeal nerve. To the best of our knowledge we present the first reported case of inferior alveolar nerve injury associated with laryngeal mask airway use.Case presentationA 35-year-old Caucasian man presented to our facility for elective anterior cruciate ligament repair. He had no background history of any significant medical problems. He opted for general anesthesia over a regional technique. He was induced with fentanyl and propofol and a size 4 laryngeal mask airway was inserted without any problems. His head was in a neutral position during the surgery. After surgery in the recovery room, he complained of numbness in his lower lip. He also developed extensive scabbing of the lower lip on the second day after surgery. The numbness and scabbing started improving after a week, with complete recovery after two weeks.ConclusionWe report the first case of vascular occlusion and injury to the inferior alveolar nerve, causing scabbing and numbness of the lower lip, resulting from laryngeal mask airway use. This is an original case report mostly of interest for anesthetists who use the laryngeal mask airway in day-to-day practice. Excessive inflation of the laryngeal mask airway cuff could have led to this complication. Despite the low incidence of cranial nerve injury associated with the use of the laryngeal mask airway, vigilant adherence to evidence-based medicine techniques and recommendations from the manufacturer's instructions can prevent such complications.

Carotid artery stenting outcomes are equivalent to carotid endarterectomy outcomes for patients with post-carotid endarterectomy stenosis

Carotid artery stenting (CAS) has been advocated as an alternative to redo surgery for patients with post-carotid endarterectomy (CEA) stenosis. This study compares early and late clinical outcomes for both groups. This study analyzes 192 patients: 72 had reoperation (Group A) and 120 had CAS for post-CEA stenosis (Group B). Patients were followed prospectively and had duplex ultrasounds at 1 month, and every 6 to 12 months thereafter. The perioperative complications (perioperative stroke, myocardial infarction/death, cranial nerve injury) and 4-year end points were analyzed. A Kaplan-Meier lifetable analysis was used to estimate rates of freedom from stroke, stroke-free survival, ≥50% restenosis, and ≥80% restenosis. Demographic/clinical characteristics were comparable for both groups, except for diabetes mellitus and coronary artery disease, which were significantly higher in Group B. The indications for reoperations were transient ischemic attacks/stroke in 72% for Group A versus 57% for Group B (P=.0328). The mean follow-up was 33 months (range, 1-86 months) for Group A and 24 months (range, 1-78 months) for Group B (P=.0026). The proportion of early (<24 months) carotid restenosis prior to intervention was 51% in Group A versus 27% in Group B (P=.0013). The perioperative stroke rates were 3% and 1%, respectively (P=.5573). There were no myocardial infarctions or deaths in either group. The overall incidence of cranial nerve injury was 14% for Group A versus 0% for Group B (P<.0001). However, there was no statistical difference between the groups relating to permanent cranial nerve injury (1% versus 0%). The combined early and late stroke rates for Groups A and B were 3% and 2%, respectively (P=.6347). The stroke-free rates at 1, 2, 3, and 4 years for Groups A and B were 97%, 97%, 97%, and 97% and 98%, 98%, 98%, and 98%, respectively (P=.6490). The stroke-free survival rates were not significantly different. The rates of freedom from ≥50% restenosis at 1, 2, 3, and 4 years were 98%, 95%, 95%, and 95% for Group A versus 95%, 89%, 80%, and 72% for Group B (P=.0175). The freedom from ≥80% restenosis at 1, 2, 3, and 4 years for Groups A and B were 98%, 97%, 97%, and 97% versus 99%, 96%, 92%, and 87%, respectively (P=.2281). Four patients (one symptomatic) in Group B had reintervention for ≥80% restenosis. The rate of freedom from reintervention for Groups A and B were 100%, 100%, 100%, and 100% versus 94%, 89%, 83%, and 79%, respectively (P=.0634). CAS is as safe as redo CEA. Redo CEA has a higher incidence of transient cranial nerve injury; however, CAS has a higher incidence of ≥50% in-stent restenosis.

Use of a Viabahn Stent for Repair of a Common Carotid Artery Pseudoaneurysm and Dissection

Carotid procedures in the previously operated neck are both technically demanding and subject to increased rates of complications. Adding radiation to the operated field only increases these risks. The incidence of cranial nerve injury in the reoperative neck has increased. Similarly, patients with a history of radiation are at increased risk for stroke, cranial nerve injury, and wound complications. Before the endovascular era, the only option for repair of an extracranial carotid aneurysm was open operation. Recently, more experience has been gained using endovascular techniques to repair these aneurysms. We present a patient with a history of radiation and radical neck dissection who developed a pseudoaneurysm of the common carotid artery. This pseudoaneurysm was repaired successfully using a Viabhan covered stent graft.

Pro: Has Carotid Angioplasty and Stenting Replaced Carotid Endarterectomy as the Treatment of Choice for Carotid Artery Disease?

AROTID ENDARTERECTOMY (CEA) has been considered the gold standard for the treatment of extracranial carotid artery disease since the publication of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS). 1,2 These trials demonstrated decreased morbidity and mortality in both symptomatic and asymptomatic patients undergoing the procedure versus medical therapy, and often are used as the comparison between CEA and carotid angioplasty and stenting (CAS). Specifically, NASCET showed a decrease in the stroke rate from 26% to 9% over 2 years in symptomatic patients, and ACAS demonstrated a reduction in the stroke rate from 11% to 5% over 5 years in asymptomatic patients with 60% stenosis. These results were recently confirmed by the Asymptomatic Carotid Surgery Trial, with a decrease in the 5-year risk of stroke from 11.8% to 6.4% in asymptomatic patients. 3 The ability to generalize these results across a broad spectrum of surgeons has been confirmed through the use of administrative databases and programs such as the National Surgery Quality Improvement Program. 4 In fact, current recommendations are that CEA will benefit asymptomatic patients with a hemodynamically significant stenosis and a life expectancy of 3 to 5 years, as long as the stroke and death rates are less than 3%. Symptomatic patients with a 70% stenosis will benefit from treatment if the expected event rate is less than 6%. However, several potential criticisms have been raised against using this data as the standard for comparison. Many high-risk patients were excluded from these randomized trials since the patients were deemed low-surgical-risk candidates. In addition, major adverse event rates as high as 14-18% were reported in some subgroups of patients included in these trials, such as those with contralateral internal carotid artery occlusion or significant coronary artery disease. In addition, it has been suggested that the results of many surgical series may be biased, with underreporting of events due to the lack of independent neurologic evaluation of patients. Finally, the results of CEA in patients with recurrent stenosis show a significantly higher incidence of cranial nerve injury in many series. 5 Thus, CAS has been proposed as a potentially less invasive and less morbid method of revascularization for some patients. It has been suggested that CAS may be of benefit in patients with anatomic high-risk factors such as previous head and neck

Cranial Nerve Injuries and the Retrojugular Approach in Carotid Endarterectomy

This is a retrospective case series analysis to compare the incidence of cranial nerve injuries in carotid endarterectomy by the retrojugular and anteromedial approaches. Data were extracted from a prospectively collected database. Ninety-one retrojugular carotid endarterectomies were compared with 145 anteromedial carotid endarterectomies. All were performed under local anaesthesia and used the eversion technique. Data were analysed using the chi-squared test. Nine (3.8%) cases were complicated by cranial nerve injuries. In four cases, multiple nerves were involved. In total, 13 (5.5%) cranial nerves were injured. The affected nerves were: two (0.8%) marginal mandibular, two (0.8%) laryngeal, three (1.2%) accessory and six (2.5%) hypoglossal. There was no statistically significant difference in total or specific cranial nerve injuries between the two surgical approaches. The risk of cranial nerve injuries was similar following either the retrojugular or anteromedial approach. Accessory nerve injuries were only seen in the retrojugular approach but this did not reach statistical significance.

Clinical features of temporal tip epidural hematomas

The purpose of this paper was to clarify the clinical features of temporal tip epidural hematomas (EDHs). A retrospective chart review was conducted for 53 patients who had suffered an EDH. They were divided into two groups, those whose hematoma occurred in the temporal tip (23 patients) and others (30 patients). The following variables were analyzed: age, sex, Glasgow Coma Scale score, systolic blood pressure on admission, Injury Severity Score, incidence of hematomas in intracerebral regions, location of skull fracture, incidence of cranial nerve injury, type of operation, and Glasgow Outcome Scale (GOS) score at 3 months postinjury. A greater incidence of zygomatic arch or lateral orbital cavity fracture was found in the "temporal tip" group than in the "other" group. There was a greater incidence of cranial nerve injury in the temporal tip (26.0%) than in the other group (6.6%; p < 0.05). Surgery to treat the EDH was more frequently performed in the other group (36.6%) than in the temporal tip group (two patients, 8.6%; p = 0.01). There were no significant differences between the groups in terms of the GOS score. A temporal tip hematoma is not a rare injury among patients with EDHs. This hematoma tends to be induced by lateral orbital cavity and/or zygomatic arch fractures. It tends to be associated with cranial nerve injury, but it rarely requires an operation. The outcome of patients with this hematoma depends on the associated intracerebral lesions, thus indicating it to be similar to an EDH in other places.

Carotid artery aneurysm: Evolution of management over two decades

Extracranial carotid artery aneurysm (CCA), although uncommon, represents a challenge to treatment strategy. The purpose of this study was to analyze the treatment evolution and clinical outcome of all patients with CCA over a two decade period. Clinical data of all patients diagnosed with CCA who underwent interventions from 1984 to 2004 were reviewed. Patients were divided into two groups. Group I (1985-1994) and group II (1995-2004) were compared with regards to clinical presentation, treatment modality, and clinical outcome. A total of 42 cases of CCA were found during the study period (group I, n=22; group II, n=20). Pulsatile neck mass was the most common presenting symptom (n=39, 93%), followed by neurological symptoms (n=6, 14%). Twenty two (52%) were atherosclerotic aneurysms, fifteen (36%) false aneurysms, and five (12%) posttraumatic aneurysms. Both groups shared similar comorbidities and demographic profiles. All patients in group I underwent operative interventions, which included 12 resection with interposition bypass grafting (55%), six resection with patch angioplasty (27%), and four carotid ligation (18%). In group II, five patients underwent resection with interposition placement (25%) and one carotid ligation (5%). The remaining 14 patients underwent endovascular interventions (70%) which included seven stent-graft exclusions, six carotid stenting with coil exclusions, and one endovascular occlusion. Hospital length of stay was significantly shorter in group II than group I (3.5 vs. 9.4 days, p<0.01). The incidence of cranial nerve injury in group I and II were 14% vs. 5% (p<0.04), respectively. The 30-day mortality/major stroke rates in group I and II were 14% vs. 5% (p< 0.04), respectively. During the follow-up period (0.8 months-20 years; mean, 4.6 years), 16 patients died, largely due to cardiac etiologies (n=11, 69%). Treatment modality of CCA has largely evolved from operative to endovascular intervention at our institution. Treatment benefits of endovascular modality include shorter convalescent and less procedural-related complications. This evolution reflects the improvement of endovascular devices and increased utility of endovascular applications.

Is carotid artery stenting equivalent or superior to carotid endarterectomy for treatment of carotid artery stenosis?

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether carotid artery stenting (CAS) is equivalent or even superior to carotid endarterectomy (CEA) for the treatment of significant carotid artery stenosis. Four hundred and ninety-four papers were identified, of which 14 papers including five randomised controlled trials (RCTs) presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. We conclude that the risk of peri-procedure stroke or death was similar for patients treated with carotid artery angioplasty+/-stenting and those treated with surgery. However, CAS did reduce the risk of minor complications at the site of vascular access, the incidence of cranial nerve injury, and may reduce economic costs due to shorter hospital stays and earlier return to work. Long term follow-up of these patients is, however, lacking. There are currently four large multi-centre RCTs in progress and their results will determine whether CAS will surpass CEA as the gold standard in the future.