Takagi H, Miyasaka Y, Kuramae T, Ohwada T, Tsunoda M
No Shinkei Geka. 1976 Oct;4(10):963-9.
Three cases of bilateral traumatic abducens nerve palsy were presented and the mechanism of damage to the abducens nerve was discussed in relation to the analysis of traumatic force at the time of impact and topographical anatomy of the abducens nerve in detail. Case 1. A 70 year old man sustained a traffic accident with one hour loss of consciousness. Physical examination revealed a contused area on the medial side of his right forehead. Neurological examination revealed bilateral abducens nerve palsy (Fig. 1). There were no ther cranial nerve abnormalities. Roentgenograms of the skull, including views of the base and orbit showed no fracture. At follow up examination 12 months later, bilateral Duane's retraction syndrome could be noticed with slight increase in size of the pupil on each side of lateral gaze (Fig. 2). Case 2. A 32 year old women sustained a traffic accident with 31 days of loss of consciousness. At the time of admission, bilateral abducens nerve palsy and slight left hemiparesis were noticed in semicomatose condition. Right carotid angiogtam showed no evidence of intracranial hematoma. One month later, the right eye began to abduct and 2 months later, the left eye began to abduct. Three months after the injury, bilateral abducens nerve palsy could no longer be demonstrated. No retraction syndrome was observed during this period. Case 3. A 3 year old boy sustained a traffic accident with 32 days of loss of consciousness. At the time of admission, neurological examination showed bilateral abducens palsy and left sided decerebrate posture in comatose condition. At the time of discharge 3 months after admission, bilateral abducens palsy, right hemiataxia, left spastic hemiparesis and scanning speach were noticed. Three months later, right eye began to abduct and 4 months later, the left eye began to abduct. At follow up examination 6 months later, there was no evidence of abducens nerve palsy. Topographical details of anatomy of the abducens nerve are shown in Fig. 3, 4. It is greatly speculated that both abducens nerves are streched by the lineal accerelated force on mid sagittal plane at the time of impact, then the apex of petrous pyramid acts as the fulculum, so that the abducens nerves are compressed, contused and streched at this point (Fig. 5-a). The authors pointed out that the abducens nerve are impossible to be damaged at the petroclinoid ligament (Grüber's lig.) by the upward movement of the brainstem, because the abducens nerve is fixed downward below this ligament by the dura and apex of the petrous pyramid (Fig. 4-b, c). One case showed bilateral acquired retraction syndrome with slight increase in size of the pupil on each side of lateral gaze, the fact greatly suggesting that the sympathetic nerve have intimate relationship to the miss direction during the recovery stage of abducens nerve palsy.
本文报告了3例双侧外伤性展神经麻痹病例，并结合撞击时的外力分析及展神经的局部解剖，详细探讨了展神经的损伤机制。病例1：一名70岁男性遭遇交通事故，昏迷1小时。体格检查发现其右前额内侧有挫伤区。神经学检查显示双侧展神经麻痹（图1）。无其他颅神经异常。头颅X线片，包括颅底和眼眶视图，未见骨折。12个月后的随访检查发现，双侧出现杜安退缩综合征，外展时两侧瞳孔略有增大（图2）。病例2：一名32岁女性遭遇交通事故，昏迷31天。入院时，在半昏迷状态下发现双侧展神经麻痹及轻度左侧偏瘫。右侧颈动脉血管造影未显示颅内血肿。1个月后，右眼开始外展，2个月后，左眼开始外展。受伤3个月后，双侧展神经麻痹消失。在此期间未观察到退缩综合征。病例3：一名3岁男孩遭遇交通事故，昏迷32天。入院时，神经学检查显示昏迷状态下双侧展神经麻痹及左侧去大脑强直姿势。入院3个月出院时，发现双侧展神经麻痹、右侧偏瘫、左侧痉挛性偏瘫及吟诗样言语。3个月后，右眼开始外展，4个月后，左眼开始外展。6个月后的随访检查未发现展神经麻痹迹象。展神经解剖的局部细节见图3、4。据推测，撞击时双侧展神经在矢状中平面受到线性加速力牵拉，然后岩尖作为支点，致使展神经在此处受到挤压、挫伤和牵拉（图5 - a）。作者指出，展神经不可能因脑干上移而在岩床韧带（格鲁伯韧带）处受损，因为展神经在该韧带下方被硬脑膜和岩尖向下固定（图4 - b、c）。1例出现双侧获得性退缩综合征，外展时两侧瞳孔略有增大，这一事实强烈提示交感神经在展神经麻痹恢复阶段与眼球运动异常密切相关。
