Telepathology is an attractive solution for providing neuropathologic intraoperative expertise to geographically diverse hospitals from a center of excellence. To date, few reports specifically address the feasibility of such a system for intraoperative neuropathology specimens. The University of Pittsburgh Medical Center is a 20-hospital system in Southwest Pennsylvania in which the pathology department has adopted a subspecialty "centers of excellence" method of managing cases. The Division of Neuropathology is physically located at 1 hospital but provides neuropathologic expertise to the entire system. Adult neurosurgery is currently limited to 2 hospitals separated by 18 city blocks. We describe our experience in providing remote intraoperative neuropathologic consultations over a 5-year period, from 2002 to 2006. Several approaches are discussed, with emphasis on the current system and the evolution of imaging technology. Diagnostic outcomes are compared among >400 telepathology cases and >1,200 conventional intraoperative cases. Current technology is capable of facilitating teleneuropathologic intraoperative diagnoses in a timely manner, with accuracy rates comparable to those for conventional methods. However, the practice of providing these remote consultations requires a sophisticated and technologically advanced environment along with substantial planning, communication, and training of both pathologists and pathology assistants.