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Cranial and cervical nerve injuries after repeat carotid endarterectomy

Ali F. AbuRahma, MD,a and Mark A. Choueiri, MD,b Charleston, WVa

Background and Purpose: The incidence of cranial and/or cervical nerve injuries after pri- mary carotid endarterectomy (CEA) ranges from 3% to 48%; however, the clinical out- come of these injuries after repeat CEA has not been thoroughly analyzed in the English- language medical literature. This prospective study analyzes the incidence and outcome of cranial nerve injuries after repeat CEA. Patients and Methods: This study includes 89 consecutive patients who had repeat CEAs. Preoperative and postoperative cranial nerve evaluations were performed, including clin- ical examinations (neurologic) and direct laryngoscopy. Patients with vagal or glos- sopharyngeal nerve injuries also underwent comprehensive speech evaluations, video stroboscopy, fluoroscopy, and methylene blue testing for aspiration. Patients with post- operative cranial nerve injuries were followed up for a long time to assess their recovery. Results: Twenty-five cranial and/or cervical nerve injuries were identified in 19 patients (21%). They included 8 hypoglossal nerves (9%), 11 vagal nerves or branches (12%) (6 recurrent laryngeal nerves [7%], 3 superior laryngeal nerves [3%], and 2 complex vagal nerves (2%]), 3 marginal mandibular nerves (3%), 2 greater auricular nerves (2%), and 1 glossopharyngeal nerve (1%). Twenty-two (88%) of these injuries were transient with a complete healing time ranging from 2 weeks to 28 months (18 of 22 injuries healed with- in 12 months). The remaining three injuries (12%) were permanent (1 recurrent laryn- geal nerve, 1 glossopharyngeal nerve, and 1 complex vagal nerve injury). The recurrent laryngeal nerve injury had a longer healing time than the other cranial nerve injuries. Conclusions: Repeat CEA is associated with a high incidence of cranial and/or cervical nerve injuries, most of which are transient. However, some of these have a long healing time, and a few can be permanent with significant disability. (J Vasc Surg 2000;32:649-54.)

With a larger number of patients undergoing and in good-risk patients with asymptomatic high- carotid endarterectomy (CEA) and with the use of grade (> 80%) recurrent stenotic lesions.1-7 In many postoperative carotid duplex scan surveillance, an studies it has been reported that repeat CEA can be increasing number of recurrent carotid artery stenoses performed by vascular surgeons, with morbidity and are being detected.1-7 Some patients with recurrent mortality rates somewhat similar to that of primary carotid stenoses are symptomatic and are referred for CEA.2-4,6,7 The major complication rates examined repeat CEAs. Most authors advocate a repeat CEA in usually involve stroke, myocardial infarction, and patients with severe symptomatic recurrent stenosis death. Cranial nerve injuries are usually considered minor complications. In multiple studies, researchers From the Vascular Sectiona and the Department of Surgery,a,b the have described cranial nerve injuries after primary Robert C. Byrd Health Sciences Center of West Virginia CEA. The incidence of these injuries is highly variable University and the Charleston Area Medical Center. according to the type of study performed (prospective Competition of interest: nil. vs retrospective) and how aggressively the injury is Presented at the Twenty-eighth Annual Symposium on Vascular sought.8-17 In several studies, a 3% to 48% incidence of Surgery of the Society for Clinical Vascular Surgery, Rancho Mirage, Calif, Mar 15-19, 2000. cranial nerve injury after a primary CEA has been 9-17 Reprint requests: Ali F. AbuRahma, MD, 3100 MacCorkle Ave, reported ; however, in most studies the range was SE, Suite 603, Charleston, WV 25304 (e-mail: ali.aburama@ 3% to 23%.16 The incidence of cranial nerve injury camcare.com). after repeat CEA is generally thought to be higher Copyright © 2000 by The Society for Vascular Surgery and The than after primary CEA because of the fibrotic tissue American Association for Vascular Surgery, a Chapter of the 4,6 International Society for Cardiovascular Surgery. reaction obscuring the planes of dissection. 0741-5214/2000/$12.00 + 0 24/6/109751 However, the clinical outcome of these injuries after doi:10.1067/mva.2000.109751 repeat CEA has not been thoroughly analyzed in the 649 JOURNAL OF VASCULAR SURGERY 650 AbuRahma and Choueiri October 2000

English-language medical literature. This prospective test to check for aspiration. These evaluations were study analyzes the incidence and outcome of cranial repeated within 30 days of the initial evaluation. nerve injury after repeat CEA. Patients who had cranial and/or cervical nerve injuries were entered into regular follow-up to assess PATIENTS AND METHODS delayed recovery. The following cranial and/or cervi- This prospective report analyzes the incidence of cal nerve injuries were specifically attended to: the cranial and cervical nerve injuries in 89 consecutive mandibular branch of the facial nerve, the vagal repeat CEAs (84 patients) during a 10-year period nerve and its branches (superior laryngeal nerve and (January 1988–December 1997). Patients were treat- recurrent laryngeal nerve), the glossopharyngeal ed by the vascular surgery service at the Charleston nerve, the hypoglossal nerve, the spinal accessory Area Medical Center, Robert C. Byrd Health Sciences nerve, and the greater auricular nerve. Center of West Virginia University, Charleston, WVa Division. The patients’ original CEA was performed RESULTS with primary closure, except in 5 cases where closure Eighty-four patients underwent 89 consecutive was achieved with a Hemashield patch in 3, a vein repeat CEAs; five patients had bilateral repeat CEAs. patch in 1, and a polytetrafluoroethylene patch in 1. Fifty-three patients were men, and 31 were women All patients had a repeat CEA with cardiovascular with a mean age of 66.5 years (range, 43-79 years). polytetrafluoroethylene patch angioplasty (Goretex, Indications for the repeat CEA included 71 (80%) of Flagstaff, Ariz) while they were under general anes- 89 CEAs for symptomatic recurrent severe carotid thesia with shunting. artery stenosis and 18 CEAs (20%) for asymptomatic All patients underwent preoperative clinical eval- high-grade (> 80%) stenosis, which was established uations before repeat CEA, including indirect by means of duplex scanning with magnetic reso- and/or direct laryngoscopy. All patients underwent nance angiography or arteriography. The incidence preoperative indirect laryngoscopy, whereas 21 of 30-day perioperative strokes was five (5.6%) of 89 patients underwent direct laryngoscopy: 5 who had a CEAs, with no perioperative mortality. prior history of cranial nerve injury, 5 who had bilat- Follow-up ranged from 6 to 126 months. eral CEA, and 11 others who had prior high carotid Twenty-five cranial and/or cervical nerve injuries lesion in the primary CEA or in whom findings were were identified in 19 patients (21%). They included found on indirect laryngoscopy. A speech therapy 8 hypoglossal nerves (9%), 11 vagal nerves or evaluation, an examination by an otolaryngologist, branches (12%) (6 recurrent laryngeal nerves [7%], and a comprehensive neurologic examination were 3 superior laryngeal nerves [3%], and 2 complex performed for five patients with a prior history sug- vagal nerve injuries [2%]), 3 marginal mandibular gestive of an injury to the cranial nerves: 2 with vagal nerves (3%), 2 greater auricular nerves (2%), and 1 nerve injuries, 2 with hypoglossal nerve injuries, and glossopharyngeal nerve (1%). 1 with an injury of the mandibular branch of the Twenty-two (88%) of these injuries were transient facial nerve. All of these patients had a complete with a complete healing time ranging from 2 weeks recovery before the repeat CEA. All patients under- to 28 months (18 of 22 healed within 12 months). went a postoperative comprehensive clinical (neuro- The remaining three injuries (12%) were permanent logic) examination and a laryngoscopic examination (1 recurrent laryngeal nerve, 1 glossopharyngeal (indirect and/or direct) before discharge. Again, all nerve, and 1 complex vagal nerve injury). patients underwent postoperative indirect laryn- When the three patients with permanent nerve goscopy, whereas 47 patients underwent direct laryn- injury were excluded, the average healing time (as goscopy. These patients included those who had pre- determined by clinical observation and laryngoscopy operative direct laryngoscopy and patients with a examination) for these nerves were as follows: clinical picture suspicious of cranial nerve injury (eg, hypoglossal nerve, 3.5 months; great auricular voice changes, difficulty in swallowing, evidence of nerve, 5 months; marginal mandibular nerve, 6.2 other cranial nerve injury, indirect laryngoscopy find- months; vagal nerve, 6.8 months; superior laryngeal ings). Also, patients with clinical evidence of postop- nerve, 8.5 months; and recurrent laryngeal nerve, erative cranial nerve injury were thoroughly evaluat- 13.5 months. The recurrent laryngeal nerve injury ed by a speech therapist and an otolaryngologist. had a longer healing time than the other cranial Patients with a vagal nerve injury or glossopharyn- nerve injuries. geal nerve injury also underwent a video stro- Fifteen patients in our series experienced postop- boscopy, a video fluoroscopy, and a methylene blue erative hoarseness or voice changes. However, dur- JOURNAL OF VASCULAR SURGERY Volume 32, Number 4 AbuRahma and Choueiri 651 ing comprehensive examination, including fiberop- sias. The greater auricular nerve courses over the tic laryngoscopy, only 11 of these patients were doc- superior aspect of the sternocleidomastoid muscle, umented to have injury to the vagal nerve or its providing sensation over the earlobe and an angle of branches. Four injuries were thought to result from the mandible. Injury to the greater auricular nerve endotracheal intubation. leads to numbness at its site of innervation. The transverse cervical nerve also arises from beneath the DISCUSSION posterior aspect of the sternocleidomastoid muscle The incidence of patients with recurrent carotid and courses anteriorly over its surface. Division of stenosis who require reoperation appears to be this nerve leads to cutaneous anesthesia to the ante- approximately 2% to 10%.2,4,6,7,18 The typical repeat rior cervical triangle. Dehn and Taylor11 described a CEA is considered to be more technically difficult high incidence of cutaneous nerve injury with a 60% than the primary surgery. Therefore, cranial nerve greater auricular nerve injury and 69% transverse injury is expected to be a more common complica- cervical nerve injury at 1 week postoperatively. tion after repeat surgery. Major cranial and cervical Although most patients recovered, 20% continued nerve injuries after CEA can result in a wide variety to complain of symptoms at 6 months. of clinical manifestations, from mild sensory deficits Injury to the marginal mandibular branch of the to life-threatening airway obstructions. facial nerve typically leads to an ipsilateral lower lip It has been well documented that cranial and cer- droop and lip biting. The marginal mandibular vical nerve damage is related to local trauma to the branch emerges from the parotid gland and courses nerve by means of retraction, stretching, clamping, below the angle of the mandible toward the mouth. and transection. However, most of the clinical injuries This nerve lies beneath the platysma muscle. occur from nerve damage during retraction.9-21 Hyperextension of the neck and rotation to the Careful surgical techniques and a thorough knowl- opposite side cause this nerve to be more inferior edge of the usual and atypical locations of the nerves and places it at an increased risk for injury during are necessary for surgeons who perform CEAs. superior extension of the incision and upward retrac- Cranial nerve injuries are thought to occur more tion. It is recommended that the superior aspect of frequently after reoperative carotid surgery because the incision be curved posteriorly toward the mas- of the dense fibrotic tissue reaction creating a much toid process to avoid injury. In addition, when supe- more difficult dissection.6 Despite the presumed rior exposure is needed, retractors should be kept higher frequency of cranial nerve injury in repeat away from the angle of the mandible and should be CEA, the incidence in several studies has been superficial to the platysma muscle.16 reported to vary from 2.4% to 18.9%.5,22 These data The glossopharyngeal nerve is located at the base are very similar to the rates reported for primary of the skull. It passes through the jugular foramen CEA. The incidence of cranial and/or cervical nerve and proceeds anteriorly to the distal internal carotid injury in our series was 21%, with most being vagal artery to provide motor and sensory innervation to and hypoglossal nerve injuries. This incidence was the pharynx and sensory and taste to the posterior higher than what we reported previously after pri- third of the tongue. Because of its location, it is mary CEA (2%).23 Other authors report that most rarely injured during CEA. Only one case of glos- of the cranial nerve injuries after repeat CEA are sopharyngeal nerve injury was noted in our series. transient.4-7 Similar observations were noted in our The risk of injury increases as dissection proceeds series where most of the nerve dysfunction improved superiorly to the posterior belly of the digastric mus- with time. However, the healing time was quite vari- cle. Damage to the glossopharyngeal nerve can able: from 2 weeks to 28 months. In addition, 12% result in uvula deviation and dysphagia with a poten- of these injuries in our patients were permanent, and tial risk of aspiration. four (18%) of 22 injuries healed after more than a Vagal nerve injuries have been well documented year. These injuries can cause significant prolonged in the medical literature. The vagus nerve and its disability and may even require further surgery for branches can be damaged as a result of direct injury palliation of symptoms and improvement of function to the vagal trunk during dissection, retraction, or (eg, gastrostomy tube [4 patients], Teflon injection clamping. The recurrent laryngeal nerve can also be of paralyzed vocal cords [3 patients], and cricopha- damaged by retraction, because it lies within the tra- ryngeal myotomy [3 patients]). cheoesophageal groove. These injuries can be the Injury to the two main cervical nerves in the area most devastating to the patient. Clinical manifesta- can lead to disturbing sensory deficits and paresthe- tions range from mild symptoms of hoarseness and JOURNAL OF VASCULAR SURGERY 652 AbuRahma and Choueiri October 2000 loss of effective cough mechanism, to upper pharyn- pain and an inability to raise the shoulder above the geal dysphagia with aspiration, to life-threatening horizontal plane.20 A physical examination may airway obstruction from bilateral recurrent laryngeal reveal mild scapular winging, a drooped shoulder, nerve injury. Injuries can involve the recurrent and superolateral displacement of the scapula. laryngeal nerve, superior laryngeal nerve, and the Shoulder and neck pain may occur as a result of vagus trunk. The vagus nerve exits the skull through fatigued muscles and ligaments. the jugular foramen and descends into the carotid The hypoglossal nerve exits the cranium through sheath posterolateral to the common carotid artery the hypoglossal canal, coursing posterior to the and internal jugular vein. Occasionally, the vagus carotid and internal jugular vein and subsequently nerve may be found in an anterior position to the passing medially across the internal and external common carotid artery (in < 5% of patients), where carotid arteries. It innervates the tongue for motor it can be mistaken for an ansa cervicalis. function. Injury to the hypoglossal nerve usually pre- The superior laryngeal nerve courses posterior to sents with tongue deviation to the side of injury. the carotid artery, passing adjacent to the superior Profound dysfunction can produce tongue biting and thyroid artery, and divides into external and internal dysarthria.16 Bilateral hypoglossal nerve injury can branches. The external branch innervates the produce upper airway obstruction in supine patients. cricothyroid muscle. Injury to the superior laryngeal Our cranial nerve injury rate was higher than that nerve or the external branch leads to an inability to reported by other authors. This may be attributed to hit high-pitched notes and easy voice fatigue. This the type of postoperative evaluation performed and can be a cause for concern in singers and public how aggressively the injuries were sought. Because of speakers. The internal branch provides sensation to the increased difficulty of dissection, we think that the supraglottic mucosa of the larynx. Injury to the cranial nerve injury after repeat CEA is higher than internal branch can lead to aspiration. Curran et al19 previously reported after primary CEA. We agree propose that superior laryngeal nerve injury can be with the assessment of Hill et al7 that repeat carotid avoided by dissecting close to the superior thyroid surgery should be performed by surgeons with artery and carotid bifurcation. extensive experience in reoperative carotid surgery. The recurrent laryngeal nerve usually takes off in Prevention of cranial nerve injuries after repeat CEA the mediastinum with the left recurrent laryngeal has been proposed as a reason to endorse carotid nerve looping around the aortic arch and the right angioplasty and stenting for patients with recurrent recurrent laryngeal nerve looping around the subcla- carotid stenosis. Further studies regarding the risks vian artery. The recurrent laryngeal nerve typically rises and benefits of carotid angioplasty will help deter- toward the larynx through the tracheoesophageal mine its place in recurrent carotid stenosis. groove. Occasionally, a nonrecurrent laryngeal nerve A detailed knowledge of the anatomy of these branches off the vagus at the carotid bifurcation, cross- nerves is essential to minimize cranial nerve injuries. ing posterior to the common carotid artery to enter It is critical to protect the vagus nerve during carotid the larynx. Damage to the vagus or recurrent laryngeal dissection and to separate it from the carotid poste- nerve leads to ipsilateral vocal cord paralysis, which riorly so it is not caught when the vascular clamps produces hoarseness and a poor cough mechanism. are applied. Excessive manipulation of the carotid Schauber et al16 have reported on the inaccuracy of sheath posteriorly should be avoided. Sharp retrac- diagnosing true vocal cord paralysis with indirect tor blades should be applied carefully to avoid trac- laryngoscopy. They advocate that all patients who are tion injury of the vagus nerve or the recurrent laryn- to undergo a contralateral CEA need to be evaluated geal nerve within the tracheoesophageal groove. for true vocal cord function with direct laryngoscopy Coagulating current should be used carefully to con- because bilateral recurrent laryngeal nerve injury can trol bleeding points beside these nerves. Dissection result in life-threatening airway obstruction. of the vessels should be carried out as close as possi- The spinal accessory nerve, which is rarely ble to the vessel wall to minimize nerve injuries. injured, exits the skull from the jugular foramen and Excessive hyperextension of the neck during patient proceeds lateral to the carotid artery. It provides positioning should be avoided. Surgeons should also motor function to the sternocleidomastoid and routinely inform their patients of the potential risk trapezius muscles. Injury to this nerve may occur of cranial nerve injuries after repeat CEA. with high lateral retraction on the sternocleidomas- In conclusion, we found a higher incidence of toid muscle. A patient with an injury to the spinal cranial nerve injuries after repeat CEA than has been accessory nerve presents with shoulder and neck previously reported. Most of these injuries are tran- JOURNAL OF VASCULAR SURGERY Volume 32, Number 4 AbuRahma and Choueiri 653

sient. However, some have a long healing time, and 13. Knight FW, Yeager RM, Morris DM. Cranial nerve injuries a few can be permanent with significant disability. during carotid endarterectomy. Am J Surg 1987;154:529-32. 14. Aldoori MI, Baird RN. Local neurologic complication during REFERENCES carotid endarterectomy. J Cardiovasc Surg 1988;29:432-6. 1. Rapp J, Stoney R. Recurrent carotid stenosis. In: Bernhard 15. Forssell C, Kitzing P, Bergqvist D. Cranial nerve injuries after VM, Towne JB, editors. Complications in vascular surgery. carotid artery surgery: a prospective study of 663 operations. 2nd ed. Orlando: Grune & Stratton; 1985. p. 763-73. Eur J Vasc Endovasc Surg 1995;10:445-9. 2. Coyle KA, Smith RB III, Gray BC, Salam AA, Dodson TF, 16. Schauber MD, Fontenelle LJ, Solomon JW, Hanson TL. Chaikof EL, et al. Treatment of recurrent cerebrovascular disease: Cranial/cervical nerve dysfunction after carotid endarterec- review of a 10-year experience. Ann Surg 1995;221:517-24. tomy. J Vasc Surg 1997;25:481-7. 3. Bartlett FF, Rapp JH, Goldstone J, Ehrenfeld WK, Stoney 17. Ballotta E, Da Giau G, Renon L, Narve S, Saladini M, RJ. Recurrent carotid stenosis: operative strategy and late Abbruzzese E, et al. Cranial and cervical nerve injuries after results. J Vasc Surg 1987;5:452-6. carotid endarterectomy: a prospective study. Surgery 1999; 4. Nitzberg RS, Mackey WC, Prendiville E, Foster E, Kastinakis 125:85-91. W, Belkin M, et al. Long-term follow-up of patients operated 18. AbuRahma AF, Robinson PA, Saiedy S, Khan JH, Boland JP. on for recurrent carotid stenosis. J Vasc Surg 1991;13:121-6. Prospective randomized trial of carotid endarterectomy with 5. Treiman GS, Jenkins JM, Edwards WH Sr, Barlow W, Edwards primary closure and patch angioplasty with saphenous vein, WH Jr, Martin RS III. The evolving surgical management of jugular vein, and polytetrafluoroethylene: long-term follow- recurrent carotid stenosis. J Vasc Surg 1992;16:354-63. up. J Vasc Surg 1998;27:222-34. 6. Mansour MA, Kang SS, Baker WH, Watson WC, Littooy FN, 19. Curran AJ, Smyth D, Sheehan SJ, Joyce W, Hayes DB, Walsh Labropoulos N, et al. Carotid endarterectomy for recurrent MA. Recurrent laryngeal nerve dysfunction following carotid stenosis. J Vasc Surg 1997;25:877-83. endarterectomy. J R Coll Surg Edinb 1997;42:168-70. 7. Hill BB, Olcott C IV, Dalman RL, Harris EJ Jr, Zarins CK. 20. Yagnik P, Chong P. Spinal accessory nerve injury: a complica- Reoperation for carotid stenosis is as safe as primary carotid tion of carotid endarterectomy. Muscle Nerve 1996;19:907-9. endarterectomy. J Vasc Surg 1999;30:26-35. 21. Sweeney P, Wilbourn A. Spinal accessory (11th) nerve palsy 8. DeBoard JR, Marshall WH, Wyffels PL, Marshall JS, following carotid endarterectomy. Neurology 1992;42:674-5. Humphrey P. Carotid endarterectomy in a community hos- 22. O’Donnell TF, Rodriguez AA, Fortunato JE, Welch JH, pital surgical practice. Am Surg 1991;57:627-33. Mackey WC. Management of recurrent carotid stenosis: 9. Hertzer NR, Feldman BJ, Beven EG, Tucker HM. A should asymptomatic lesions be treated surgically? J Vasc prospective study of the incidence of injury to the cranial Surg 1996;24:207-12. nerves during carotid endarterectomy. Surg Gynecol Obstet 23. AbuRahma AF, Khan JH, Robinson PA, Saiedy S, Short YS, 1980;151:781-4. Boland JP, et al. Prospective randomized trial of carotid 10. Evans WE, Mendelowitz DS, Liapis CD, Wolfe V, Florence endarterectomy with primary closure and patch angioplasty CL. Motor speech deficit following carotid endarterectomy. with saphenous vein, jugular vein, and polytetrafluoroethylene: Ann Surg 1982;196:461-4. perioperative (30-day) results. J Vasc Surg 1996;24:998-1007. 11. Dehn TC, Taylor GW. Cranial and cervical nerve damage asso- ciated with carotid endarterectomy. Br J Surg 1983;70:365-8. 12. Theodotou B, Mahaley MS Jr. Injury of the peripheral cranial nerves during carotid endarterectomy. Stroke 1985;16:894-5. Submitted Mar 27, 2000; accepted Jun 6, 2000.

DISCUSSION Dr John Ricotta (New York, NY). Can you clarify the cases that they believe there is a dramatic difference in the number of cranial nerve injuries and how many of these threshold of injury to different cranial nerves and to the were permanent and how many were transient? I’m afraid same traction or same injury that some nerves will either that if these numbers were misinterpreted, then many not show the same degree of injury or will recover much people will see this as justification for carotid stenting more quickly. That doesn’t seem to be implied in your rather than a redo CA. study, whether you’re talking about more severe or less Dr Ali F. Abu Rahma. This is an excellent point. Let me severe injuries to those nerves or whether the threshold is remind the audience that the incidence of permanent cra- different. For example, they tell me that the hypoglossal nial nerve injury was 3%; however, in two patients (around nerve, unless it’s divided, virtually always recovers and has 2%), the injuries were permanent with serious conse- tremendous resistance to traction. I guess my question for quences. When this is combined with an overall 5.5% peri- you is, can you give us some advice as to what nerves we operative stroke rate, this number, in my judgment, is very should take great steps to avoid, even placing traction, such reasonable when compared with the reported incidence of as I would do, for the phrenic nerve as opposed to nerves perioperative strokes using carotid stenting, which varies that might tolerate significant manipulation in getting to between 5% and 10%. these very difficult areas for recurrent carotid stenosis? Dr Peter F. Lawrence (Irvine, Calif). I enjoyed your Dr Abu Rahma. That’s an excellent point. This is presentation. I’ve learned from working with head and reflected by injuries to the hypoglossal nerve, which were neck cancer colleagues working on complex head and neck the quickest to recover. Gentle retraction on the hypoglos- JOURNAL OF VASCULAR SURGERY 654 AbuRahma and Choueiri October 2000 sal nerve can be tolerated; however, retraction or injury of Dr Frank Criado (Baltimore, Md). I feel that this is other nerves such as the recurrent laryngeal nerve may not important information, and it is particularly significant be tolerated as well. In our series, this nerve required the coming from an acknowledged center of excellence. We in longest recovery time. The same thing is applicable to the Baltimore have been treating these patients with percuta- vagal nerve. neous endovascular stent placement since 1994 and feel Dr J. Dennis Baker (Los Angeles, Calif). One thing that this technique of stenting really has a bright future for that wasn’t clear was whether you carried out the same selected indications, and as Dr Ricotta suggested, I am careful and thorough evaluation preoperatively so that you one of those guys who is going to use this information to could define whether deficits were new or preexisting further justify their practice. from the original operation. Dr Abu Rahma. I agree with your comments; howev- Dr Abu Rahma. You make a good point. This is thor- er, keep in mind that the incidence of permanent cranial oughly defined in the manuscript. nerve injury was only 2% to 3%.

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