Microsurgical Three-Dimensional Reconstruction of Complex Nasal and Midfacial Defect: Multistep Procedure Respecting Aesthetic Unit Criteria.

ABSTRACT: Extended tumor resection in the middle third of the face leads to complex defects: wide, 3-dimensional, and multitissutal. Appropriate reconstruction is challenging but mandatory to obtain a functional and aesthetic outcome for the preservation of an acceptable quality of life. Three-dimensional combined flaps and multistep procedures concur to reach this scope.This is exemplified on the treatment of an invasive recurrent skin malignancy involving the cheek and maxillary bone in association with a full-thickness nasal defect. Reconstruction was performed with 3-dimensional multifolded anterolateral tigh chimeric flap, followed by multistep procedure respecting the aesthetic nasal reconstruction guidelines. Reconstructive surgery had the following targets: targets: rebuilding the oral and nasal lining, filling the paranasal cavities, covering the facial skin defect respecting the aesthetic unit concept and providing a proper support to the facial structures.The aesthetic unit concept has to be respected throughout all steps, from tumor debulking, to reconstruction and even for the management of complications.

Fedor Krause (1857-1937): the father of neurosurgery.

Fedor Krause's inspiring biography shows the value of translational thinking: one of the fathers of modern neurosurgery, this gifted child was recognized for his musical talent; he was able to study medicine thanks to financial support in recognition for his study performances. He wrote his doctor thesis on pneumology, and contributed to general surgery, neuroanaesthesiology, and neurosurgery application of novel technologies in neurosurgery and ethics. More in detail, in the neurosurgical field, he performed the first lumbar discectomy, set up intraoperative nerve monitoring, and pioneered trigeminal and acusticus nerve surgery, epilepsy surgery, and cortical mapping. His passion and engagement for surgery allowed him to make small centers turn into great centers recognized as renowned academic environments.

Intraneural haemangioma of peripheral nerves.

Haemangiomas are rare benign tumors developing in cutaneous tissue and sometimes even in deep tissues. The existing literature reviewed, focusing on patients' age and gender, clinical features, diagnostics used, treatment, and, where available, follow-up data. Our review is the largest available at present time, including an additional case with a total of 41 patients.

Infodemiology of status epilepticus: A systematic validation of the Google Trends-based search queries.

People increasingly use Google looking for health-related information. We previously demonstrated that in English-speaking countries most people use this search engine to obtain information on status epilepticus (SE) definition, types/subtypes, and treatment. Now, we aimed at providing a quantitative analysis of SE-related web queries. This analysis represents an advancement, with respect to what was already previously discussed, in that the Google Trends (GT) algorithm has been further refined and correlational analyses have been carried out to validate the GT-based query volumes. Google Trends-based SE-related query volumes were well correlated with information concerning causes and pharmacological and nonpharmacological treatments. Google Trends can provide both researchers and clinicians with data on realities and contexts that are generally overlooked and underexplored by classic epidemiology. In this way, GT can foster new epidemiological studies in the field and can complement traditional epidemiological tools.

Is intravenous lorazepam really more effective and safe than intravenous diazepam as first-line treatment for convulsive status epilepticus? A systematic review with meta-analysis of randomized controlled trials.

BACKGROUND: Some guidelines or expert consensus indicate that intravenous (IV) lorazepam (LZP) is preferable to IV diazepam (DZP) for initial treatment of convulsive status epilepticus (SE). We aimed to critically assess all the available data on efficacy and tolerability of IV LZP compared with IV DZP as first-line treatment of convulsive SE. METHODS: Systematic search of the literature (MEDLINE, CENTRAL, EMBASE, ClinicalTrials.gov) to identify randomized controlled trials (RCTs) comparing IV LZP versus IV DZP used as first-line treatment for convulsive SE (generalized or focal). Inverse variance, Mantel-Haenszel meta-analysis to obtain risk ratio (RR) with 95% confidence intervals (CI) of following outcomes: seizure cessation after drug administration; continuation of SE requiring a different drug; seizure cessation after a single dose of medication; need for ventilator support; clinically relevant hypotension. RESULTS: Five RCTs were included, with a total of 656 patients, 320 randomly allocated to IV LZP and 336 to IV DZP. No statistically significant differences were found between IV LZP and IV DZP for clinical seizure cessation (RR 1.09; 95% CI 1.00 to 1.20), continuation of SE requiring a different drug (RR 0.76; 95% CI 0.57 to 1.02), seizure cessation after a single dose of medication (RR 0.96; 95% CI 0.85 to 1.08), need for ventilator support RR 0.93; 95% CI 0.61 to 1.43, and clinically relevant hypotension. CONCLUSION: Despite its favorable pharmacokinetic profile, a systematic appraisal of the literature does not provide evidence to strongly support the preferential use of IV LZP as first-line treatment of convulsive SE over IV DZP.

Clinical prevalence and outcome impact of pituitary dysfunction after aneurysmal subarachnoid hemorrhage: a systematic review with meta-analysis.

PURPOSE: Pituitary dysfunction is reported to be a common complication following aneurysmal subarachnoid hemorrhage (aSAH). The aim of this meta-analysis is to analyze the literature on clinical prevalence, risk factors and outcome impact of pituitary dysfunction after aSAH, and to assess the possible need for pituitary screening in aSAH patients. METHODS: We performed a systematic review with meta-analysis based on a comprehensive search of four databases (PubMed/MEDLINE, ISI/Web of Science, Scopus and Google Scholar). RESULTS: A total of 20 papers met criteria for inclusion. The prevalence of pituitary dysfunction in the acute phase (within the first 6 months after aSAH) was 49.30 % (95 % CI 41.6-56.9), decreasing in the chronic phase (after 6 months from aSAH) to 25.6 % (95 % CI 18.0-35.1). Abnormalities in basal hormonal levels were more frequent when compared to induction tests, and the prevalence of a single pituitary hormone dysregulation was more frequent than multiple pituitary hormone dysregulation. Increasing age was associated with a lower prevalence of endocrine dysfunction in the acute phase, and surgical treatment of the aneurysm (clipping) was related to a higher prevalence of single hormone dysfunction. The prevalence of pituitary dysfunction did not correlate with the outcome of the patient. CONCLUSIONS: Neuroendocrine dysfunction is common after aSAH, but these abnormalities have not been shown to consistently impact outcome in the data available. There is a need for well-designed prospective studies to more precisely assess the incidence, clinical course, and outcome impact of pituitary dysfunction after aSAH.

Diagnosis of cerebral vasospasm and risk of delayed cerebral ischemia related to aneurysmal subarachnoid haemorrhage: an overview of available tools.

In the first weeks following aneurysmal subarachnoid haemorrhage, cerebrovascular alterations may impact the outcome significantly. Diagnosis of cerebral vasospasm and detection of alterations at risk of delayed cerebral ischemia are key targets to be monitored in the post-acute phase. Available tools include clinical monitoring, as well as studies that can detect possible arterial narrowing, alterations of perfusion, metabolism and neurophysiology. Each technique is able to investigate possible vascular impairment and has different advantages and limits. All available techniques have been described. Among these, the most practical have been selected and compared for their peculiar characteristics. Based on this analysis, a flowchart to monitor these patients is finally proposed.

A safety, length of stay, and cost analysis of minimally invasive microsurgery for anterior circulation aneurysms.

OBJECTIVES: The aim of our study was to evaluate minimally invasive techniques for the treatment of anterior circulation aneurysms versus standard surgery, and to calculate the impact of these techniques on health resources, length of stay, and treatment costs. METHODS: A consecutive series of 24 patients with ruptured and 30 with unruptured anterior circulation aneurysms treated with minimally invasive microsurgery (MIM) by the same surgeon was compared with a matched series of standard microsurgeries (SM) conducted for 23 ruptured and 22 unruptured aneurysms. Complication rates, aneurysm obliteration, modified Rankin Scale (mRS) outcomes, length of stay, and treatment costs were assessed. RESULTS: Surgical complications, aneurysm obliteration rates and mRS outcomes were comparable between MIM and SM groups in ruptured and unruptured aneurysm cohorts. MIM resulted in shorter operative times both in unruptured (102.7 ± 4.35 vs 194.7 ± 10.26 min, p < 0.0001) and ruptured aneurysms (124.3 ± 827 vs 209 ± 13.84 min, p < 0.0001). Length of stay was reduced in patients with MIM for unruptured aneurysms (1.55 ± 24 vs 4.28 ± 0.71 days, p < 0.000,1) but not in those with ruptured aneurysms. MIM reduced treatment costs of unruptured aneurysm patients, mainly through reduced utilization of inpatient resources (non-acute bed costs in CAD: 371.2 ± 80.99 vs 1440 ± 224.1, p < 0.0001), whereas costs were comparable in patients with ruptured aneurysms. CONCLUSION: Minimally invasive surgery is a safe and effective approach for the treatment of ruptured and unruptured aneurysms of the anterior circulation. In patients with unruptured aneurysms, reduced invasiveness and shorter operative times decreased length of stay, which reflects improved patient postoperative recovery. Overall, this translated into bed resource economy and cost reduction.

Aneurysms of the medullary segments of the posterior-inferior cerebellar artery: considerations on treatment strategy and clinical outcome.

Proximal aneurysms of the medullary postero-inferior cerebellar artery (PICA) tract are peculiar due to critical anatomical location, small size and tortuosity of the parent vessel, close origin to brainstem perforators, and fragility of the sac wall. Moreover, most patients present after bleeding, increasing the challenges. Aim of this study is to evaluate the treatment modality and outcome of these patients during the last decade at the University Clinic of Torino. Databases of the Neurosurgical and Neuroradiological Department of the University of Torino were analyzed to retrieve patients treated for aneurysms of the medullary PICA tract. Charts and neuroradiological documentation were revised to complete the database. Of 621 patients treated for an intracranial aneurysm, 23 had PICA aneurysm, 18 located at the medullary tract. Only two were unruptured and 16 were ruptured aneurysms. Sixteen underwent endovascular treatment and two underwent surgery. In six cases the aneurysm was cured by parent vessel occlusion. At 6 months follow-up, the Glasgow outcome scale was high (5 and 4) in 16 patients; two patients had died in the acute phase, for reasons unrelated to the procedure. If not adequately compensated, parent vessel occlusion associates with high risks of ischemia and related brain swelling. In the present series sufficient collateral flow contributed to a good tolerance toward occlusion in all cases. Despite the small size of the present series, most treated cases presented a good outcome. Nevertheless, distal revascularization of the occluded artery would be indicated where collateral flow is insufficient.

Artificial neural networks can be effectively used to model changes of intracranial pressure (ICP) during spinal surgery using different noninvasive ICP surrogate estimators.

BACKGROUND: Artificial intelligence (AI) techniques play a major role in anesthesiology, even though their importance is often overlooked. In the extant literature, AI approaches, such as artificial neural networks (ANNs), have been underutilized, being used mainly to model patient's consciousness state, to predict the precise number of anesthetic gases, the level of analgesia, or the need of anesthesiological blocks, among others. In the field of neurosurgery, ANNs have been effectively applied to the diagnosis and prognosis of cerebral tumors, seizures, low back pain, and also to the monitoring of intracranial pressure (ICP). METHODS: A multilayer perceptron (MLP), which is a feedforward ANN, with hyperbolic tangent as activation function in the input/hidden layers, softmax as activation function in the output layer, and cross-entropy as error function, was used to model the impact of prone versus supine position and the use of positive end expiratory pressure (PEEP) on ICP in a sample of 30 patients undergoing spinal surgery. Different noninvasive surrogate estimations of ICP have been used and compared: namely, mean optic nerve sheath diameter (ONSD), noninvasive estimated cerebral perfusion pressure (NCPP), Pulsatility Index (PI), ICP derived from PI (ICP-PI), and flow velocity diastolic formula (FVDICP). RESULTS: ONSD proved to be a more robust surrogate estimation of ICP, with a predictive power of 75%, whilst the power of NCPP, ICP-PI, PI, and FVDICP were 60.5%, 54.8%, 53.1%, and 47.7%, respectively. CONCLUSIONS: Our MLP analysis confirmed our findings previously obtained with regression, correlation, multivariate receiving operator curve (multi-ROC) analyses. ANNs can be successfully used to predict the effects of prone versus supine position and PEEP on ICP in patients undergoing spinal surgery using different noninvasive surrogate estimators of ICP.

Long-term visual outcome and aneurysm obliteration rate for very large and giant ophthalmic segment aneurysms: assessment of surgical treatment.

BACKGROUND: Standard endovascular therapy has shown little success in treatment of very large and giant ophthalmic segment aneurysms. We hypothesize that surgical treatment of these aneurysms yields better results in terms of visual function and aneurysm obliteration. METHODS: The Toronto Brain Vascular Malformation Study Group database was analyzed to retrieve patients treated surgically for very large (>15 mm) and giant aneurysms of the ophthalmic segment of the carotid artery. Preoperative data and postoperative long-term outcomes with specific consideration for visual function and aneurysm obliteration were evaluated. RESULTS: Of the 257 patients with ophthalmic and paraophthalmic aneurysms, 38 patients had very large or giant aneurysms. Twenty-one underwent surgical treatment; 19 had direct clipping; 1 had trapping, and 1 underwent trapping and bypass. Fifteen patients had unruptured and six had ruptured aneurysms. The mean follow-up period was 88 months. Six (28%) aneurysms had a small residual neck remnant. Of the 12 patients with documented preoperative visual deficit, 9 (75%) improved, 2 (16%) remained stable, and 1 (8%) worsened. Two patients had mild to moderate new visual deficit. Thus, the surgery-related visual complications were 14%. Eighteen patients (86%) had a good or excellent outcome (GOS IV and V). Presentation with prior visual deficit and poor neurological function were predictors of worse visual and clinical outcome, respectively (P = 0.02 and 0.01). CONCLUSIONS: There is considerable surgery-related risk for optic pathways during treatment of very large and giant ophthalmic segment aneurysms. Surgery, however, seems to be the treatment of choice in terms of overall visual outcome and aneurysm obliteration as compared to the current endovascular results in this subset of patients.

Systemic Inflammatory Response in Spontaneous Subarachnoid Hemorrhage from Aneurysmal Rupture versus Subarachnoid Hemorrhage of Unknown Origin.

Objective: It is well known that spontaneous non-aneurysmal subarachnoid hemorrhage (SAH), also known as sine materia SAH (smSAH), has usually a better course and prognosis than its aneurysmal counterpart (aSAH). This might depend on different inflammatory mechanisms initiated by bleeding events of different origins. The aim of the present study was to explore the systemic inflammatory response in spontaneous SAH, comparing aSAH and smSAH. Methods: We performed a prospective observational study over a consecutive series of patients with SAH. For these patients, we collected all clinical data and, furthermore, performed venous blood sampling over six time points to analyze blood cells. We further performed the analysis of lymphocytes and monocytes by means of flow cytometry to quantify common subtypes. Statistical analysis included a t-student test, Chi-square test, multivariate logistic regression, and ROC analysis. Results: 48 patients were included: six (12.5%) with a diagnosis of spontaneous smSAH, and forty-two patients (87.5%) with aSAH. Significant differences on Day 0 were found for neutrophils and a systemic neuro-inflammatory index, namely, systemic inflammatory response index (SIRI). At the ROC analysis, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and SIRI exhibited satisfactory predictive power on day 0. At the multivariable logistic regression analysis, the combined index (NLR, LMR, SIRI at day 0) yielded an OR of 0.59 (95% CI 0.29-1.21]). LMR at day 0 yielded an OR of 1.25 ([95% CI 0.94-1.68]), NLR at day 0 exhibited an OR of 0.68 ([95% CI 0.42-1.09]), and SIRI at day 0 displayed an OR of 0.31 ([95% CI 0.06-1.49]). Conclusion: This preliminary study indicated a possible role of some inflammatory indices that point out the importance of innate and adaptive immunity in the etiopathogenetic mechanisms. Drugs modulating these responses could eventually counteract or, at least, reduce secondary damage associated with SAH.

Optimization of Vascular Supply in Free Flaps for Head and Neck Reconstruction: Analysis of a Young Team's Experience.

Background: For head and neck reconstructive procedures, free flap survival depends on microsurgical and anatomical choices besides multimodal clinical management. The aim of the present study is to identify relevant variables for flap survival in our initial consecutive series. Methods: A single-center, novel reconstructive team consecutive surgical series was revised. The outcome was analyzed in terms of flap survival observing variables considered more relevant: flap type, recipient artery, vein(s), and graft interposition were discussed for facial thirds to be reconstructed. Statistical analysis was performed with Chi-square, Mann-Whitney, and Odds ratio. Results: A total of 118 free flaps were performed in 115 microsurgical procedures (93.9% for malignancies) on 109 patients, with a flap survival rate of 91.5%. For reconstruction of the middle and lower third of the face, the facial artery was privileged, because it was already transected during lymph node dissection in order to save the superior thyroid artery for further microsurgical needs. Flap failure was 50% venous. Double vein anastomosis was not related to flap survival. Deep venous drainage (as the internal jugular vein system) required fewer revisions. Half of the re-explorations saved the flap. Grafts were a risk for flap survival. Bony flaps were more critical. Conclusion: At comparable reconstructive quality, flap choice should avoid a vascular graft. The facial artery is a preferable recipient vessel, since it saves other arteries both in the case of an arterial revision and in the case of recurrence, for further free flap reconstruction. For venous anastomosis, a deep venous recipient is safer, since it offers the possibility to choose the level of anastomosis optimizing the vascular pedicle geometry. A close postsurgical flap monitoring is advisable up to 7 days postoperatively to allow for timely flap salvage.

Pituitary dysfunction after aneurysmal subarachnoidal hemorrhage.

Aneurysmal subarachnoid hemorrhage (aSAH) results from the rupture of an intracranial aneurysm and represents a highly debilitating and devastating disorder. The prevalence rate of neuroendocrine impairment in the acute phase is extremely variable, ranging from 3.8% to 92.3%, depending on the time point considered, the method/test utilized, the clinical severity at admission, and probably also ethnicity. Further studies are needed to clarify such a wide range in neuroendocrine dysfunction in patients with aSAH. The overall neuroendocrine impairment rate in chronic aSAH is in the range 47%-83.3% with specific neuroendocrine impairment varying from 2.5% to 83.3%. The overall pituitary deficiency rate tends to decrease over time after SAH, with recovery of most endocrine and some de novo dysfunctions being reported. Only one study has reported an increase of overall endocrine impairment in the chronic follow-up. Neuroendocrine dysfunction seems to have a high prevalence in aSAH patients, even though its exact impact is not precisely known and is based on contrasting findings. More high-quality studies and trials are necessary before informing guidelines and protocols recommending preventive endocrine screening and related treatment (hormone replacement therapy) on a routine basis. The usage of standardized testing and reporting procedures could significantly move the field forward.

Prognostic factors in chronic subdural hematoma: results from a monocentric consecutive surgical series of 605 patients.

BACKGROUND: The study of age-related diseases like chronic subdural hematoma (CSDH) is of high interest, considered the general ageing of the population. This investigation aimed to identify the main clinical characteristics of CSDH patients, to evaluate the impact of the disease on quality of life, its treatment and comorbidities/complications and to compare our data with other surgical series published over the past 5 years. METHODS: A retrospective cohort study including all consecutive patients operated for CSDH between January 1, 2006 and December 31, 2013 at the Unit of Neurosurgery of our hospital was carried out. RESULTS: 605 patients were included in the study (66.0% male, mean age 77.5±10.5 years). History of brain trauma was reported in 65.6%. Common comorbidities were hypertension (59.0%), cardiopathies (36.0%), and previous stroke (23.6%). Clotting and coagulation alterations were present in 27.2% and 17.0%, respectively. In 24.0% of cases, the hematoma was bilateral. 17.3% had more than one surgery. Length of stay was of 14.8±10.1 days. Baseline Karnofsky Performance Score (KPS), presurgical KPS, and KPS at discharge were 87.7±14.9, 64.9 ±19.8 and 76.7±27.2, respectively. A complete recovery was observed in 62.9% of patients. Mortality rate during hospitalization was 7.4%. CONCLUSIONS: The knowledge of clinical and surgical factors which might impact on the clinical outcomes could help to better manage patients with CSDH, which represents a surgically "simple" but, indeed, not trivial disease.

An international call for a new grading system for cerebral and cerebellar cavernomas.

Surgical indications for cerebral cavernous malformations remain significantly center- and surgeon-dependent. Available grading systems are potentially limited, as they do not include epileptological and radiological data. A novel grading system is proposed for supratentorial and cerebellar cavernomas: it considers neuroradiological features (bleeding, increase in size), neurological status (focal deficits and seizures), location of the lesion and age of the patient. The score ranges from -1 to 10; furthermore, surgery should be considered when a score of 4 or higher is present. Based on neuroradiological characteristics, 0 points are assigned if the CCM is stable in size at different neuroradiological controls, 1 point if there is an increase in volume during follow-up, 2 points if intra- or extra-lesional bleeding <1 cm is present and 3 points if the CCM produced a hematoma >1 cm. Regarding focal neurological deficits, 0 points are assigned if absent and 2 points if present. For seizures, 0 points are assigned if absent, 1 point if present, but controlled by medications, and 2 points if drug resistant. We considered the site of the CCM, and in case of deep-seated lesions in a critical area (basal ganglia, thalamus) 1 point (-1) is subtracted, while for subcortical or deep cerebellar lesions 0 points are assigned, for CCMs in a cortical critical area 1 point is assigned and in case of lesions in cortical not in critical area or superficial cerebellar area, 2 points are assigned. As far as age is concerned, 0 points are assigned for patients older than 50 years and 1 point for patients younger than 50. In conclusion, a novel grading for surgical decision making in cerebral cavernomas, based on the experience of selected neurosurgeons, basic scientists, and patients, is suggested with the aim of further improving and standardizing the treatment of CCMs. The aim of this paper was also to call for both retrospective and prospective multicenter studies with the aim of testing the efficacy of the grading system in different centers.

Midline lumbar fusion with cortical bone trajectory as first line treatment in a selected series of patients with lumbar instability.

BACKGROUND: The aim of the present study was to proof that for certain complex spinal conditions, midline lumbar fusion (MIDLF) technique is very convenient in terms of length of hospitalization, functional recovery and pain relief and time to back to work. METHODS: MIDLF indications were set for patients with not more than 3 unstable levels, presence of osteoporosis (alternative to cemented screws), or cardiomyopathy with anticoagulation with or without spinal stenosis, and or discopathy. Surgical difficulties, operative time, hemoglobin loss and postoperative 45 days, 6 months and one-year follow-up data are shown. RESULTS: In one-year period MIDLF was applied for 9 patients. For all cases motor deficits improved, pain decreased from a high VAS Score to VAS 1. No complications were seen so far. In one case small pedicles prevented the use of MIDLF technique. CONCLUSIONS: Operative time, acceptable hemoglobin loss, short length of stay and encouraging follow-up result indicate that this technique is a valid option to improve patient's quality of life where osteoporosis makes traditional transpedicular screws less stable or where the surgeon has the need to reduce intraoperative blood loss or has to work in a deep surgical field.

An Early Increase of Blood Leukocyte Subsets in Aneurysmal Subarachnoid Hemorrhage Is Predictive of Vasospasm.

Objective: Vasospasm is a severe complication in patients with aneurysmal subarachnoid hemorrhage (aSAH) and cannot be reliably predicted. Its pathophysiology remains elusive with the current body of evidence suggesting inflammation as one of the main driving forces. We here aimed to analyze circulating immune cell subsets over time in patients with aSAH with or without vasospasm. Methods: We performed a prospective observational study recruiting patients with spontaneous aSAH. Peripheral blood withdrawn at pre-specified time-points after aSAH, day 0, days 3-4, 6-8, 10-11, 13-15, and 18-21. Flow cytometry analysis, cell blood counts, and laboratory and diagnostic parameters were performed. Patients were monitored by transcranial Doppler for vasospasm as well as by advanced imaging and divided into a group with (VS) and without vasospasm VS (NVS). Results: We included 42 patients for study analysis, 21 VS and 21 NVS. An early significant increase at day 0 in platelet, leukocyte, neutrophil, lymphocyte, NK lymphocyte, monocyte, and CD 14++ CD16- DR+ monocyte counts was found in patients with later ensuing vasospasm. The early differences in platelets, leukocytes, lymphocytes, and NK lymphocytes remained significant on multivariate analysis. Conclusions: An early increase of immune cellular subsets in aSAH may contribute to predict VS.

Schilder's disease: non-invasive diagnosis? :A case report and review.

Schilder's disease, or myelinoclastic diffuse sclerosis, is a rare disorder characterised by an inflammatory white matter plaque of demyelination. Clinical signs and symptoms might be atypical for early multiple sclerosis and at imaging the lesion is easily taken for a brain tumour. Regardless of the use of Poser's criteria for clinical diagnosis of Schilder's disease proposed in 1986, diagnostic difficulties are still present, as evidenced by the many reported cases in the English literature revised (Pubmed indexed, period 1998-2008). It clearly emerges that neuroradiological features, observable in additional magnetic resonance sequences are crucial, besides the consideration of Poser's criteria, in differentiating between demyelinating lesions and brain tumours. A 29-year-old female patient is presented, where a careful evaluation of both the clinical and radiological features, which might have been at a first glance misleadingly suggestive for a brain tumour, allowed non-invasive diagnosis of Schilder's disease.