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<p>The abducens nerve’s long intracranial course makes it highly vulnerable to injury during traumatic brain injury. While traditionally attributed to skull base fractures, high-resolution MRI has identified avulsion in cistern as a significant, yet underrecognized, mechanism, which can occur even without adjacent fractures.&#xa0;The study retrospectively analyzed 31 patients with traumatic abducens nerve palsy and radiologically suspected or surgically confirmed cisternal segment avulsion. Injuries were classified via MRI as complete or partial/suspected avulsion. Patients received different treatments: neurosurgical intervention (<i>n</i> = 8, including exploration, microvascular decompression, end-to-end anastomosis, or trigeminal motor branch-abducens nerve anastomosis), strabismus surgery (<i>n</i> = 7), or medication alone (<i>n</i> = 16). Outcomes were assessed using a standardized symptom improvement score (0–4, higher scores represent better recovery).&#xa0;The cohort included 13 males (41.9%) and 18 females (58.1%), with a median age of 56 years. The cause of injury were traffic accidents in 27 cases (87.1%) and falls in 4 cases (12.9%). The palsy was left-sided in 14 patients (45.2%), right-sided in 14 (45.2%), and bilateral in 3 (9.7%). The MRI revealed 16 (47.1%) sides of complete avulsion and 18 (52.9%) sides of partial/suspected avulsion of abducens nerves. Over a follow-up period of 3–96 months, a significant difference in symptomatic improvement was observed among the three treatment groups (Generalized estimating equation model, <i>P</i> &lt; 0.001). The strabismus surgery group showed the most substantial improvement (mean score: 2.54), followed by the neurosurgery group (mean score: 2.13), while the medication group demonstrated the least improvement (mean score: 1.10).&#xa0;Avulsion at the cisternal segment is a critical mechanism of traumatic abducens nerve palsy. High-resolution MRI is indispensable for accurate diagnosis. A tailored, multi-disciplinary approach is paramount. Strabismus surgery offers predictable relief for established deficits, while timely microvascular decompression can benefit selected patients with partial/suspected avulsions and vascular compression. Direct nerve repair remains a crucial, though challenging, pursuit in complete avulsions.</p>

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Isolated traumatic abducens nerve avulsion in the cisternal segment: mechanism, diagnosis and neurosurgical treatment

  • 期刊论文

  • 发表日期：

    2026年1月23日

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  • Zhongding Zhang,
  • Baimiao Wang,
  • Xianda Wu,
  • Wenyan Yang,
  • Zhuoning Tang,
  • Haopeng Wang,
  • Xiaomin Cai,
  • Hua Zhao,
  • Jin Zhu,
  • Xin Zhang,
  • Yinda Tang,
  • Baohui Feng,
  • Shiting Li

摘要

The abducens nerve’s long intracranial course makes it highly vulnerable to injury during traumatic brain injury. While traditionally attributed to skull base fractures, high-resolution MRI has identified avulsion in cistern as a significant, yet underrecognized, mechanism, which can occur even without adjacent fractures. The study retrospectively analyzed 31 patients with traumatic abducens nerve palsy and radiologically suspected or surgically confirmed cisternal segment avulsion. Injuries were classified via MRI as complete or partial/suspected avulsion. Patients received different treatments: neurosurgical intervention (n = 8, including exploration, microvascular decompression, end-to-end anastomosis, or trigeminal motor branch-abducens nerve anastomosis), strabismus surgery (n = 7), or medication alone (n = 16). Outcomes were assessed using a standardized symptom improvement score (0–4, higher scores represent better recovery). The cohort included 13 males (41.9%) and 18 females (58.1%), with a median age of 56 years. The cause of injury were traffic accidents in 27 cases (87.1%) and falls in 4 cases (12.9%). The palsy was left-sided in 14 patients (45.2%), right-sided in 14 (45.2%), and bilateral in 3 (9.7%). The MRI revealed 16 (47.1%) sides of complete avulsion and 18 (52.9%) sides of partial/suspected avulsion of abducens nerves. Over a follow-up period of 3–96 months, a significant difference in symptomatic improvement was observed among the three treatment groups (Generalized estimating equation model, P < 0.001). The strabismus surgery group showed the most substantial improvement (mean score: 2.54), followed by the neurosurgery group (mean score: 2.13), while the medication group demonstrated the least improvement (mean score: 1.10). Avulsion at the cisternal segment is a critical mechanism of traumatic abducens nerve palsy. High-resolution MRI is indispensable for accurate diagnosis. A tailored, multi-disciplinary approach is paramount. Strabismus surgery offers predictable relief for established deficits, while timely microvascular decompression can benefit selected patients with partial/suspected avulsions and vascular compression. Direct nerve repair remains a crucial, though challenging, pursuit in complete avulsions.