Subdural hematomas (SDH) may be noted right from the start or may complicate a subdural hygroma. They may be thin and asymptomatic but can be large with enough mass effect to compress the underlying brain and cause midline shift. If symptomatic and growing, surgical intervention will become necessary.[57, Selleck GW572016 58] Vigilant postoperative neurosurgical care and follow-up is important as creating a skull defect may violate the Monro-Kellie principle and lead to more sinking of the brain.[59] It

is prudent to have the issue of the leak also addressed at some point along with the treatment of SDH. Rebound intracranial hypertension is sometimes encountered after successful treatment of the leak by EBP or surgery.[60] The incidence of this phenomenon is likely higher than is thought as some cases are asymptomatic or only minimally symptomatic. Sometimes the clinical presentation is dramatic enough to even cause florid papilledema. Most of these patients return to their physicians thinking that they have recurrence of the leak. This condition, fortunately, is often self-limiting but can take a frustratingly long time even though acetazolamide may help with the symptoms. At this juncture,

it should be noted that occasionally one might encounter a patient with previously diagnosed or undiagnosed pseudotumor cerebri who has self-decompressed through a weak area of dura. This may lead to the syndrome of intracranial Temozolomide price hypotension

or CSF hypovolemia. When such leaks are successfully treated, the manifestations of pseudotumor will reappear. Acetazolamide can help, but a few patients have finally ended up with shunting procedures (B. Mokri, unpublished data). Fortunately, as a phenomenon, this is very uncommon. In patients with active CSF leaks, when headache characteristics change in a short period, it is prudent to look for MCE unexpected events and surprises. This complication will often call for anticoagulant therapy.[61] Bibrachial amyotrophy is seen in connection with extra-arachnoid fluid collection, typically in the ventral aspect of the cord in the cervical region that often extends to the thoracic and even lumbar levels. There is weakness and atrophy at a few sequential myotomal distributions of upper limbs with only mild asymmetry resembling and mimicking motor neuron disease,[62] especially when the sensory symptoms are curiously absent or at best minimal. Although a rare occurrence, it can be a remote complication of spinal CSF leaks[63, 64] or CSF leak from brachial plexus injury and nerve root avulsion.[65] In superficial siderosis associated with CSF leaks, frequently extra-arachnoid elongated fluid collections are seen typically ventral to the cord and similar to the fluid collections seen in bibrachial amyotrophy.