Intracranial Hypotension with Coma: Microsurgical Repair of a Spinal Ventral Dural Tear and Drainage of Subdural Hematoma with Intracranial Pressure Monitoring.

Abstract

Difficulties are associated with the diagnosis and management of patients with coma because of intracranial hypotension. A 70-year-old man with coma (Glasgow Coma Scale score of 6) with fixed dilated pupils because of severe intracranial hypotension is described. After unsuccessful epidural blood patch (EBP), the patient underwent microsurgical dural repair and drainage of hematoma with intracranial pressure (ICP) monitoring. Intraoperatively, a dural tear associated with a cerebrospinal fluid (CSF) leak was identified at the thoracolumbar junction ventral to the spinal cord. The dural tear was repaired using posterior laminoplasty with a transdural approach without spinal fixation. Immediately after surgery, ICP was low, but it recovered to a physiologic range in 4 hours. Consciousness level favorably improved in a week, and the patient has remained stable for 1.5 years with good quality of life without recurrence. The patient represents the first described case, to our knowledge, of intracranial hypotension with coma because of a CSF leak caused by a spinal ventral dural tear. In the setting of failed EBP attempt, our technique may be a treatment option for severe intracranial hypotension.