Long-term functional consequences of cranial nerve injuries after carotid endarterectomy.

BACKGROUND: The aim of the study was to investigate long-term patient consequences of cranial nerve injury (CNI) caused by carotid endarterectomy (CEA) in patients with identified CNI at the 30-day follow-up. METHODS: Consecutive patients operated for symptomatic carotid artery stenosis 2015-2019 with a documented CNI at the 30-day follow-up after CEA were recruited to this cross-sectional survey. Telephone interviews were conducted >1 year after CEA utilizing survey instruments developed to uncover CNI symptoms. Patients graded their symptoms on a 4-point scale: 1) no symptoms; 2) mild symptoms; 3) moderate symptoms; and 4) severe symptoms. RESULTS: Altogether, 477 patients underwent CEA, of which 82 were diagnosed with CNI; 70/82 patients remained alive at the time for the survey and 68 patients completed the interview. The mean follow-up time was 3.7 years. Severe persistent CNI symptoms were reported in 2/68 (2.9%), moderate symptoms in 1/68 (1.5%) and mild symptoms in 14/68 (21%) whereas 51/68 patients (75%) reported no residual symptoms. When extrapolating these findings to all patients, approximately 4.4% reported persistent symptoms at the long-term follow-up and only 0.8% reported moderate or severe symptoms. CONCLUSIONS: The long-term consequences of CNI following CEA are benign in most patients, with a high rate of symptom resolution and a very low rate of persistent clinically significant symptoms.

A new pattern of cranial nerve injuries caused by unfavorable fractures during Le Fort I osteotomy.

Cranial nerve injury is a described complication of Le Fort I osteotomy technique. The authors present the case of a 45-year-old patient that underwent bimaxillary orthognathic surgery and suffered unfavorable skull base fractures, which resulted in cranial nerve injury of the II, III, IV, V, and VI nerves on the left side and of the V nerve on the right side, through different mechanisms. One of the mechanisms was cavernous sinus thrombosis, which was never described following Le Fort I technique in a non-cleft patient. The fracture pattern involved the foramen ovale and Meckel's cave, which was also never described after this technique. The resolution of the deficits at the final follow-up at 14 months was incomplete. Le Fort I osteotomy technique is considered a safe technique to correct dentofacial deformities, but serious complications can occur. Pterygomaxillary disjunction and down-fracture must be performed with the utmost care to avoid it.

High Mib-1-score correlates with new cranial nerve deficits after surgery for frontal skull base meningioma.

Postoperative new cranial nerve deficits comprise severe concomitant morbidity in skull base meningioma surgery. Therefore, long-term cranial nerve integrity represents an important outcome measure. In the current study, we analyzed our institutional database in order to identify risk factors for postoperative new cranial nerve morbidity in the course of frontobasal meningioma surgery. Between 2009 and 2017, 195 patients were surgically treated for frontobasal meningioma at the authors' institution. Postoperative cranial nerve function was assessed immediately after surgery as well as 12 months postoperatively. A univariate and multivariate analysis was performed to identify factors influencing favorable postoperative cranial nerve outcome. Tumors with histological Mib-1-labeling indices > 5% were associated with a significantly higher percentage of new cranial nerve deficits immediately after surgery compared with those with Mib-1-labeling indices ≤ 5% (39% versus 20%, p = 0.029). Elevated Mib-1-labeling indices could be correlated with high CD68-positive macrophage staining (54% for Mib-1 index > 5% versus 19% for Mib-1 index ≤ 5%, p = 0.001). Elevated Mib-1-labeling index correlates with initial new cranial nerve dysfunction after resection of frontal skull base meningioma. With regard to elevated CD68-positive macrophage staining in high Mib-1-positive meningiomas, initial postoperative new cranial nerve morbidity might partly reflect macrophage-based inflammatory immune responses.

Colon Interposition for Corrosive Esophageal Stricture: Single Institution Experience with 119 Cases.

The colon is an alternative graft organ for esophageal reconstruction. The present study reviewed our experience with the colon interposition for esophageal replacement following corrosive ingestion, to evaluate the outcomes of colon interposition based on our surgical experience. The clinical data of 119 patients who underwent colon interposition for esophageal replacement from January 2005 to March 2017 were retrospectively analyzed. The routes of the colon interposition were retrosternal in 119 (100%). The median operative time was 390 min (range: 290-610 min) and the median blood loss was 615 mL (range: 270-2500 mL). Of these 119 patients, the cervical anastomosis was performed at the hypopharynx (n=20, 16.8%), the larynx (n=3, 2.5%), and the cervical esophagus (n=96, 80.7%). Five patients experienced cervical anastomotic leakage (4 cases for esophagus-colon, and one for hypopharynx-colon). One patient experienced wound infection of the abdominal wall. Three patients had injury of recurrent laryngeal nerve and hoarseness. Three patients had stress ulcer with bleeding and treated with octreotide. Two patients suffered from incomplete intestinal obstruction. The postoperative follow-up was made for 12 months in all patients and all of them were alive. In conclusion, The colon is well-suited for esophageal reconstruction. The selection of the colon graft should be flexible and be based on the inspection of blood supply and the length needed. We must therefore make every effort to reduce the number of postoperative complications, and improve the quality of life for patients.

New predictors of complications in carotid body tumor resection.

OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

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.

Clinical and Electromyographic Characteristics of Unilateral Vocal Fold Paralysis With Lower Cranial Nerve Injury.

OBJECTIVES: The aim was to investigate the clinical and electromyographic characteristics of patients with unilateral vocal fold paralysis (UVFP) combined with lower cranial nerve injury. STUDY DESIGN: This is a case series with chart review. METHODS: Among 368 patients with idiopathic UVFP, 31 patients (8.4%) were eventually diagnosed with lower cranial nerve palsy after examinations of the head and neck, radiology, and electromyogram (EMG). The clinical and electromyographic characteristics of these patients were analyzed. RESULTS: Of the 31 patients, 27 patients exhibited obvious abnormal lower cranial nerve injury physical signs, and 4 patients showed atypical physical signs, identified by EMG. Ultimately, 41.9% (13/31) were diagnosed with idiopathic causes, 38.7% (12/31) with intracranial or skull-base lesions on radiology, 12.9% (4/31) with lower cranial neuritis, and 6.4% (2/31) with radiation-induced lower cranial nerve palsy. Among the cranial lesions, lesions of the jugular foramen region were the most common (50%, 6/12). All 26 patients who underwent EMG tests were confirmed to have vagus nerve impairments (11 complete and 15 incomplete) and accessory nerve impairments (16 complete and 10 incomplete), whereas only 13 patients (50%) exhibited hypoglossal nerve injuries (5 complete and 8 incomplete). CONCLUSIONS: For patients with clinically "idiopathic" UVFP, physical examinations of the lower cranial nerves are essential screening procedures. For patients with abnormal or suspicious physical signs, radiology should be performed to detect possible cranial or cervical lesions. EMG tests were strongly recommended to identify suspicious lower cranial nerve injury and its severity, and may help to predict the prognosis.

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

OBJECTIVE: To determine predictors of cranial nerve injury (CNI) after carotid endarterectomy (CEA). METHODS: 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 30 days. RESULTS: 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 30 days, 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%), 9 reoperations (0.7%) and 10 hospital readmissions (0.8%). Median duration of stay was 1 day (interquartile range, 1-2 days). 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, 32 months; 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). CONCLUSIONS: 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.

Face and neck: airway and sensorial capacities.

Face and neck: airway and sensorial capacities. For the assessment and the management of face and neck trauma knowledge of the neuro-anatomy and physiology of the ear, nose, throat (ENT) and head and neck (HN) region and structures is essential, as this area is particularly vulnerable to injury. Indeed, the complex anatomy and physiology in this specific area supports important basic functions. In addition, this review elaborates on upper airway and sensorial capacities. Upper airway dimensions are influenced by bony and soft tissues. Age is of fundamental importance in the upper airway assessment, as significant differences in size and proportions apply in children and adults. The cranial nerves (CN) supply motor, sensory ad special sensory fibres to the upper airway. Injury of the CN is a frequent complication of trauma.

Maxillofacial Fractures: Midface and Internal Orbit-Part I: Classification and Assessment.

Fractures of the midface and internal orbit occur isolated or in combination with other injuries. Frequently, the patients are first seen in emergency rooms responsible for the coordination of initial diagnostic procedures, followed by the transfer to specialties for further treatment. It is, therefore, important for all physicians treating facial trauma patients to understand the basic principles of injuries to the midface. Thus, this article aims to describe the anatomy and the current classification systems in use, the related clinical symptoms, and the essential diagnostic measures to obtain precise information about the injury pattern.

Post-traumatic Collet-Sicard syndrome: personal observation and review of the pertinent literature with clinical, radiologic and anatomic considerations.

STUDY DESIGN: The lesion of the lower four cranial nerves, commonly called Collet-Sicard syndrome, can be caused by a blunt head and neck trauma. It may be associated to an isolated fracture of the occipital condyle or of the atlas. OBJECTIVE: The aim of this report is to assess the modality of the trauma, the type of fracture, the anatomic characteristics, the treatment and clinical results of this syndrome. We discuss 14 cases of fracture of occipital condyle and of atlas and 1 personal case. METHODS: We analyzed 14 cases collected from the literature between 1925 and 2013, reported a further personal case and performed an anatomical study of the paracondylar, atlas and styloid process region. The anatomical dissection was performed to assess the anatomic relationships in the site of transit in which the nerves IX, X, XI and XII are injured. RESULTS: A total of 14 cases of p-CSS were collected: 9 caused by a condyle fracture and 5 by an atlas fracture. The patients were 13 males and only 1 female, 10 of them had a blunt trauma due to the result of axial loading (force directed through the top of the head and through the spine) falling on the head. The nine cases with a condyle fracture were associated to the dislocation of part of it, while those with atlas fractures showed the fracture and/or disjunction of the articular mass. The anatomical evaluations reveal that the lower four cranial nerves, at their emergency, pass through a close osteo-ligamentous space in relationship to the condyle. Below they run through a little wider channel between the articular mass of C1 and the styloid process. Two cases underwent surgical procedure. All the other cases were treated conservatively with immobilization of the cervical spine. During follow-up three cases with condylar fractures were found to be clinically unchanged and six showed modest improvements while one case with atlas fracture had a complete recovery and four improved significantly. CONCLUSIONS: The p-CSS is caused by force directed through the top of the head. We suppose that the nerve injuries are due to their laceration caused by a displacement of a condyle fragment or to their compression and stretching when they pass between the lateral mass of the atlas and the styloid process. These modalities of trauma explain the better clinical results in patients affected by C1 fractures. Conservative treatment is the option of choice. Surgical option, when choosed, is not considered to fix nerve damages.

Síndrome de Collet–Sicard como forma de presentación de las fracturas combinadas del atlas y cóndilosoccipitales / Collet–Sicard syndrome as presentation form of atlas and occipital condyles fracture

INTRODUCCIÓN: El síndrome de Collet–Sicard consiste en una afectación unilateral y combinada de los nervios craneales bajos, originado por lesiones en la base craneal.CASO CLÍNICO: Paciente masculino de 27 años de edad con antecedentes de sufrir accidente del tránsito. A su llegada al hospital refiere dolor cervical alto, voz apagada y dificultad para tragar. Al examen físico se constata la paresia de los nervios craneales bajos. Se realizan radiografías de columna cervical y tomografía axial de región cráneo espinal. Se diagnostica una fractura de los cóndilos occipitales y una fractura tipo II del atlas. Se coloca un halo chaleco. Se consulta al paciente al final del primer mes de tratamiento con alivio del dolor cervical y sin empeoramiento neurológico.CONCLUSIONES: La afectación de los nervios craneales bajos puede ser la forma clínica de presentación de las lesiones traumáticas de la región cráneo espinal. Su reconocimiento temprano favorece el pronóstico de estos pacientes(AU)

INTRODUCTION: ColletSicard syndrome is a combined unilateral involvement and lower cranial nerves, caused by damage in cranial base.CLINICAL CASE: Male patient, 27 years old with history of suffering a traffic accident. Upon arrival at the hospital hereferred high cervical pain, muffled voice and difficult to swallowing. Physical examination detects lower cranial nerve paresis. Radiography, and cervical spine and skull–spinal region CT was performed. The diagnosis was fracture of the occipital condyles and type II fracture of the atlas. After that he was treated with placement of halo vest. The follow up consultation at the end of the first month of treatment showed cervical pain relief without neurological deterioration.CONCLUSIONS: The lower cranial nerve involvement can be the clinical presentation of traumatic injuries of the skull spinal region. Its early recognition is related with better prognosis of these patients(AU)

Lesiones de múltiples nervios craneales luego de traumatismo craneal cerrado: reporte de caso y revisión del tema / Multiple cranial nerve injuries following closed head trauma: case report and review

La lesión de los nervios craneales es un acompañamiento común de un trauma en la cabeza. Lesiones de los nervios craneales asociados con la lesión cerrada de la cabeza ha sido encontrado para ser asociado con una mayor gravedad de la lesión. Los objetivos de este estudio son documentar la incidencia de lesiones de los nervios craneales en lesiones en la cabeza, que se correlaciona con la incidencia de los hallazgos radiológicos, para evaluar el tiempo de recuperación con respecto a los signos y síntomas en la presentación inicial. Se presenta un caso de un varón de 51 años de edad, con lesiones nerviosas del segundo, sexto, séptimo, octavo, noveno y décimo después de una lesión grave en la cabeza. Lo admitieron a la víctima con un historial de conducir una motocicleta utilizando un casco y con una caída a alta velocidad. Su Resonancia Magnética (RM) presenta contusión en el tronco cerebral y su tomografía computarizada (TC) simple mostró pequeña hemorragia a la derecha del tronco cerebral y el paciente fue tratado de forma conservadora. Por otra parte, si se detectan múltiples lesiones de los nervios craneales hay una necesidad de evaluar más a fondo la lesión del tronco cerebral por RM con el fin de evaluar mejor el tronco cerebral. La mayoría de las lesiones de los nervios craneales pueden recibir tratamento conservador, aunque algunos autores indican intervención quirúrgica temprana para el tratamiento de la parálisis facial con fractura a través del canal facial.

Injury to the cranial nerves is a common accompaniment of head trauma. Cranial nerve injuries associated with closed head trauma has been found to be associated with injuries of a higher severity. The incidence of cranial nerve injury in head trauma varies in the literature, ranging from 5 to 23 percent. The objectives of this study are: to document the incidence of cranial nerve injuries in head trauma; to correlate the incidence with radiological findings and to assess recovery time according with signs and symptoms at initial presentation. We report a case of a 51-year-old male having second, sixth, seventh, eighth, ninth and tenth nerve injuries after severe head trauma. He was admitted after an accident with a history of riding a motorcycle wearing a helmet and falling at high speed. Study by Magnetic Resonance Imaging (MRI) of this case presented stem contusion and a plain Computerized Tomography (CT) showed small hemorrhage on the right of the brain stem. The patient was managed conservatively. Multiple cranial nerve palsies after head injury may not carry a bad prognosis as previously thought, and may be reversible. Moreover, if multiple cranial nerve injuries are detected, a better evaluation of the stem brain is needed by MRI in order to evaluate possible lesions in this site. The majority of the cranial nerve injuries are treated conservatively, although some authors indicate early surgical intervention to treat facial palsy with fracture through the facial canal.