A Prospective Survey of the Incidence of Cranial and Cervical Nerve Injuries After Carotid Surgery.

BACKGROUND: To prospectively evaluate the involvement of the cranial nerves and cervical plexus branches during carotid surgery and to look for risk factors. METHODS: All patients (n = 50) undergoing carotid endarterectomy between June 1st and October 31st, 2016 in our center were evaluated prospectively. A complete neurological examination was done before the intervention then daily until hospital discharge, and then at 2 months, 6 months and 1 year. A nasal endoscopy was systematically performed postoperatively before discharge by an ear, nose, and throat specialist. RESULTS: Twenty-six patients (52%) had at least one damaged nerve immediately after surgery. There were 15 cases involving the VII nerve (30%), 12 the C2-C3 branches (24%), 7 the XII nerve (14%), and 2 the X nerve (4%). At 2 months, 6 months, and 1 year, 22%, 16%, and 8% of lesions remained, respectively. We found no independent factor for nerve damage at 6 months or 1 year. In the case of dysphonia and/or dysphagia without recurrent nerve paralysis, 6 hematomas and 7 laryngeal edemas were identified under nasal endoscopy and all healed without sequelae. CONCLUSIONS: This prospective study showed cranial and cervical nerve injury to be much more frequent than expected in the short-term, when assessed by independent ear, nose, and throat and nasal endoscopy exam. Though mainly transient, these lesions can cause post-operative functional discomfort and must be disclosed preoperatively to the patient, in view of the judicialization of health care.

Editor's Choice - Early and Late Outcomes after Transcarotid Revascularisation for Internal Carotid Artery Stenosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: Transcarotid/transcervical revascularisation (TCAR) is an alternative to carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS). This review aimed to evaluate pooled data on patients undergoing TCAR. DATA SOURCES: Medline, Embase, Scopus, and Cochrane Library databases were used. REVIEW METHODS: This systematic review was conducted under Systematic Reviews and Meta-Analysis guidelines. Eligible studies (published online up to September 2020) reported 30 day mortality and stroke/transient ischaemic attack (TIA) rates in patients undergoing TCAR. Data were pooled in a random effects model and weight of effect for each study was also reported. Quality of studies was evaluated according to Newcastle - Ottawa scale. RESULTS: Eighteen studies (three low, seven medium, and eight high quality) included 4 852 patients (4 867 TCAR procedures). The pooled 30 day mortality rate was 0.7% (n = 32) (95% confidence interval [CI] 0.5 - 1.0), 30 day stroke rate 1.4% (n = 62) (95% CI 1.0 - 1.7), and 30 day stroke/TIA rate 2.0% (n = 92) (95% CI 1.4 - 2.7). Pooled technical success was 97.6% (95% CI 95.9 - 98.8). The cranial nerve injury rate was 1.2% (95% CI 0.7 - 1.9) (n = 14; data from 10 studies) while the early myocardial infarction (MI) rate was 0.4% (95% CI 0.2 - 0.6) (n = 16; data from 17 studies). The haematoma/bleeding rate was 3.4% (95% CI 1.7 - 5.8) (n = 135; data from 10 studies), with one third of these cases needing drainage or intervention. Within a follow up of 3 - 40 months the restenosis rate was 4% (95% CI 0.1 - 13.1) (data from nine studies; n = 64/530 patients) and death/stroke rate 4.5% (95% CI 1.8 - 8.4) (data from five studies; n = 184/3 742 patients). Symptomatic patients had a higher risk of early stroke/TIA than asymptomatic patients (2.5% vs. 1.2%; odds ratio 1.99; 95% CI 1.01 - 3.92); p = .046; data from eight studies). CONCLUSION: TCAR is associated with promising early and late outcomes, with symptomatic patients having a higher risk of early cerebrovascular events. More prospective comparative studies are needed in order to verify TCAR as an established alternative treatment technique.

Surgical Management of Carotid Body Tumor and Risk Factors of Postoperative Cranial Nerve Injury.

BACKGROUND: To identify risk factors of postoperative cranial nerve injury (CNI) following surgical treatment of a carotid body tumor (CBT) by retrospective analysis of the data during the past decade in our center. METHODS: From May 2008 to September 2018, patients who underwent CBT resections at the Department of Vascular Surgery, Zhongshan Hospital, Fudan University, were included in the study. Demographic, preoperative, intraoperative, and postoperative data of patients were collected and analyzed. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors of CNI. RESULTS: A total of 203 CBTs were excised in 196 patients; 17.7% was classified as Shamblin I, 59.1% as Shamblin II, and 23.2% as Shamblin III. CNI after surgery occurred in 57 (28.1%) patients. Postoperative CNI, external carotid artery (ECA) ligation, internal carotid artery (ICA) reconstruction, tumor volume, and established blood loss (EBL) were significantly correlated with Shamblin classification. On univariate analysis, there were statistically significant differences in Shamblin classification (p = 0.002), tumor volume (p = 0.014), number of lymph nodes removed (NOLNR) (p < 0.001), and EBL (p = 0.019) between two groups (with and without CNI after surgery). Multivariate logistic regression analysis revealed a significant positive correlation between CNI and Shamblin III (AOR, 4.744; 95% CI, 1.21-18.56; p = 0.025) and NOLNR (AOR, 0.25; 95% CI, 1.23-1.46 for each three-interval increase, p < 0.001). CONCLUSIONS: Shamblin III and NOLNR are independent risk factors of CNI for patients who undergo CBT resections.

Petroclival meningiomas: the risk of post-operative cranial nerve deficits among different surgical approaches-a systematic review and meta-analysis.

BACKGROUND: The surgical resection of petroclival meningiomas (PCMs) remains a challenge. Both the relationship with neurovascular structures and the deep location of the tumor can affect the extent of resection and the rate of post-operative morbidity. METHODS: The authors performed a systematic review and meta-analysis of the literature examining the rate of new cranial nerve (CN) deficits after resection of PCM. A systematic search of two databases was performed for studies published between 1990 and 2018. Random-effect meta-analysis was used to pool the rate of post-operative CN deficits, mortality rate, and rate of radical resection. RESULTS: We included twelve studies and 334 patients harboring PCM. The overall rate of complete resection was 68% (95% CI 57.9-78.2%; p < 0.01; I2 = 83%). The rate of early and late post-operative CN deficits was the following: 3.8 and 2.7% (III CN), 6.6 and 3% (IV), 7.3 and 5.5% (V CN), 8 and 3.6% (VI CN), 8.9 and 8.9%% (VIII), and 4 and 2.7% (IX-XI CNs) (I2 = 0%, and p < 0.01 for all analyses). The risk of post-operative deficit of the IV CN was higher among the petrosal group (7.6%; I2 = 0% vs 2.1%; I2 = 0%), whereas the impairment of VII CN function was higher among retrosigmoid group (16.6%; I2 = 64.6% vs 11.4%; I2 = 52.8%), but it was transient in the majority of cases. CONCLUSIONS: This systematic review and meta-analysis provides a detailed overview of post-operative CN deficits ensuing surgical resection of PCMs. These findings should be acknowledged when counseling patients with PCMs regarding the more appropriate approach for their tumor.

Clinical outcomes of radiation-induced carotid stenosis: A systematic review and meta-analysis.

OBJECTIVES: Clinical outcomes of radiation-induced carotid stenosis are still unclear. Therefore, a systematic review and meta-analysis is needed to evaluate the short- and long-term outcomes after interventions to treat radiation-induced carotid stenosis. METHODS: PubMed, EMBASE, the Cochrane Library and Web of Science were searched from 1 January 2000 for relevant RCTs and observational studies which reported outcomes after carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) for carotid stenosis induced by radiation. Risk of bias were assessed through different scales according to study design. I2 statistic were used to evaluate the heterogeneity, and meta-regression were performed to investigate the source of heterogeneity. Visual inspection of funnel plots was used to judge publication bias. RESULTS: A total of 26 studies with 1002 patients were included. CEA was performed in 364 patients and CAS in 638 patients. The overall estimated rate of short-term stroke was 0.19% (95% CI: 0-0.90%), and the rate of long-term stroke was 2.68 % (95% CI: 1.19-4.57%). The rate of cranial nerve injury in CEA group was significantly higher than that in CAS group [risk ratio (RR): 6.03, 95% CI: 1.63-22.22, P = .007]. The univariate regression analysis showed that the risk of stroke in CAS group were significantly higher than CEA group in both short- and long-term [incidence rate ratio (IRR): 3.62, 95% CI: 1.21-10.85, P = 0.22; IRR: 2.95, 95% CI: 1.02-8.59, P = .046, respectively]. CONCLUSIONS: This systematic review provided the worldwide profile of outcome of treatment for radiation-induced carotid stenosis, and also found that CEA can yield better results for these patients than CAS. Nonetheless, as large-scale studies have not yet been conducted, and there is a definite need for further studies in the future.

A Systematic Review and Meta-Analysis of the Presentation and Surgical Management of Patients With Carotid Body Tumours.

OBJECTIVES: The aim was to determine the mode of presentation and 30 day procedural risks in 4418 patients with 4743 carotid body tumours (CBTs) undergoing surgical excision. METHODS: This is a systematic review and meta-analysis of 104 observational studies. RESULTS: Overall, 4418 patients with 4743 CBTs were identified. The mean age was 47 years, with the majority being female (65%). The commonest presentation was a neck mass (75%), of which 85% were painless. Dysphagia, cranial nerve injury (CNI), and headache were present in 3%, while virtually no one presented with a transient ischaemic attack (0.26%) or stroke (0.09%). The majority (97%) underwent excision, but only 21% underwent pre-operative embolisation. Overall, 27% were Shamblin I CBTs; 44% were Shamblin II; and 29% were Shamblin III. The mean 30 day mortality was 2.29% (95% CI 1.79-2.93). The mean 30 day stroke rate was 3.53% (95% CI 2.91-4.29), while the mean 30 day CNI rate was 25.4% (95% CI 24.5-31.22). The prevalence of persisting CNI at 30 days was 11.15% (95% CI 8.42-14.64). Twelve series (544 patients) correlated 30 day stroke with Shamblin status. Shamblin I CBTs were associated with a 1.89% stroke rate (95% CI 0.92-3.82), increasing to 2.71% (95% CI 1.43-5.07) for Shamblin II CBTs and 3.99% (95% CI 2.34-6.74) for Shamblin III tumours. Twenty-six series (1075 patients) correlated CNI rates with Shamblin status: 3.76% (95% CI 2.62-5.35) for Shamblin I CBTs, 14.14% (95% CI 11.94-16.68) for Shamblin II, and 17.10% (95% CI 14.82-19.65) for Shamblin III tumours. The prevalence of neck haematoma requiring re-exploration was 5.24% (95% CI 3.45-7.91). The proportion of patients with a neck haematoma requiring re-exploration was not reduced by pre-operative embolisation (5.92%; 95% CI 2.56-13.08) vs. no embolisation (5.82%; 95% CI 2.76-11.88). Pre-operative embolisation did not reduce drainage losses (639 mL vs. 653 mL). CONCLUSIONS: This is the largest meta-analysis of outcomes after CBT excision. Procedural risks associated with tumour excision were considerable, especially with Shamblin III tumours where 4% suffered a peri-operative stroke and 17% suffered a CNI.

Cranial Nerve Injury After Carotid Endarterectomy: Incidence, Risk Factors, and Time Trends.

OBJECTIVE/BACKGROUND: To review the incidence of post-carotid endarterectomy (CEA) cranial nerve injury (CNI), and to evaluate the risk factors associated with increased CNI risk. METHODS: The study was a meta-analysis. Pooled rates with 95% confidence intervals (CIs) were calculated for CNIs after primary CEA. Odds ratios (ORs) were calculated for potential risk factors. A fixed-effects model or a random effects model (Mantel-Haenszel method) was used for non-heterogeneous and heterogeneous data, respectively. Meta-regression analysis was performed to examine the influence of publication year upon CNI rate. RESULTS: Twenty-six articles, published between 1970 and 2015, were included in the meta-analysis, corresponding to 20,860 CEAs. Meta-analysis revealed that the vagus nerve was the most frequently injured cranial nerve (pooled injury rate 3.99%, 95% CI 2.56-5.70), followed by the hypoglossal nerve (3.79%, 95% CI 2.73-4.99). Fewer than one seventh of these injuries are permanent (vagus nerve: 0.57% [95% CI 0.19-1.10]; hypoglossal nerve: 0.15% [95% CI 0.01-0.39]). A statistically significant influence of publication year on the vagus and hypoglossal nerve injury rate was found, with the injury rate having decreased from about 8% to 2% and 1%, respectively, over the last 35 years. Urgent procedures (OR 1.59, 95% CI 1.21-2.10; p = .001), as well as return to the operating room for a neurological event or bleeding (OR 2.21, 95% CI 1.35-3.61; p = .002) were associated with an increased risk of CNI, whereas no statistically significant association was found between CNIs and the type of anaesthesia, the use of a patch, redo operation, and the use of a shunt. CONCLUSION: The vagus nerve appears to be the most frequently injured cranial nerve after CEA, followed by the hypoglossal nerve, with only a small proportion of these injuries being permanent. The CNI rate has significantly decreased over the past 35 years to a point indicating that CNIs should not be considered a major influencing factor in the decision making process between CEA and stenting.

Risk factors for cranial nerve injury after carotid endarterectomy.

BACKGROUND: Although numerous studies have described the incidence of postoperative cranial nerve injury (CNI) after carotid endarterectomy (CEA), there have been few attempts to identify risk factors for this complication. METHODS: The 2012 CEA-targeted American College of Surgeons National Surgical Quality Improvement Program database was used to determine the incidence of CNI after CEA. Multivariate logistic regression analysis was performed to identify independent predictors of CNI after CEA, using a comprehensive array of patient-, carotid disease-, and procedure-related factors as potential predictor variables. RESULTS: Of the 3762 CEA patients who were included in our analysis, 84 (2.2%) were noted to have sustained CNI in the first 30 days after their operation. Independent predictors of this complication included age ≥80 years (reference group, <70 years; adjusted odds ratio [AOR] for CNI, 1.74; 95% confidence interval [CI], 1.00-3.03; P = .05), presence of a preoperative bleeding disorder (including patients in whom preoperative nonaspirin anticoagulation therapy was not stopped before CEA; AOR, 1.66; 95% CI, 1.03-2.68; P = .04), duration of operation (AOR, 1.15 for each 30-minute interval beyond an operative time of 90 minutes; 95% CI, 1.06-1.25; P = .001), and need for reoperation (AOR, 2.65; 95% CI, 1.03-6.80; P = .04). CONCLUSIONS: Our study demonstrates clinically evident CNI to be a relatively uncommon event after CEA at institutions that participate in the CEA-targeted American College of Surgeons National Surgical Quality Improvement Program and identifies four separate factors that are independently associated with an increased risk of CNI.

Preoperative Imaging Features are Associated with Surgical Complications Following Carotid Body Tumor Resection.

BACKGROUND: Surgical resection remains the treatment of choice for carotid body tumors (CBTs). Although perioperative complications such as carotid artery injury and neurological deficits occur infrequently, they can be devastating. The aim of this study was to evaluate whether clinical factors or preoperative imaging findings can accurately predict perioperative complications. METHODS: Twenty CBTs were resected from 19 patients. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) of the neck were used to measure the degree of circumferential involvement of the CBT to the internal carotid artery (ICA), carotid artery narrowing, tumor length, tumor volume, and the distance from the tip of the C2 dens to the superior aspect of the CBT (dens-CBT). Operative reports and Shamblin classification (I-III) of each tumor were independently reviewed. Preoperative imaging features were compared to perioperative cranial nerve injury (CNI), rates of carotid artery injury, and major carotid artery repairs, as well as Shamblin classifications≥II. RESULTS: CNI was associated with a high-lying CBT (dens-CBT=1.8 vs. 2.9 cm, p<0.01). All four patients with CNI had a dens-CBT of <3 cm. Neither tumor length and tumor volume nor the involvement of the ICA (≥180° as measured by CT or MRI) was associated with CNI, carotid artery injury, major carotid artery repair, or Shamblin II or III classification. No carotid artery narrowing was observed in any of the cases. CONCLUSIONS: Preoperative measurement of the dens-CBT is helpful in identifying CBTs at risk for CNI after surgical resection.

Carotid Body Tumor: Clinical Features.

Although carotid body tumor (CBT) is a rare neoplasm, it should always be considered in differential diagnosis of lateral neck masses. We shared the 10 years of CBT experience in our clinic and started a discussion on CBT with literature support. A total of 21 patients with CBT diagnosis in Firat University Hospital, Otorhinolaryngology Clinic, participated in the study. Patients were evaluated based on demographical data and particularities of the tumor. Participant patients were 19 women and 2 men, and their ages were between 21 and 79 (mean age 54.06 ± 12.48). The most frequent reason for the patients to apply to the hospital was painless swelling in the neck (76.2%). Tumor was located in the right side of the neck in 10 patients (47.6%), and in the left side of the neck in 11 (52.4%). Twenty patients (95.2%) had undergone computerized tomography angiography. Surgical treatment was applied to 19 patients (90.5%) and the tumor was totally excised. According to Shamblin classification, 15 of the tumors of these patients were class II (78.9%) and 4 were class III (21.1%). In 1 patient (5.3%), postoperative contusion infection that recovered after medical treatment was observed; in 2 patients (10.5%), n. vagus injury was observed because of tumor's pervasion of n. vagus; and in 1 of these patients vocal cord paralysis was developed and this patient was later taken into thyroplasty surgery. Two patients (10.5%) suffered n. hypoglossus injury, 1 of these recovered within 3 months postoperative and the other developed n. hypoglossus palsy. The size and extension of the tumor should be determined by preoperative imaging for the correct planning of surgical procedure. It should be taken into consideration that despite advanced surgical techniques, the rate of postoperative cranial nerve damage is still high.

[Mandibular advancement: bilateral sagittal split versus -distraction osteogenesis]. / Verlenging van de onderkaak: bilaterale sagittale splijtingsosteotomie versus distractieosteogenese.

In the 1990s intra-oral distraction osteogenesis (DO) became available as an alternative for bilateral sagittal splitosteotomy (BSSO) for advancement of the mandible. It was thought that DO would lead to more stability in the results and fewer neurosensory disturbances of the inferior alveolar nerve. However, there was no scientific evidence for this assumption. This article describes a number of recently published, prospective studies that demonstrate that BSSO is not inferior to DO with respect to stability and neurosensory disturbances of the inferior alveolar nerve. They also demonstrate that BSSO leads to less pain in patients and to lower total costs. It can be concluded that BSSO should be considered the standard therapy for mandibular advancement up to 10 mm in non-syndromal patients.

National experience with extracranial carotid artery aneurysms: epidemiology, surgical treatment strategy, and treatment outcome.

OBJECTIVE: Extracranial carotid artery aneurysms (CAAs) are rare but confer risk of stroke, rupture, and local symptoms. Few cases have been reported, even from large centers, and therefore knowledge of the disease is limited. The purpose of this study was to review epidemiology, surgical treatment, and outcomes of CAAs in a nationwide setting using the Swedish National Registry for Vascular Surgery (Swedvasc). METHODS: Data on all surgical interventions for CAAs from January 1997 to December 2011 were retrieved from the Swedvasc registry. Additional clinical information was collected from hospital records. RESULTS: A total of 48 cases of CAAs were identified. The cause was atherosclerosis in 34 cases, infection in 2, and pseudoaneurysm in 12. The most common presentation was a pulsatile mass with or without local symptoms. Aneurysms isolated to the internal carotid artery predominated. Resection with end-to-end anastomosis was the most common technique used for treatment. Among true aneurysms, 24% had a known synchronous aneurysm elsewhere. Stroke-free survival (n = 48) was 90% after 30 days and 85% after 1 year. A total of 12.5% patients experienced permanent cranial nerve injury and 33% experienced any complication. CONCLUSIONS: CAAs are rare entities in vascular surgery. In terms of stroke-free survival, the Swedish national results approach reports from large volume centers. The relatively high risk for permanent cranial nerve injury advocates caution when performing surgery on CAAs.

[Complications after therapeutic dissection of the neck in the treatment of differentiated thyroid gland cancer].

There were analyzed retrospectively 1078 patients, operated on for differentiated cancer of thyroidal gland (DCTHG) in 2009-2012 yrs in the Centre, who have had following surgical complications: the injury of the X, XI, XII cranial nerves pairs, of the motor and sensitive branches of cervical and brachial plexuses, lymphorrhea, hypoparathyrosis and hematoma of the neck. In 868 patients the primary operations were performed, 304 - were operated for the recurrent forms. In 271 patients (the comparison group) thyroidectomy was performed, in 884 (the main group)--thyroidectomy and different kinds of the neck dissection, in 121--the operation was done, using neuromonitoring. Therapeutic dissection of the neck--the central and lateral one, as well as primary and repeated, may be performed relatively safely in patients, suffering DCTHG. In reoperations the rate of injury of the X, XI, XII cranial nerves pairs, of the motor and sensitive branches of cervical and brachial plexuses is increasing. Application of intraoperative electroneuromonitoring for identification of peripheral nerves permits to lower the neurotrauma occurrence.

Surgical resection of large and giant petroclival meningiomas via a modified anterior transpetrous approach.

The authors describe a modified anterior transpetrous approach (ATPA) for the surgical resection of 21 cases of petroclival meningiomas (PCMs). Briefly, a curved periauricular skin incision was used. The cerebellar tentorium and the dura on the petrous apex were coagulated and incised to expose the petrous apex bone fully. The drilling of the petrous apex bone was performed subdurally and began internally from the trigeminal impression, not exceeding 1.5 cm laterally, not exceeding 6 mm from the posterior edge of the petrous ridge, and not exceeding 8 mm in depth from the surface of the petrous bone. The tumors were removed totally in 12 (57.1%) cases, subtotally in 8 (38.1%) cases, and partially in 1 (4.8%) case. The transient neurological deficit includes mild oculomotor nerve palsy in three cases, abducens nerve palsy in six cases, language disorder in three cases, and mild hemiplegia in two cases. Facial numbness became worse postoperatively in six patients, and only two patients improved at 6 months after surgery. No death occurred in this series. The modified ATPA is an efficient treatment alterative for large or giant PCMs located at the medial and superior internal acoustic meatus with relatively low risk of complications.

Neurological complications of carotid revascularisation.

Carotid endarterectomy (CEA) is an effective treatment for patients with recently symptomatic severe carotid stenosis and in selected patients with symptomatic moderate carotid stenosis. Carotid artery angioplasty and stenting (CAS) is emerging as an alternative to CEA, and randomised controlled trials suggest comparable efficacy to CEA in prevention of non-perioperative stroke. Neurovascular complications can result from both procedures, usually from thromboembolism from the operated vessel, cerebral hypoperfusion causing ischaemia and, rarely, intracerebral haemorrhage. The overall incidence of perioperative strokes complicating CEA and CAS is approximately 4% and 6%, respectively, and represents a devastating outcome that the procedure was designed to prevent. Other neurological sequelae complicating carotid revascularisation include cerebral hyperperfusion syndrome, cranial and peripheral nerve injuries, and contrast encephalopathy in patients undergoing CAS. In this review, we analyse the incidence, mechanisms and perioperative management of neurological complications for patients undergoing carotid revascularisation.

Cranial nerve injuries in patients with moderate to severe head trauma - Analysis of 91,196 patients from the TraumaRegister DGU® between 2008 and 2017.

OBJECTIVE: Traumatic brain injury (TBI) constitutes a major cause of trauma-related disability and mortality. The epidemiology and implications of associated cranial nerve injuries　(CNI)　in moderate to severe TBI are largely unknown. We aimed to determine the incidence of CNI in a large European cohort of TBI patients as well as clinical differences between TBI cases with and without concomitant CNI (CNI vs. control group) by means of a multinational trauma registry. METHODS: The TraumaRegister DGU® was evaluated for trauma patients with head injuries ≥ 2 Abbreviated Injury Scale, who had to be treated on intensive care units after emergency admission to European hospitals between 2008 and 2017. CNI and control cases were compared with respect to demographic, clinical, and outcome variables. RESULTS: 1.0% (946 of 91,196) of TBI patients presented with additional CNI. On average, CNI patients were younger than control cases (44.3 ± 20.6 vs. 51.8 ± 23.0 years) but did not differ regarding sex distribution (CNI 69.4% males vs. control 69.1%). Traffic accidents were encountered more frequently in CNI cases (52.3% vs. 46.7%; p < 0.001; chi-squared test) and falls more commonly in the control group (45.2% vs. 37.1%; p < 0.001). CNI patients suffered more frequently from concomitant face injuries (28.2% vs. 17.5%; p < 0.001) and skull base fractures (51.0% vs. 23.5%; p < 0.001). Despite similar mean Injury Severity Score (CNI 21.8 ± 11.3; control 21.1 ± 11.7) and Glasgow Coma Scale score (CNI 10.9 ± 4.2, control 11.1 ± 4.4), there was a considerably higher proportion of anisocoria in CNI patients (20.1% vs. 11.2%; p < 0.001). Following primary treatment, 50.8% of CNI and 35.5% of control cases showed moderate to severe disability (Glasgow Outcome Scale score 3-4; p < 0.001). CONCLUSION: CNI rarely occur in the context of TBI. When present, they indicate a higher likelihood of functional impairment following primary care and complicating skull base fractures should be suspected.

[Damage to craniocerebral nerves in reconstructive surgery of carotid arteries].

Reconstructive operations on aortic arch branches appear to be the most efficient method of preventing acute and chronic impairments of cerebral circulation. Iatrogenic lesions of the craniocerebral nerves deteriorate the course of the immediate, and especially the remote postoperative period, decreasing quality of life and social status of the patients after endured carotid reconstructions. The authors analysed herein the outcomes in a total of 562 patients after endured carotid artery surgery for atherosclerosis or pathological tortuosity. The authors examined the incidence rate, patterns and risk factor of damage to the craniocerebral nerves in all the patients. Comprehensive prevention of damage to the craniocerebral nerves was carried out in a total of 412 patients from the Study Group and was aimed at excluding or decreasing intensity of the eff ect of the eliminable risk factors. The proposed measures made it possible to decrease the rate of lesions of craniocerebral nerves from 18.7 to 6.9% and to substantially improve the postoperative patients' quality of life.

Cranial nerve injuries are associated with specific craniofacial fractures after blunt trauma.

Identification of cranial nerve (CN) injuries after blunt trauma is often delayed due to concomitant life-threatening trauma, altered mental status, and associated bony or soft tissue injuries. We hypothesized that specific craniofacial fracture (FX) patterns are associated with CN injuries, permitting earlier diagnosis. The trauma registry at a single institution was queried for all CN injuries and craniofacial FXs. Associations were determined by Fisher's exact test. Ninety CN injuries were identified in 59 patients. CN injuries were diagnosed on the day of admission in 24 (41%) patients. The most frequently injured CNs were CN VII (22), CN I (16), and CN VI (14). Occipital FXs were associated with CN I injury (P = 0.001). Sphenoid and ethmoid FXs were correlated with CN III trauma (P = 0.019 and 0.04). Temporal bone FXs were associated with CN VII injuries (P = 0.025). Maxillary FXs were associated with CN V injuries (P = 0.041). Complete or partial recovery was documented after 17 per cent and 39 per cent of CN injuries, respectively. Diagnostic delay was documented in 59 per cent of patients. Specific craniofacial FXs were correlated with certain CN injuries. Partial or complete recovery of function occurred after 56 per cent of CN injuries.