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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.

Background. We describe the unusual case of a person suffering from lumbar pain, by herniated disc, treated with betamethasone. The abrupt suspension of the drug caused so called steroid withdrawal syndrome that may occur when receiving a glucocorticoid hormone for a long time it is abruptly stopped. Method. We administered it to a patient suffering from intense lumbar pain.The drug was suspended abruptly a few days after the onset of therapy. Results. The reaction to the suspension of the steroid was the onset of a severe migraine headache, which disappeared with the re-administration of betamethasone. Conclusions. What are the causal hypotheses of this event? An increase in endocranial pressure, of pseudotumor cerebri type? A case of delayed hypersensitivity, since the subject had already taken on betamethasone, without reporting any side effects? We think that the disorder is due to a condition of late hypersensitivity to the steroids, from unknown cause.

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.

Aim The purpose of this study was to treat burning mouth syndrome (BMS) with a combination of painful gabapentin and ultramicronized palmitoylethanolamide (umPEA), in an attempt to improve the severe symptomatology of BMS. Methods We examined the case of a 60-year-old male, suffering from late-onset burning mouth syndrome. He found that gabapentin had a poor control of symptoms, thus we added umPEA, after administering a Visual Analog Scale (VAS), showing a score of 8-9. The patient also underwent laboratory examinations, neuroimaging exams such as brain CT/MRI and others, which all showed normal results. Results The result of combined therapy was satisfactory. After 3 months, the frequency and intensity of the pain had improved considerably, as demonstrated clinically and by VAS, with a score of 5. Conclusion BMS is an oral pain-burning syndrome scarcely responsive to therapy. The most widely used medications are GABA-like substances, antidepressants, topiramate. In this case, we used PEA, which proved effective in the treatment of BMS, as well as in neuropathies and migraines.

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. We report a rare association of Alice in Wonderland syndrome and brucellosis. Alice in Wonderland syndrome is a term applied to altered perceptions of the size or shape of own body or other objects. It can occur in a variety of disorders, including migraine, epilepsy, infections, and brain lesions. Brucellosis is a contagious zoonosis caused by infected milk or meat from animals, mainly goats. It causes a fever known as undulant or Malta fever, associated with gastrointestinal symptoms. Case. A young 16 year-old male manifests Alice in Wonderland syndrome and migraine headache after suffering from brucellosis. Symptoms are represented by distortion of objects, animals, humans, which appear deformed, so called metamorphopsias. This is a strange case in which a somatosensory syndrome appears after suffering from an infectious disease. Conclusions. Mechanisms of this case are unclear, we hypothesize a toxic-infective cause, targeting brain parietal lobe. responsible for somesthesic functions.

Objective. The aim of this study was to establish the prevalence of hemodialysis headache in a population of Calabrian subjects, in Italy. Methods. We observed a sample of hemodialysis subjects, studied at the University Hospital of Catanzaro and the Hospital of Melito PS, Reggio Calabria. The patients were investigated for the search for hemodialysis headache. The inclusion criteria of the subjects in the study were respected, such as the characteristics of the headache and the close relationship with dialysis. Results. The results showed a percentage of hemodialysis headache around 5% of cases. The percentage we found was very low compared with some literature data revealing percentages up to 70% of cases. Conclusions. This discrepancy of data is unclear, the results we obtained are in line with few cases of literature. However, our results pose important reflections on the actual prevalence of hemodialysis headache.

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

Cerebral cavernous angioma or cavernoma is a benign vascular malformation, usually asymptomatic. It is infrequent and often its discovery is incidental, a so-called incidentaloma. However, these lesions can be symptomatic, causing headaches, epilepsy, cerebral hemorrhage and other neurological signs depending on the brain area involved. Frontal localization is responsible for psychiatric disorders, particularly the prefrontal region, leading to prefrontal syndrome, a condition common in all frontal lobe tumors. Psychopathological syndrome can be depression-type, pseudodepression syndrome or maniac-type, pseudomaniac syndrome. Surgical treatment of lesions like this may not always be possible due to their location in eloquent areas. In this study, we describe an unusual association of migraine-like headache, epilepsy and frontal lobe pseudodepression late-onset syndrome in the same patient. We have considered this case interesting mainly for the rarity of both a headache with migraine features and for the late onset of pseudodepression syndrome. Pathophysiology underlying migraine-like headache and that concerning the late-onset pseudodepression frontal lobe syndrome seems to be unclear. This case leads to further hypotheses about the mechanisms responsible for headache syndromes and psychopathological disorders, in the specific case when caused by a cerebral frontal lobe lesion.

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.

Epilepsy in the elderly is a very debated case because much depends on the causes and associated pathologies. In particular, in the presence of comorbidity it is often difficult to find an effective and safe antiepileptic therapy that does not interfere with other drugs and therefore must be personalized. New-onset epilepsy in the elderly is caused by two types of cerebral lesions: The first concerns progressive, evolutive lesions, on which one can intervene, such as tumors or cerebrovascular pathologies, often acute.

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

In cardiac myxomas, the malignant transformation process, selecting incidental gene mutations and leading to loss of proliferation control, has not a so drastic effects in terms of growth rate of tumor mass, but frequently the particular location of lesion engrosses the high risk for health. For accurate cancer cell profiling, it is important to establish the embryologic origin of malignant cells and their initial commitments, above all, in the sight of therapeutic strategies and solutions. Here, we advance, for cardiac myxoma, the hypothesis of an origin from cardiac neural crest cells and we attempt to support it by an integrated discussion of current knowledge about embryological characteristics of neural crest cells and most recent studies focusing cardiac myxomas. We discuss the relationship between the basic plasticity of cardiac neural crest cells and some typical mutations arising in neoplastic lesions as well as the expression of typical cell markers of neural crests derivatives. Dysfunctions in proliferative and migratory programs, focused in other studies, are evaluated in the context of the topological and histopathological characteristics of cardiac myxomas.

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 =

Background: Frontal lobe brain tumors often cause psychiatric disorders such as depression, if damage is related to dorsolateral part of the prefrontal cortex.It is more appropriate the term pseudodepression in cases where it is secondary to organic causes, such as in brain tumors. Vice versa, it is a very rare condition in which depressive symptoms anticipate the onset of a brain tumor, as showed by few cases reported in literature. Procedure: We describe a case of pseudodepression syndrome followed 20 years after, by the appearance of a frontal lobe meningioma. Conclusions: There are many hypotheses whereby a depression can anticipate the onset of a brain tumor. According to some authors, depression could be a risk factor for the onset of brain tumors. Hence the need, in a subject suffering from depression, to perform periodic control neuroimaging exams, to detect the possible presence of a brain tumor.

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.

Migraine prophylaxis is a demonstrated viable therapeutic option, providing positive results through the use of drugs, more and more safe and effective. These drugs are anticonvulsant, antidepressant, calcium channel blockers, beta blockers, making a notable contribution according to studies reported in the literature. But they also have side effects, usually less than their efficacy. In this study we report our series of migraineurs with and without aura, treated with prophylactic drugs. In the study we used the drugs of first choice and we used VAS scale to assess pain intensity, checking patients for 8 months, with good results, in some cases excellent. Data from literature show that these new nutraceutical substances, besides to those already in use, are utilized successfully, opening new therapeutic perspectives. Do not resort to symptomatic drugs, it is very important, being rich in adverse, potentially harmful effects, so migraine prophylaxis remains a useful instrument of defense in these patients.

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.

Introduction: Tumor surgery within eloquent areas represents a formidable challenge and the use of electrical cortico-subcortical stimulation mapping (ESM), allows to localize sensorimotor and language areas and pathways. Our aim is to point out methodological issues of ESM and its impact on outcome at the light of a prospective analysis of a two-institution series of 159 patients with lesions involving eloquent areas with a lengthy follow up. Material and Methods: All patients operated on for lesions involving eloquent areas between May 2000 and May 2010 at the Neurosurgical Department of the Neurological and Neurosurgical Hospital “P. Wertheimer” in Lyon (France) and at the Neurosurgical Departement of the University Hospital in Catanzaro (Italy), were enrolled prospectively in our study. Results: Of 159 consecutive patients, 141 of them underwent surgical removal of the lesion with the aid of electrical cortico-subcortical stimulation mapping integrated in a setting of intraoperative localization of anatomic land marks for eloquent areas. For the remaining 18 patients ESM was not deemed useful or feasible: 15 patients received a biopsy and 3 patients received tumor debulking under general anesthesia. For patients operated with ESM, it was possible to achieve a gross total removal of the lesion in 67,4% of cases (95 patients). One patient died in the immediate postoperative period for a pulmonary embolism. At a total mean follow-up of 62.8 months 78 patients were alive, 62 of which were recurrence free and had a KPS of 70% or more, while the other 80 patients had a mean survival time of 23.9 months, with a mean high quality survival period (KPS ≥70) of 21.6 months. Discussion and Conclusion: Intraoperative electrical language and motor mapping, when feasible and indicated, consistently localizes eloquent cortical areas and subcortical pathways and allows to set the tumor resection boundaries according to functional limits, with a favorable impact on survival and quality of life. Integration of neurofunctional data with anatomic land marks is nonetheless useful to expedite the surgical procedure and improve specificity and sensibility of functional mapping.

Neuromodulation is an appealing new technique that can be proposed even to treat paediatric neurogenic bladder dysfunction in view of its usefulness and miniinvasiveness. Further technological improvements, including the production of miniaturized, more flexible and resistant electrodes, more stable and empowered integrated circuits and the application of telemetry for computerized setting of the stimulators and transfer of data, will likely broaden the indications of neuromodulation, which could become the standard treatment option for neurogenic bladder dysfunction.

Comorbid depression in tension-type headache is a condition well known. A link correlates the two disorders but the mechanism is not perfectly clear. The purpose of this work is to give our experience on the subject and to compare it with the literature data. We investigated a number of cases of tension-type headache patients, with the aim of fi nding signs of depression as comorbidity. The results showed a depression comorbidity in tension-type headache, with a 67% percentage, in line with the literature data. There is a evidence of comorbidity of depression in tension-type headache. The mechanisms that bind the two disorders appear to be explained by the activity ofneurotransmitters common to both.

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.