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Lumbar disc herniation (LDH) is a common cause of low back pain (LBP) and/or radicular pain (RP). Over the years, different therapies have been proposed to treat symptomatic LDH, including different minimally invasive techniques and open surgical methods. Recently, percutaneous intradiscal injection of radiopaque gelified ethanol (RGE) DiscoGel® has emerged as an effective therapeutic option in patients with LDH. Nevertheless, only few studies addressed the reliability of this technique. The purpose of this study was to evaluate the efficacy and safety of this procedure. We analysed surgical and outcome data of patients with small or medium LDH treated by DiscoGel between 2012 to 2015. Outcome variables included pain relief, the limitation on physical activity and severity of depression status. Overall, complication rate was defined as the occurrence of any perioperative adverse events. A total of 94 consecutive patients were enrolled in the study. Pain relief was achieved in 90.6% and 88.8% of patients at 1- and 4-year follow-up, respectively. At the last follow-up, at least a satisfactory result was achieved in 92.5% of patients. Similar results were obtained in the limitation on physical activity. Depression status did not significantly change after treatment. There was no mortality, and no patients experienced permanent sequelae. In well-selected patients, DiscoGel has proved effective in maintaining excellent functional results in terms of pain relief and limitation on physical activity while minimizing the overall rate of complications related to these kinds of surgical procedures.

Introduction: Major depressive disorder (MDD) is the leading cause of years lost to disability worldwide. Pharmacotherapy and psychotherapy are effective treatments in most depressive episodes; but, about 30% of MDD patients remain symptomatic, and relapse is a common event. Recently, deep brain stimulation (DBS) has emerged as a valid therapeutic option in treatment-resistant depression (TRD) patients.Areas covered: In this paper, the authors summarize the findings of studies focused on these pathophysiologic phenomena and specifically on the role of DBS as a therapeutic option in TRD patients. The authors simply reviewed RCTs, open-label studies, neurophysiological mechanisms of DBS in MDD, and the possible role of different targets. Finally, we suggest possible future options.Expert opinion: Depression is a systems-level disorder, involving several brain structures. Neuroimaging studies demonstrate multiple interconnected regions that modulate different neural networks. DBS can modulate different targets, and others are under investigation. Among these subcallosal cingulate gyrus (SCG), ventral capsule and ventral striatum (VC/VS) seems to be the most relevant targets. We believe that, in the next future, DBS for TRD might become a first-line of treatment, especially using directional leads, that may help us to improve therapeutic effects.

Oxygen-ozone therapy is used to treat degenerative pathology of the spine when surgery is not needed (e.g., removal of a herniated disk). Some authors have described it as a safe and effective procedure in ∼ 70 to 90% of patients. The aim of the therapy is to dehydrate the intervertebral disk and alter its contents. However, this treatment has been associated with some rare but very serious side effects. Both cardiac damage and a case of fulminant septicemia were reported. We describe a case of suspected pulmonary embolism, followed by sudden death, in an elderly woman treated with oxygen-ozone therapy for lumbar pain caused by disk protrusion. We believe a massive pulmonary embolism occurred, probably caused by an intradiskal injection that accidentally punctured a venous vessel and created emboli.

Introduction: Increasing evidence supports the relationship between vitamin D and stroke. Vitamin D has now been proposed as a prognostic biomarker also for functional outcome in stroke patients. Methods: A revision of the data suggests that low vitamin D is associated more with ischemic than with haemorrhagic stroke, even if the role of optimal vitamin D levels for vascular wall is still unclear. Vitamin D deficiency induces with different mechanisms an alteration of vascular wall. Results: However, to date, the research supporting the effectiveness of vitamin D supplementation in stroke and in post-stroke recovery is still inadequate and conclusive evidences have not been published. Conclusion: In this review, we provide a better understanding of the role of vitamin D in stroke.

The prefrontal cortex is deputed to higher functions, such as behavior and personality. It includes three regions: ventromedial, orbitofrontal, and dorsolateral. Each of them has a function. Devising, programming, and planning are all conditions related to the dorsolateral cortex, also responsible for rational content and decision. Damage to this region results in apathetic syndrome, a condition that causes loss of interest, initiative, and attention, and in the most severe cases leads to a lethargic state. It is also known as a form of secondary depression, the so-called pseudo-depression syndrome, according to Karl Kleist or apathetic-abulic-akinetic syndrome, according to Alexander Luria. The prefrontal dorsolateral syndrome is responsible for the reduction or abolition of free will. Free will is an expression of individual freedom. It allows the human being to have and express own opinions as well as to respect those of others. Free will is related to moral sense, a binomial which directs the individual towards a proper social conduct. In this review, we describe the effects of the pseudo-depression syndrome on free will, of which we treat both the anatomical site and the social aspect.

This retrospective review focuses on some illustrious personalities of history, who have suffered from neurological illnesses. Neurological diseases represent about 10% of all illnesses, and therefore do not spare anyone, much less, famous people. In this review, we discuss the neurological disorders that have struck some celebrities throughout history. We briefly examine the lives of emperors, writers, poets, and musicians that have suffered from neurological diseases such as epilepsy, stroke, tumors, and other illnesses, and which caused death or disability. From a historical point of view, recollection of the lives of famous people afflicted by neurological disorders holds important lessons for future generations.

Rita Levi-Montalcini was an extraordinary personality and with her profession she made a tremendous contribution to humanity. Doctor, Nobel laureate for medicine, neuroscientist, she contributed, thanks to her research, to improve the knowledge of the nervous system. She discovered the nerve growth factor, which is applied in various fields of neurology, concerning neurodegenerative diseases. She also studied, in relatively newer years, the mechanisms of neuroinflammation. This last is a research that has been developing in recent years and is based on the predominantly anti-inflammatory properties of endogenous substances that able to act not only on diseases of the nerves, neuropathies, on the nerve roots, and radiculopathies but also on migraine and other non-neurological diseases. Her long life was full of positive and negative events. Born in a Jewish family, she lived her life as a young woman through war, Nazi deportations, and the Holocaust. Despite the difficulties, she found time to do research in the medical field, organizing research laboratories with other scholars. She had a difficult life, interspread with pain, destruction, extermination of human beings but also rewarded by scientific discoveries. A “small” woman but a great neuroscientist.

Background The surgical spinal degenerative pathology mainly concerns the herniated intervertebral disks. Surgery is indicated when the pain becomes chronic and intense, and when motor signs appear. The results are positive in about 90% of cases, leading to the solution of the problem. However, an estimated percentage of 4% to 20% reported residual pain and postural instability after the surgical treatment of discectomy. Method We have examined a sample of patients, retrospectively registered, undergoing surgical treatment for degenerative lumbar disease. Some of them developed postural instability. They were subjected to cycles of postural gymnastics. Postural gymnastics has proved to be a tool capable of solving unstable post-surgical posture. It included an exercise of breathing, one or two of muscular distension, one of muscular reinforcement, and one of postural correction. We used an evaluation form we created in agreement with the physiatrist for postural exercises that was based on some basic parameters such as muscle and respiratory function. At each cycle, a score was attributed to the performance of muscular and respiratory exercise to evaluate the function and therefore the degree of instability (1–3 = mild, 4–7 = medium, 8–10 = severe). Results Results were satisfactory, with return to normal posture. The improvement of postural instability has been demonstrated both by the score of the evaluation forms that have highlighted the transition from a state of severe intensity to one of normality and by a clinical aspect, concerning the static and dynamic posture. Conclusions The postural instability has a multifactorial genesis, and different mechanisms are involved: the vertebral bone structures and the pelvis, the paraspinal muscular structures, and the nerve structures. These structures are altered after surgery due to predisposing factors, and for the action of conditions acquired as obesity.

Liver cirrhosis can cause neurological, extrapyramidal-type disorders, such as stiffness, bradykinesia, tremor, confusion, depression. Cirrhotic extrapyramidal syndrome can worsen clinically, leading to encephalopathy, which in the most severe cases leads to coma. Brain MRI is able to highlight the extrapyramidal signs, through the presence of hyperintensity areas at the basal ganglia. In addition, extrapyramidal symptoms appear already in the metabolic compensation phase. We describe the case of a 50-year-old male, suffering from new-onset extrapyramidal syndrome, secondary to alcoholic hepatic cirrhosis, diagnosed seven years before. The case is singular for some features: the late-onset of the extrapyramidal syndrome, the absence of tremor, and especially the lack of neuroimaging findings such as MRI hyperintense areas along the basal ganglia.We hypothesize a mechanism of metabolic compensation, which would be responsible for the late appearance of the extrapyramidal syndrome and the lack of signs of encephalopathy in brain MRI.The lack of tremor is less clear, because it is a constant symptom of extrapyramidal pathology, and it is unusual that it is lacking as a symptom, after so many years. Keywords: Extrapyramidal syndrome, Hepatic cirrhosis, Hepatic encephalopathy

Hemangioblastomas (HBLs) are challenging vascular tumours with rare suprasellar location Surgery is recommended in patients with visual impairment, endocrine disorders or hydrocephalus. Surgical removal of pituitary stalk HBLs is challenging due to their location and high vascularity. Our narrative review was guided by the question: "what is the more suitable surgical approach to excise a suprasellar HBL?". Pertinent English literature was scrutinized from database inception to October 2016. Eighteen articles matched our selection criteria. Among the surgically treated patients, 4 were treated through a trans-sphenoidal (TS) approach, 13 through a transcranial approach (2 of them after TS failure). Five other cases were treated with radiotherapy (adjuvant in 3 cases) and 9 patients were managed with simple observation and/or medical treatment. We add a case of complete suprasellar HBL resection through an orbito-zygomatic (OZ) craniotomy with extradural anterior clinoidectomy (EAC). To achieve satisfactory oncologic results with acceptable morbidity for symptomatic suprasellar HBLs, complete tumour removal with pituitary stalk sparing should be attempted through an OZ craniotomy with EAC that provides adequate exposure of the tumour, its vascular supply and the adjacent neural structures.

Palmitoyl ethanol amide (PEA) is an endogenous substance that plays a role in neuropathic pain. In this article, we evaluated both the safety and the efficacy of ultramicronized PEA (um-PEA) in the treatment of low back pain related to nonsurgical lumbar radiculopathy. In this prospective single-blind study, patients with low back pain related to nonsurgical lumbar radiculopathy received the fixed combination acetaminophen/codeine (500 mg + 30 mg/d) for 7 days, and then it was stopped and changed to um-PEA (1200 mg/d) for 30 days. Patients without an improvement in pain or disability started a second cycle of treatment with um-PEA (600 mg/d in tablets) for 30 days and then acetaminophen/codeine for 30 days. A total of 155 patients were included in the analysis. After the first cycle of treatment we recorded an improvement of pain in all patients with mild pain (visual analog scale score from 3-4 to 1) and in 75% of the patients with moderate pain (visual analog scale score from 5-6 to 2). After the second cycle, we recorded an improvement of pain and disability in all patients with moderate pain (P .01), but in 26% of patients with severe pain we did not record any improvement in disability (P .05). In conclusion we evaluated the role of um-PEA in patients with lumbar radiculopathy with a long-term follow-up (24 months) and put in evidence the effectiveness and the safety of this formulation in patients with mild and moderate pain.

Cortex neuromodulation is promising approach for treatment of some neurological conditions, especially neuropathic pain and Parkinson's disease. Effects of non-invasive cortical stimulation are short lived; transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS) may be useful to assess the suitability for invasive cortical stimulation. Direct cortical stimulation (DCS) is the method able to provide long-lasting effects in treatment of neuropathic pain and some symptoms of Parkinson's disease through the use of totally implantable systems that ensure a chronic stimulation.

Background: Neck-tongue syndrome is a disorder causing unilateral neck pain, accompanied by simultaneous ipsilateral numbness of the tongue. It is explicable by compression of the second cervical root in the atlantoaxial space on sharp rotation of the neck. It may be secondary, idiopathic, familial, more frequent in females, in young people and the pain lasts from a few seconds to a few minutes. Treatment is symptomatic but also prophylactic, benefit is made by physiotherapy treatment. International Headache Society (IHS) places it between “Painful lesions of the cranial nerves and other facial pain”, describing as sudden onset of pain in the occiput or upper neck associated with abnormal sensation in the same side of the tongue. Methods: A 42-year-old female, who a month after reported a whiplash injury, following a car accident, manifested the symptoms of neck-tongue syndrome. The rotational movements of the head to the right side provoked intense pain in the neck and along the right half of the tongue. The pain also appeared spontaneously, duration varied from a few seconds to few minutes, associated with burning, frequency of about two episodes per day. Radiography and cervical spine MRI showed signs of spondylosis. Results: Topiramate combined with non-steroidal anti-inflammatory drugs, improved pain both in the neck and the tongue, reducing the episodes in frequency and intensity. Conclusions: Neck-tongue syndrome is a rare disorder, which manifests with pain in the neck and pain associated with burning of half of the tongue, by unknown etiology. Secondary forms following whiplash injury have not been described, Treatment of these secondary forms concerns use of symptomatic drugs for pain, buth also anticonvulsants as prophylaxis. Keywords: Neck-tongue syndrome, Headache, Cervical whiplash

In this study, we have made a historical review of epilepsy through the centuries, from pre-Christian era to the present time. The epileptic was examined by Hippocrates, the first to recognize epilepsy as a disease and not as a supernatural manifestation called Morbus Sacer. The dark years of the Middle Ages were the worst for the disease, where the sufferer was even subjected to torture. The period of the Renaissance saw the epileptic isolated from society while the Enlightenment century improved the knowledge about the disease, thanks also to the first autopsies that showed post traumatic neurological lesions. However, some stigmata of the disease that prevented the marriage of epileptics persisted. It was the prelude to the years 1800-1900, characterized by Lombrosian concepts and Nazi convictions. Lombroso included epileptics among delinquents and criminals, identifying them as such on the basis of physical alterations. Nazi racism introduced the concept of eugenics excluding the epileptic from the so-called pure race. Today, epilepsy is considered a treatable neurological disorder. Morbus Sacer belongs to a remote past.

MicroRNAs (miRs) have emerged as biomarkers of migraine disease in both adults and children. In this study we evaluated the expression of hsa-miR-34a-5p and hsa-miR-375 in serum and saliva of young subjects (age 11 &plusmn, 3.467 years) with migraine without aura (MWA), while some underwent pharmacological treatment, and healthy young subjects were used as controls. miRs were determined using the qRT-PCR method, and gene targets of hsa-miR-34a-5p and hsa-miR-375 linked to pain-migraine were found by in silico analysis. qRT-PCR revealed comparable levels of hsa-miRs in both blood and saliva. Higher expression of hsa-miR-34a-5p and hsa-miR-375 was detected in saliva of untreated MWAs compared to healthy subjects (hsa-miR-34a-5p: p &lt, 0.05, hsa-miR-375 p &lt, 0.01). Furthermore, in MWA treated subjects, a significant decrease of hsa-miR-34a-5p and of hsa-miR-375 was documented in saliva and blood compared to MWA untreated ones. Altogether, these findings suggested thathsa-miR-34a-5p and hsa-miR-375 are expressed equally in blood and saliva and that they could be a useful biomarker of disease and of drug efficacy in patients with MWA.

Background In this work, we describe an association of brainstem headache with aura (BHA) and Alice in Wonderland syndrome (AIWS) in a 17-year-old male, suffering from crises of vertigo, weakness, dysarthria, and diplopia, in half-hour duration, followed by diffuse or occipital headache, lasting several hours. Methods The frequency of the attacks was monthly, and once there was short loss of consciousness. The last episodes were accompanied by symptoms such as deformation of figures and objects, small or large in shape. Results Diagnostic examinations were performed, mainly neuroimaging tests such as brain MRI and brain angio-MRI, all resulting normal; and treatment with flunarizine was followed by improvement of both BHA and AIWS symptoms. Conclusions There would be a correlation between BHA and AIWS, presumably represented by dysfunction of temporo-parieto-occipital carrefour.

Occipital nerve stimulation (ONS) is electric stimulation of the distal branches of the greater occipital nerve by cylindrical or paddle leads implanted in subcutaneous occipital tissue. This surgical option has emerged as a promising treatment for different types of disabling medical refractory headache and recently also for residual occipital and nuchal pain after previous occipitocervical fusion. The mechanisms of action have not yet been clearly explained: electrical stimulation of the occipital nerve has both peripheral and central effects on the nervous system, which may modulate nociception. ONS is a well-tolerated and safe procedure in comparison with other invasive modalities of treatment. Lead migration/dislodgement is a common complication, but use of new surgical techniques and leads may reduce the rate of this complication.

Background: Surgery of brain tumors has made excellent progresses over time. Its characteristic is to be an extremely invasive surgery, becoming a limit that neurosurgeons have tried to overcome with the discovery of more and more modern diagnostic tools. Aim: In brain tumor surgery the aim is to excise the tumor without creating superior function deficits, so try to spare the so-called eloquent areas. Since the early twentieth century, neurosurgeons like Penfield and Ojemann have paid attention to the preservation of the language areas as well as of the motor pathways during brain surgery. Methods and results: Cortical electrical stimulation and brain mapping were used with good results. The problem was for a long time the invasiveness of the surgery which however foresaw a craniotomy. A few years ago a new and revolutionary technique has established itself. The diffusion tensor Imaging (DTI) is a non-invasive method that includes the use of MRI, allowing the study of white matter and therefore of the cortico-spinal tracts. Then, DTI tractography is able to distinguish normal nerve fibers from those infiltrated by the tumor, detecting pathological features of white matter such as axonal damage, ischemia, inflammation, edema. Conclusions: The literature is rich in cases related to the use of DTI in brain tumors, the results are excellent if one thinks of the saving of functionally important brain areas. Therefore, the excision of malignant tumors such as gliomas and glioblastomas is followed by a different and better outcome and a different quality of life. DTI tractography today represents the best and safest way of preserving the superior cortical functions in brain tumor surgery. Keywords: Diffusion tensor imaging, Tractography, Brain tumors

Background Von Hippel-Lindau (VHL) disease is an autosomal dominant condition characterized by formation of multiple benign and malignant tumors. In this disease supratentorial lesions are rare and no falcine meningioma has been previously reported. Differential diagnosis is very difficult and the histopathological examination is the definitive method for diagnosis. Case description A patient with VHL underwent a suboccipital craniotomy for removal of cerebellar hemangioblastoma and after 2 years magnetic resonance imaging (MRI) showed an iperintense solid mass located at posterior part of the falx. Histological diagnosis revealed meningioma. Conclusion The only case in the literature of falcine meningioma in a patient with Von Hippel-Lindau disease, discovered during radiological follow-up, is described and a surgical management is proposed.

Background: Palmitoyl ethanol amide (PEA) is an endogenously produced substance showing anti-nociceptive effect through both receptor and non-receptor mediated effects at the level of different cellular and tissue sites. This study showed the results of a single blind study that was conducted to evaluate both the safety and the efficacy of ultramicronized PEA (umPEA; 1,200 mg/day) for up 90 days in patients suffering of Migraine with Aura (MA) treated with NSAIDs. Methods: A total of 20 patients, 8 male (33–56-years, average 41.4 ± 7.8) and 12 female (19–61-years, average 38.5 ± 11.9) with MA were admitted to our observation and diagnosed according to ICHD-3 criteria, they received umPEA (1,200 mg/day) in combination with NSAIDs for up to 90 days. They were revaluated at 30, 60, and 90 days after treatment. Results: umPEA administration induced a statistically significant and time dependent pain relief. In particular, these effects were evident at 60 days (male P = 0.01189; female P =

The face as an element of diversity. The ugliness of a face or a body and deformities were considered in 1800 as symbols of atavism, regression to being primates, or expression of inferior beings. The Italian physician Cesare Lombroso was the author of the concept of morphoanthropology, according to which the human being is judged on the basis of his or her physical connotations. The ugly person, with particular marks on his or her face and body, would be brought in as a criminal. Time has dissolved the value of Lombrosian theories, and scientific research has highlighted the influence of various factors in the genesis of crime. Genetic, biological, socioenvironmental factors, regulated by neurophysiology, which adds the effect of antagonism between the prefrontal cortex and the limbic cortex, explain the tendency to commit crime.

Nummular headache has been recently described as a primary disorder characterized by head pain exclusively felt in a small rounded area typically 2–6 cm in diameter, not attributed to another disorder. Both size and shape of the painful area remain constant since the onset of symptoms. A 57-year-old woman presented with a history of focal episodic pain in a circumscribed area on the right parietal region. The administration of standard oral doses of palmitoylethanolamide and topiramate in combination showed an improvement in pain symptoms and on pain measuring scales.

In this clinical/observational study we have reported the administration of Palmitoylethanolamide (PEA) in patients suffering from radicular lumbar spinal pathology, who had no indication for surgical treatment. We analyzed a series of 100 cases retrospectively, all undergoing clinical and diagnostic investigations, which had shown the presence of abnormalities of the vertebral body and intervertebral discs, mainly degenerative, such as spondyloarthrosis, spondylo-discarthrosis, disc protrusion, excluding disc herniation, which fell within surgical cases. We then administered ultramicronized PEA (umPEA) to these patients, in combination with paracetamol and codeine, obtaining interesting results regarding the improvement of pain symptoms of the spine pathology, in the various checks carried out, through the administration of pain assessment scales. We also noted its safety due to the total absence of adverse effects. The obtained results encourage the use of PEA in degenerative spine pathologies.

INTRODUCTION Von Hippel-Lindau (VHL) disease is a dominantly inherited condition associated with tumors in multiple organs, whose treatment requires heightened multidisciplinary teamwork. Therefore, a document summarizing all the pertinent knowledge is needed to enhance coordination of care. EVIDENCE ACQUISITION A systematic review of the literature from the Medline, Embase and Cochrane Central databases was performed. From 1970 to 2017, all articles meeting specific inclusion criteria were included by at least one specialist physician for each field. EVIDENCE SYNTHESIS We included 95 articles, mostly dealing with genetics or management of VHL associated tumors in one organ system. There were no papers discussing the manifestations of VHL altogether, which was the aim of our paper. CONCLUSIONS VHL requires a multidisciplinary management to provide the highest quality of care. Coordination and communication between patients and caregivers is enhanced when knowledge is shared. Gathering together specialists in different domains around the production and reading of a comprehensive document such as the one hereby may contribute to this purpose.

Insular gliomas are heterogeneous lesions whose management presents multiple challenges for their tendency to affect young patients in good neurological and cognitive conditions, their deep anatomic location and proximity with critical functional and vascular structures. The appropriate management of insular gliomas requires a multidisciplinary evidence-centred teamwork grounded on the best anatomic, neurophysiological and oncological knowledge. The present study provides a reappraisal of the management of insular gliomas based on a systematic review of the literature with the aim of guiding clinicians in the management of such tumors. A systematic review of the literature from the Medline, Embase and Cochrane Central databases was performed. From 2006 to 2016, all articles meeting specific inclusion criteria were included. The present work summarizes the most relevant evidence about insular gliomas management. The anatomy and physiology of the insula, the new WHO 2016 classification and clinico-radiological presentation of insular gliomas are reviewed. Surgical pearls of insular gliomas resection as well as oncologic and functional outcomes after insular gliomas treatment are discussed. Management of insular gliomas remains challenging despite improvement in surgical and oncological techniques. However, the literature review supports a growing evidence that recent developments in the multidisciplinary care account for constant improvements of survival and quality of life.

Hemodialysis headache (HDH) is an infrequent new-onset symptom, occurring mainly in old uremic patients. Type of pain is nonspecific, occurs during hemodialysis treatment, assuming features similar to tension-type headache and representing a problem, also as regards the therapy to be taken. International Headache Society (IHS) has placed this form of headache among the headaches disorders of homeostasis. We found a case of new-onset HDH in old uremic man, presenting with migraine aura features. A similar case has not been reported in literature, placing us some questions: why and how does this happen? What are the mechanisms involved? Role of trigeminal-vascular system and cortical spreading depression as regards the aura could be considered, through the activation of neuroinflammatory events, lastly causing migraine aura. Moreover, the administration of flunarizine strongly improved migraine symptoms in our patient, as happens in migraine syndromes. Definitely, this case leads us to think that some mechanisms involved in headaches will need to be further clarified.

Cervical spinal compression is a serious and rare complication of spinal cord stimulation (SCS) that can occur using leads placed via open surgical approach. The present report describe a case of cervical plate lead implant that developed spinal and radicular compression symptoms after seven years due to the growth of fibrotic epidural mass at the level of lead. A review of literature is provided. A 59-year‑old woman with 3-year history of left arm post‑traumatic complex regional pain syndrome (CRPS) was treated with SCS performed with the implant of paddle lead in the epidural space from C3-C5. Seven years later she reported progressive paresthesia along the spine and the limbs, gait ataxia with sensation of weakness in the legs, increased muscle tone and tendon reflexes in the lower extremities and decrease in effectiveness of stimulation. Cervical CT showed a tissue mass into the cervical canal posteriorly to the lead. This finding was confirmed by MR performed after lead removal that also allowed to document the amount of spinal cord compression. The patient underwent C4-C5-C6 laminectomy and a thick scar was removed from the dura. After surgery there was progressive and incomplete improvement of neurological signs but symptoms related to algodystrophy recurred partly. The formation of hypertrophic epidural scar tissue at the level of lead implant must be taken into consideration in presence of the onset of progressive cervical myelopathy in patient treated with SCS using laminectomy lead.

Intracranial dural arteriovenous fistulas are a rarely diagnosed type of vascular malformations, yet they are clinically relevant in a subspecialized neurovascular setting because a misdiagnosis may lead to permanent morbidity and mortality. Modern brain imaging techniques such as flat panel detector computed tomographic angiography and magnetic resonance imaging angiography have a significant role in the preoperative work-up, still digital subtraction angiography remains the neuroimaging mainstay. The most important factor guiding their management is the presence of cortical venous reflux, significantly associated with aggressive symptoms due to cerebral or spinal cord venous congestion and hemorrhage. Cutting-edge developments in endovascular and neurosurgical treatment of these vascular malformations, which should be undertaken in specialized referral centers, have substantially improved their prognosis. While transarterial or transvenous endovascular techniques represent frequently the therapy of choice, surgery remains a very valuable option both as a first line treatment and after partial embolization has been carried out. A significant neurosurgical advance is the introduction of indocyanine green video angiography, which allows precise identification of the arterialized draining vein of the dural fistula to be disconnected and confirms interruption of the arteriovenous shunt. Stereotactic radiosurgery may be considered in case of intracranial dural arteriovenous fistulas without cortical venous drainage for which surgical and endovascular options have been consumed or for palliation.