In a series of 109 carotid arterial reconstructions cranial nerve injury was observed in 14 of 102 patients. Ipsilateral peripheral hypoglossal nerve injury occurred in nine patients with carotid occlusive disease. The marginal mandibular nerve was injured in three patients and recurrent laryngeal nerve dysfunction was noted in four patients. Two cranial nerves were injured in two patients. Full recovery of hypoglossal dysfunction was seen within 2-52 weeks (average 20 weeks). The nerves are injured by retraction to clear the operative field or by postoperative haematoma. Risk factors include crossing of the hypoglossal nerve close to the carotid bifurcation or procedures requiring long arteriotomy or skeletonization of the internal carotid artery. Unilateral cranial nerve injury is usually mild but will require delay of controlateral carotid reconstruction to avoid severe bilateral cranial nerve palsy.