title: Clinical relevance of cranial nerve injury following carotid endarterectomy.
abstract: OBJECTIVE
  The benefit of carotid endarterectomy (CEA) may be diminished by cranial nerve injury (CNI). Using a quality improvement registry, we aimed to identify the nerves affected, duration of symptoms (transient vs. persistent), and clinical predictors of CNI.
  
  
  METHODS
  We identified all patients undergoing CEA in the Vascular Study Group of New England (VSGNE) between 2003 and 2011. Surgeon-observed CNI rate was determined at discharge (postoperative CNI) and at follow-up to determine persistent CNI (CNIs that persisted at routine follow-up visit). Hierarchical multivariable model controlling for surgeon and hospital was used to assess independent predictors for postoperative CNI.
  
  
  RESULTS
  A total of 6,878 patients (33.8% symptomatic) were included for analyses. CNI rate at discharge was 5.6% (n = 382). Sixty patients (0.7%) had more than one nerve affected. The hypoglossal nerve was most frequently involved (n = 185, 2.7%), followed by the facial (n = 128, 1.9%), the vagus (n = 49, 0.7%), and the glossopharyngeal (n = 33, 0.5%) nerve. The vast majority of these CNIs were transient; only 47 patients (0.7%) had a persistent CNI at their follow-up visit (median 10.0 months, range 0.3-15.6 months). Patients with perioperative stroke (0.9%, n = 64) had significantly higher risk of CNI (n = 15, CNI risk 23.4%, p < .01). Predictors for CNI were urgent procedures (OR 1.6, 95% CI 1.2-2.1, p < .01), immediate re-exploration after closure under the same anesthetic (OR 2.0, 95% CI 1.3-3.0, p < .01), and return to the operating room for a neurologic event or bleeding (OR 2.3, 95% CI 1.4-3.8, p < .01), but not redo CEA (OR 1.0, 95% CI 0.5-1.9, p = .90) or prior cervical radiation (OR 0.9, 95% CI 0.3-2.5, p = .80).
  
  
  CONCLUSIONS
  As patients are currently selected in the VSGNE, persistent CNI after CEA is rare. While conditions of urgency and (sub)acute reintervention carried increased risk for postoperative CNI, a history of prior ipsilateral CEA or cervical radiation was not associated with increased CNI rate.
authors.affiliation: Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: M
authors.initials: M
authors.lastname: Fokkema
authors.affiliation: University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: G J
authors.initials: GJ
authors.lastname: de Borst
authors.affiliation: Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: B W
authors.initials: BW
authors.lastname: Nolan
authors.affiliation: Yale Medical Center, New Haven, CT, USA.
authors.forename: J
authors.initials: J
authors.lastname: Indes
authors.affiliation: Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: D B
authors.initials: DB
authors.lastname: Buck
authors.affiliation: Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: R C
authors.initials: RC
authors.lastname: Lo
authors.affiliation: University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: F L
authors.initials: FL
authors.lastname: Moll
authors.affiliation: Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA. Electronic address: mscherme@bidmc.harvard.edu.
authors.forename: M L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D020209:Cranial Nerve Injuries / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009511:New England; D016017:Odds Ratio; D010351:Patient Discharge; D018579:Patient Selection; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D020127:Recovery of Function; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Carotid; Cranial nerve injury; Endarterectomy