Abstract
Cerebrospinal fluid (CSF) leakage due to large ventral dural tears (VDT) often requires
surgical intervention. Surgical closure of a high thoracic VDT is challenging and
associated with high morbidity, especially if it is performed after multiple epidural
blood patch (EBP)/fibrin glue injections. A 44-year-old woman was diagnosed with spontaneous
intracranial hypotension due to VDT at T1-T2, causing CSF leakage. Multiple EBP and
fibrin glue injections failed to treat her symptoms; hence, the patient underwent
surgical closure using the posterior approach. The patient was anesthetized using
standard anesthetic drugs and was maintained under total intravenous anesthesia to
facilitate continuous motor-evoked potential (MEP) monitoring. The surgical course
was complicated by bleeding, hypotension, and MEP loss. Continuous MEP monitoring,
effective team communication, quick restoration of blood pressure(BP) and BP augmentation
with fluid, blood, and vasopressor helped to restore the MEP back to baseline. Hence,
the patient recovered without neurological morbidity. This case report highlights
the importance of adequate vascular access, multimodal spinal cord monitoring, and
BP augmentation during a high thoracic VDT repair.
Keywords cerebrospinal fluid leakage - hemodynamic management - intracranial hypotension -
multimodal spinal cord monitoring - ventral dural tear
