Objective To explore the neuroprotective effect of preoperative diffusion tensor imaging (DTI) reconstruction combined with intraoperative electrophysiological monitoring of facial auditory nerve on acoustic neuroma.Methods The medical records of 82 patients with acoustic neuroma treated in Suzhou hospital from July 2016 to October 2021 were selected and analyzed retrospectively. They were divided into study group and control group according to the treatment scheme. The control group (41 cases) underwent plain and enhanced magnetic resonance imaging (MRI) before operation, and the study group (41 cases) combined with DTI facial nerve reconstruction on the basis of the control group. The spatial position of tumor and facial nerve, the accuracy of facial nerve routing, the length of operation, the amount of intraoperative bleeding and surgical resection were compared between the two groups, and the postoperative complications of the two groups were recorded. The facial nerve function and postoperative hearing level of the affected side were compared between the two groups.Results The accuracy of preoperative nerve course detection in the study group was compared by χ²-test, the difference was statistically significant (P < 0.05), and the study group was higher than the control group. There was no significant difference between the two groups in the spatial relationship between facial nerve and tumor (P > 0.05). The amount of intraoperative bleeding and the length of operation in the study group were significantly different by t-test (P < 0.05), which was less in the study group than in the control group. There was no significant difference between the two groups by χ²-test (P > 0.05). There was no significant difference in the functional grade of facial nerve between the two groups before operation by rank sum test (P > 0.05). The rank sum test showed that the facial nerve function of the study group was better than that of the control group (P < 0.05). After rank sum test, there was no significant difference between the two groups (P > 0.05). There was no significant difference in the incidence of postoperative complications between the two groups by χ²-test (P > 0.05).Conclusion The application of preoperative DTI reconstruction combined with intraoperative electrophysiological monitoring of facial auditory nerve in acoustic neuroma resection is more helpful to improve the positioning accuracy of facial nerve before operation, shorten the operation time, reduce the amount of intraoperative bleeding, and reduce the risk of facial nerve function injury.