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BRAIN TUMORS ARE ONE  of the most frightening forms of cancer as they damage the soft sponge, packed inside the skull, that controls our lives. Symptoms include headaches, seizures and problems with memory, speech and communication. Often treatment can only slow the spread of the tumor — the odds for survival are bleak. “Most people are dead within six months of diagnosis,” says Dr. Prem Pillay, a neurosurgeon in private practice in Singapore. But there is a glimmer of hope from a radical new treatment which doubles survival time and may increase the survival rate. Usually the first step in treatment is surgery to remove as much of the tumor as possible. Next comes a course of chemotherapy and radiation to try to destroy the remnants and roots of the tumor. This traditionally involves taking drugs orally or by injection. In the new procedure, called interstitial chemotherapy, six to eight biodegradable disc-shaped wafers, soaked with the anti-tumor drug, are placed in the affected area of the brain. This is done during the surgery, after the accessible part of the tumor has been removed. The drug is slowly released from the discs — each just 14mm in diameter and 1mm thick — over several weeks. The wafers were developed at the Massachusetts Institute of Technology and went into use in 1996. “This is the first major new treatment for brain tumors in 22 years,” says Pillay. In the U.S., brain tumors are the second-fastest-growing form of cancer in those over 65 and the No. 2 cause of cancer death among children under 15. Unlike the treatment now, in which the drugs run through the body to the brain, the medicated wafers attack the tumor directly. This circumvents the main obstacle to conventional brain-tumor chemotherapy — the blood-brain barrier, which filters out harmful substances before they reach the brain. This natural defense mechanism reduces the amount of medication able to reach the tumor. The new procedure minimizes the side-effects associated with conventional chemotherapy. These side-effects, which arise when the drugs flow through the body, include anemia, severe nausea, hair loss and a drop in white blood cell count. And with direct application no drug is lost along the way, so the dosage can be reduced. Patients with lower tolerance for chemotherapy can particularly benefit. Last year, Pillay performed the procedure for the first time in Asia. His two patients had advanced malignant tumors. Nine months later and more than two years after their initial diagnosis, both are recovering well. One has returned to work. But Pillay cautions that interstitial chemotherapy is not a one-stop cure-all. “This is a supplement to other treatments, not the sole method,” he says. In European trials some 63% of patients were alive one year after surgery compared to 19% who did not get the wafers. The wafer, essentially an innovative “on-site” delivery system for drugs, could also be effective with other types of cancers, as well as other diseases whose treatments have bad side-effects from chemotherapy. Says Pillay: “I expect that other agents can be introduced into the brain in a similar fashion to treat not only brain tumors but conditions like Alzheimer’s disease, Parkinson’s disease and epilepsy. “Though the front-end costs of wafers are higher, says Pillay, they “actually end up cheaper.” To those diagnosed with a brain tumor, the cost may not be important. The treatment may buy them something priceless: more time and perhaps an eventual cure. — By Andrea Hamilton

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Introduction Brain and spine tumours refers to tumours that grow in or around the brain and the spinal cord and can cause severe disability and even death if undetected and untreated by damaging the central nervous system. According to Dr Prem Pillay, a Senior Neurosurgeon and Neurosurgical Oncologist in Singapore, the number of people affected by these tumors is increasing because of better detection and also our aging population. These tumors can also affect children. There are two categories of brain and spine tumors. There are those that are benign and often slow growing such as Meningiomas, pituitary tumors ,Scchwannomas and acoustic neuromas. These are often seen in adults and can sometimes reach a large size by the time symptoms appear and are recognized. Dr Prem Pillay advocates early detection in order to increase the chance of a smaller tumor size at diagnosis. This could make treatment more effective and safer . The second category of tumors are those that are more malignant. They either start in the brain or spinal cord or come from elsewhere to that location. Someone who has breast or lung cancer can have spread of this cancer to the brain or spinal location. Malignant tumours that start in the brain or spinal cord are often Gliomas including astrocytomas. Diagnosis Brain tumors can cause headaches, seizures, weakness of a limb or limbs, loss of sensation, and loss of one the senses (smell, taste, vision, hearing, balance). However, Dr. Prem Pillay cautions that headaches are common and are more often from tension and migraines than a brain tumor. However, the presence of the other problems mentioned should lead one to a doctor for a neurological and spinal examination. Spine tumors can present with back pain, neck pain and loss of strength or feeling in the arms or legs or sometimes both. However, again Dr. Pillay observes that neck and back pain is often from slipped discs or spine degeneration rather than a spine tumor. Evaluation of the problem by a qualified specialist can help in arriving at a diagnosis and the proper use of tests including MRI and CT (computed tomography). In order to confirm the diagnosis, useful tests include MRI of the brain and the spine. The MRI does not use radiation but a magnetic field to arrive at images that can clearly show the nervous system of the brain and the spine and any tumors. The size and location of tumors can be precisely determined. PET-MRI (Positron Emission Tomography) of the Brain and whole Body when indicated is another test to determine a cancer.  A Biopsy is often needed to know the tumor type. This can either be done during the operation for tumor removal or using a needle. The needle type biopsies are now often computer and image guided meaning that MRI or CT technology is used for navigation and precision. New types of biopsy include Liquid biopsy of the blood or the CSF (Cerebrospinal Fluid). Molecular profiling of tumor fragments including circulating DNA and cell fragments can be done using NGS (Next Generation Sequencing). Modern Treatments In the past the treatment modalities for brain and spinal tumors in adults and children was often limited to the use of surgery alone often with attempts at radical removal with large openings. Modern surgery includes the use of advanced neuro microscopes with fluoroscopic imaging capabilities, Computer Guidance linked to MRI and CT scans, and finer tools for tumor removal. Parts of the tumor that are difficult or risky to remove can be treated later by other modalities such as Stereotactic Radiosurgery (SRS). According to Dr Prem Pillay, Stereotatic Radiosurgery has become a major and useful tool in the treatment of both brain and spine tumors. Stereotactic Radiosurgery uses precision and guided energy beams that penetrate painlessly and invisibly to the tumor site without needing an open operation. In the past there was the Gamma knife but now there are a wider range of radiosugery platforms including Tomotherapy, LINAC (linear accelerator/Photon) systems with micro-multileaf collimators for high precision, Robotics and the ability to treat the brain and the spine. There is also Proton Therapy for treating tumors of the Brain and Spine. There are tumors that can be treated with Stereotatic radiosurgery alone without open surgery as the first step. Malignant tumors may need several modalities of treatment including surgery, radiation and chemotherapy and/or Immunotherapy. Conclusions Although brain and spine tumors can be dangerous and devastating in adults and children ,Dr Prem Pillay believes that earlier diagnosis and the use of technologically advanced tools including microsurgery, robotics and radiosurgery is playing a role in saving many lives throughout the world including Singapore. With many years of experience in treating Brain and Spine Tumors and access to the latest technological advancements, Dr Prem Pillay offers patients the highest standard of care. From accurate diagnosis to tailored treatment plans, our approach ensures the best possible outcomes for individuals affected by this challenging condition. If you or a loved one has been diagnosed with a Brain and Spine Tumor / Cancer problem, we welome you to seek a consultation with our specialized team. Together, we can develop a comprehensive evidence based and personalized treatment strategy that addresses your unique needs and provides the best chance for a positive outcome. *FELLOW IN NEUROSURGICAL ONCOLOGY, MD ANDERSON CANCER CENTER AND HOSPITAL, USA.

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) What is an Acoustic Neuroma? An acoustic neuroma is an intra-cranial (within the head but outside the brain) tumor that arises from the superior vestibular nerve (a nerve for balance). The more accurate term is therefore vestibular schwannoma. Histopathology They are firm and encapsulated and classified as benign. Antoni A and Antoni B biphasic patterns are found. They can be cystic, hemorrhagic or entirely solid tumors. Malignancy is rare. Location I t starts in the internal acoustic meatus but can grow medially towards the brainstem and occupy space in the cerebellopontine angle. Related tumors Trigeminal schwannoma, facial nerve schwannoma, hypoglossal schwannoma and glossopharyngeal nerve schwannoma,  can occur in the same location (Cerebellar Pontine Angle or CP angle). Symptoms / Presentation This includes tinnitus (ringing in the ears), hearing loss, imbalance, numbness of the face, weakness of the face, difficulty in chewing and swallowing (caused by compressing nerves, brainstem and cerebellum in the CP angle as the tumor grows).  Large tumors may cause hydrocephalus by obstructing CSF circulation and this may cause symptoms related to this condition. Large tumors may cause coma, paralysis and death. Diagnosis: It can be overlooked in the early stages and the diagnosis missed as tinnitus and mild hearing loss are often not investigated with MRI scanning.  The best single test is MRI of the brain and IAM (internal acoustic meatus) with contrast (gadolinium). Hearing and balance tests can document the effects of the tumor. Treatment: There are in general, three options: Monitoring of small tumors (< 1cm in size) if hearing is still intact is an option in older patients and in younger patients with bilateral tumors associated with NF (Neurofibromatosis, NF-2). This includes clinical and hearing tests supplemented with regular MRI scans. If the tumor increases in size and significant hearing loss occurs treatment is recommended. Surgery and tumor excision was once the only  treatment option for most of the 20th century. Microsurgery, improved anesthesiology, Image-guidance , better microsurgical tools and nerve monitoring have improved the results of surgery. Microsurgery may still be the best treatment option for large tumors (>3.5cm) in selected patients who have symptoms from the mass effect of the tumor. Radiosurgery is now an accepted treatment modality for acoustic neuromas as there is overall a lower risk than surgery in terms of anesthesia risks, bleeding and infection. Mortality which is a possibility with any brain surgery is extremely rare and even exceptional with modern radiosurgery/stereotactic radiotherapy. In addition numerous centers and clinical papers have documented the safety and effectiveness of Radiosurgery. Newer forms of radiosurgery include Micro-MLC radiosurgery, fractionated radiosurgery (also referred to as Stereotactic Radiotherapy and vice versa) and Proton beam therapy. Combined Microsurgery and Radiosurgery (CMR) is an option that can work well with large acoustic neuromas and schwannomas of the CP angle. Microsurgery is used to remove tumor in a safe way without damaging near by nerves (especially the facial nerve and trigeminal nerve and the brainstem) and any remaining smaller volume tumor is then treated subsequently with radiosurgery / SRT / FSR / Micro (MLC) Radiosurgery. Conclusions: With modern diagnostic methods acoustic neuromas and other cranial schwannomas can be diagnosed earlier when they are smaller and have lesser symptoms and lesser brain and nerve damage. Modern treatment methods including no surgery methods as described above have improved treatment success and allowing more people to have a better quality and length of life.

LATEST CLASSIFICATION FOR BRAIN TUMORS (ADULTS AND CHILDREN) Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) The 2021 World Health Organization (WHO) Classification of Tumors of the Central Nervous System (CNS), also known as WHO CNS5, represents a significant update in the classification and diagnosis of brain tumors. This fifth edition builds upon the 2016 classification, incorporating new molecular insights and diagnostic approaches. Here is a comprehensive summary of the key changes and features of the latest WHO brain tumor classification: General Changes and Principles Integrated Diagnosis The WHO CNS5 emphasizes the importance of integrated diagnoses, combining histological, molecular, and clinical information. This approach aims to provide more accurate and clinically relevant tumor classifications. Layered Reporting The classification introduces a layered reporting structure, including: Integrated diagnosis Histological classification CNS WHO grade Molecular information This structure allows for a more comprehensive and nuanced understanding of each tumor which allows a better selection of treatment options for patients. Grading System The classification now uses Arabic numerals (1, 2, 3, 4) instead of Roman numerals for tumor grades. Importantly, grading is now done within tumor types rather than across different types. This change aims to better reflect the biological behavior of specific tumor entities. Molecular Diagnostics WHO CNS5 significantly expands the role of molecular diagnostics in tumor classification. Many tumor types now require molecular testing for accurate diagnosis and grading. This is important for a more personalized approach to the treatment of these tumors with potentially better outcomes. Major Changes in Tumor Classification Adult-Type Diffuse Gliomas Astrocytoma, IDH-mutant Grades: 2, 3, or 4 Key molecular markers: IDH1/2 mutation, ATRX loss, TP53 mutation CDKN2A/B homozygous deletion indicates grade 4. Oligodendroglioma, IDH-mutant and 1p/19q-codeleted Grades: 2 or 3 Key molecular markers: IDH mutation, 1p/19q codeletion, TERT promoter mutation. Glioblastoma, IDH-wildtype Always grade 4 Molecular markers for diagnosis: EGFR amplification, TERT promoter mutation, or combined gain of chromosome 7 and loss of chromosome 10. Pediatric-Type Diffuse Gliomas Diffuse astrocytoma, MYB- or MYBL1-altered Angiocentric glioma Polymorphous low-grade neuroepithelial tumor of the young Diffuse low-grade glioma, MAPK pathway-altered. Pediatric-Type High-Grade Gliomas Diffuse midline glioma, H3 K27-altered Diffuse hemispheric glioma, H3 G34-mutant Infant-type hemispheric glioma. Circumscribed Astrocytic Gliomas Pilocytic astrocytoma High-grade astrocytoma with piloid features Pleomorphic xanthoastrocytoma Subependymal giant cell astrocytoma. Glioneuronal and Neuronal Tumors This category includes various entities such as ganglioglioma, dysembryoplastic neuroepithelial tumor, and rosette-forming glioneuronal tumor, among others. Ependymal Tumors The classification of ependymal tumors now incorporates molecular subgroups, particularly for posterior fossa ependymomas . Choroid Plexus Tumors These tumors are now graded within their tumor type, with molecular features playing a role in diagnosis and prognosis. Embryonal Tumors Medulloblastoma : Now classified into molecularly defined subgroups (WNT-activated, SHH-activated, and non-WNT/non-SHH). Atypical teratoid/rhabdoid tumor Embryonal tumor with multilayered rosettes CNS neuroblastoma, FOXR2-activated Molecular Diagnostic Tools The WHO CNS5 classification relies heavily on molecular diagnostic tools for accurate tumor classification. Some key methods include: DNA and RNA Next-Generation Sequencing : For detecting mutations, fusions, and copy number alterations Methylome Profiling : Particularly useful for tumor classification and identification of novel entities. Immunohistochemistry : For detecting protein expression of key molecular markers (e.g., IDH1 R132H, ATRX, H3 K27M) Fluorescence In Situ Hybridization (FISH) : For detecting chromosomal alterations like 1p/19q codeletion Implications for Clinical Practice Multidisciplinary Approach : The integrated diagnosis approach necessitates close collaboration between pathologists, molecular biologists, and Neurosurgeons. Personalized Medicine : More precise tumor classification allows for more targeted therapies and better prognostication and potentially better outcomes. Challenges in Implementation : The increased reliance on molecular testing may pose challenges in resource-limited settings. Ongoing Research : The classification acknowledges that our understanding of CNS tumors is evolving, and future updates are anticipated as new molecular insights emerge. In conclusion, the WHO CNS5 classification represents a significant step towards a more molecularly informed and clinically relevant approach to brain tumor diagnosis. It integrates histological and molecular features to provide a comprehensive tumor classification system that aims to improve patient care through more accurate diagnosis, prognosis, and treatment selection.

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Hydrocephalus in adults is a complex and multifaceted condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain. This condition can result from a variety of etiologies, leading to increased intracranial pressure and subsequent neurological impairment. The management of adult hydrocephalus requires a nuanced understanding of its pathophysiology, clinical presentation, diagnostic modalities, and therapeutic interventions. Etiology and Pathophysiology Adult hydrocephalus can be classified into several categories based on its underlying cause: obstructive (non-communicating), communicating, and ex-vacuo hydrocephalus. Obstructive hydrocephalus arises from a physical blockage within the ventricular system or at the outlets of the fourth ventricle, impeding the flow of CSF. Common causes include tumors, such as colloid cysts , pineal tumors, gliomas including tectal gliomas, and aqueductal stenosis, which may be congenital or acquired due to inflammation or hemorrhage. Communicating hydrocephalus, on the other hand, occurs despite the absence of an obstruction in the ventricular system. It is often attributed to impaired CSF absorption at the arachnoid granulations, which can be secondary to subarachnoid hemorrhage, hemorrhagic strokes, meningitis, or idiopathic normal pressure hydrocephalus (iNPH). Ex-vacuo hydrocephalus is a misnomer, as it reflects ventricular enlargement secondary to brain atrophy rather than true hydrocephalus, and is commonly seen in neurodegenerative diseases such as Alzheimer’s Dementia. Clinical Presentation The clinical presentation of hydrocephalus in adults can vary widely. Symptoms may develop acutely or slowly, depending on the rate of CSF accumulation and the underlying pathology. Classic manifestations include headaches, nausea, vomiting, blurred vision, and papilledema, indicative of raised intracranial pressure. In contrast, iNPH is characterized by a triad of gait disturbance, cognitive impairment, and urinary incontinence, often with normal or only slightly elevated intracranial pressure. Diagnostic Evaluation Clinical findings are supported by imaging studies, which are essential for diagnosis and treatment planning. Computed tomography (CT) and magnetic resonance imaging (MRI) are the primary modalities used to assess ventricular size, identify potential causes of CSF flow obstruction, and evaluate for transependymal CSF flow. MRI provides superior soft tissue contrast and can delineate the anatomy of the ventricular system and surrounding structures in greater detail. Patients with suspected Normal Pressure Hydrocephalus often have a lumbar spine CSF tap to observe any improvement in their symptoms such as gait before having a programable ventriculoperitoneal shunt (VP shunt) placement states Dr Prem Pillay. Treatment The cornerstone of hydrocephalus management is the diversion of CSF to reduce intracranial pressure and alleviate symptoms. Ventriculoperitoneal (VP) shunts are the most commonly employed devices, consisting of a proximal catheter placed within the lateral ventricle, a valve mechanism to regulate flow, and a distal catheter that terminates in the peritoneal cavity. Alternatives include ventriculoatrial (VA) and lumboperitoneal (LP) shunts, which are selected based on patient-specific anatomical and physiological considerations. Endoscopic third ventriculostomy (ETV) is a minimally invasive surgical option for obstructive hydrocephalus, which involves creating an opening in the floor of the third ventricle to allow CSF to bypass the obstruction and flow directly into the subarachnoid space. ETV is associated with lower infection rates and may reduce the need for shunt placement, particularly in patients with aqueductal stenosis or tectal gliomas. Microsurgical removal of tumors obstructing the CSF pathways may also relieve hydrocephalus without needing to place a shunt or do an ETV. Examples of this including removing a large cerebellar tumor that is compressing the fourth ventricle and causing hydrocephalus explains Dr Prem Pillay. Latest and Future Innovations Advancements in neuroimaging, including the development of phase-contrast MRI techniques, are enhancing the ability to visualize CSF dynamics and may lead to improved diagnostic accuracy. The integration of machine learning algorithms with imaging data holds promise for predicting shunt responsiveness and optimizing patient selection for ETV. Neuronavigation with computer aided Image guidance allows the more precise placement of Ventricular shunts reducing bleeding and obstruction. Robotics may also improve the precision of shunt placements. Neuroendoscopic innovations continue to evolve, with the advent of flexible endoscopes and improved intraventricular navigation systems, potentially expanding the indications for ETV and enhancing surgical outcomes. Additionally, the development of programmable shunt valves and telemetric pressure sensors is refining the management of shunt systems, allowing for non-invasive adjustments and monitoring to prevent over- or under-drainage complications. In the realm of molecular biology, research into the pathophysiological mechanisms underlying CSF production and absorption may yield novel pharmacological targets for the treatment of hydrocephalus. Gene therapy and stem cell-based approaches are also being explored as potential avenues for repairing or replacing dysfunctional CSF pathways. Conclusions Hydrocephalus in adults is a condition with diverse etiologies and clinical manifestations, requiring a tailored approach to diagnosis and management. Current treatment strategies focus on CSF diversion through shunting or endoscopic procedures, with ongoing research aimed at improving patient outcomes through technological and biological innovations. As our understanding of hydrocephalus deepens, the future holds the potential for more precise and less invasive therapeutic options explains Dr Prem. With many years of experience in treating hydrocephalus and access to the latest technological advancements, Dr Prem Pillay endeavours to offer patients the highest standard of care. From accurate diagnosis to tailored treatment plans, our approach aims for the best possible outcomes for individuals affected by this challenging condition. If you or a loved one has been diagnosed with Hydrocephalus, we welcome you to seek consultation with our specialist and his team. Together, we can develop a comprehensive evidence based and personalized treatment strategy that addresses your unique needs and provides the best chance for a positive outcome.

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) A new technology to help those with disabilities from Brain damage after a stroke, head injury, brain tumor, brain infection, birth related brain dysfunction and other causes of brain damage The human brain, with its intricate network of neurons and synapses, remains one of the most fascinating and complex systems in the universe. For decades, scientists have dreamt of directly interfacing with this enigmatic organ, unlocking its secrets and harnessing its potential. This dream is now becoming a reality with the rapid advancement of Brain-Computer Interfaces (BCIs). BCIs are devices that translate brain activity into external outputs, enabling communication and control without the need for traditional muscle movements. This technology holds immense promise for individuals with disabilities, allowing them to regain lost function and interact with the world around them in new and exciting ways. Brain-computer interfaces (BCIs) have emerged as a promising technology that allows direct communication between the human brain and external devices. Over the years, significant advancements have been made in the field of BCIs, enabling new possibilities for medical applications, neurorehabilitation, and human-machine interactions. In this article, we will explore some of the recent advances in brain-computer interfaces and their potential implications. Non-Invasive Brain Computer Interfaces: Non-invasive BCIs utilize external sensors to measure brain activity without the need for invasive procedures. Recent advancements in non-invasive BCIs include: High-resolution Electroencephalography (EEG) Improved electrode designs and signal processing techniques have enhanced the spatial and temporal resolution of EEG-based BCIs . This allows for more accurate and reliable detection of brain signals. Functional Near-Infrared Spectroscopy (fNIRS) fNIRS measures changes in blood oxygenation levels in the brain. It offers portability and the ability to monitor deeper brain regions, making it suitable for various applications, including neurofeedback and cognitive training . Invasive BCIs: Invasive BCIs involve implanting electrodes directly into the brain to record neural activity. Recent advancements in invasive BCIs include: Neuralink Elon Musk’s ambitious project aims to implant high-density electrode arrays directly into the brain, enabling seamless communication between humans and computers. Early trials have shown promising results in restoring movement and communication in paralyzed individuals.Paradromics This company in Austin, Texas has developed the highest data rate transfer BCI system using platinum-iridium electrodes thinner than a human hair and are able to pack 1600 of them into a tiny brain module. They plan to help paralysed people move their limbs, and potentially may in the future allow vision for the blind and hearing for those with brain damage.* Synchron This company has developed a minimally invasive BCI that can be implanted under the skin without the need for open brain surgery. The device has been successfully used to treat patients with severe paralysis, allowing them to control prosthetic limbs and communicate through a virtual keyboard.* BrainGate This pioneering BCI system has been used in clinical trials for over a decade, demonstrating the potential for restoring movement and communication in individuals with spinal cord injuries. Recent advancements have focused on improving signal processing and developing more intuitive control interfaces.* Brain-to-Brain Communication Researchers have achieved groundbreaking success in enabling direct communication between two individuals using BCIs. This technology opens up possibilities for collaborative tasks and enhanced social interaction. 3.  Hybrid BCIs: Hybrid BCIs combine multiple modalities to improve the accuracy and reliability of brain signal detection. Recent advancements in hybrid BCIs include: Electroencephalography and Functional Magnetic Resonance Imaging (EEG-fMRI): EEG-fMRI fusion combines the high temporal resolution of EEG with the high spatial resolution of fMRI. This hybrid approach enables more precise localization of brain activity and enhances the understanding of brain dynamics [[2]]( https://www.nature.com/articles/s41378-022-00453-4 ). Electroencephalography and Eye-Tracking Combining EEG with eye-tracking technology allows for more accurate interpretation of brain signals by incorporating gaze information. This hybrid BCI approach has potential applications in human-computer interaction and assistive technologies [[2]] ( https://www.nature.com/articles/s41378-022-00Recent advances in brain-computer interfaces have opened up new possibilities for understanding the human brain, treating neurological disorders, and enhancing human-machine interactions. Non-invasive, invasive, and hybrid BCIs have all seen significant progress, improving the accuracy, resolution, and usability of these interfaces. As research continues, we can expect further advancements in BCIs, leading to more effective and accessible applications in various fields. Recent Advances in BCI Technology: Neuralink Elon Musk’s ambitious project aims to implant high-density electrode arrays directly into the brain, enabling seamless communication between humans and computers. Early trials have shown promising results in restoring movement and communication in paralyzed individuals.Paradromics This company in Austin, Texas has developed the highest data rate transfer BCI system using platinum-iridium electrodes thinner than a human hair and are able to pack 1600 of them into a tiny brain module. They plan to help paralysed people move their limbs, and potentially may in the future allow vision for the blind and hearing for those with brain damage.* Synchron This company has developed a minimally invasive BCI that can be implanted through blood vessels in the head without the need for open brain surgery. The device has been successfully used to treat patients with severe paralysis, allowing them to control prosthetic limbs and communicate through a virtual keyboard. BrainGate This pioneering BCI system has been used in clinical trials for over a decade, demonstrating the potential for restoring movement and communication in individuals with spinal cord injuries. Recent advancements have focused on improving signal processing and developing more intuitive control interfaces. Brain-to-Brain Communication: Researchers have achieved groundbreaking success in enabling direct communication between two individuals using BCIs. This technology opens up possibilities for collaborative tasks and enhanced social interaction. Ethical Considerations: As BCI technology advances, ethical considerations become increasingly important. Issues such as privacy, security, and potential misuse of this powerful technology need careful attention. Open discussions and regulations are crucial to ensure responsible development and implementation. The Future of BCIs: Recent advances in brain-computer interfaces have opened up new possibilities for understanding the human brain, treating neurological disorders, and enhancing human-machine interactions. Non-invasive, invasive, and hybrid BCIs have all seen significant progress, improving the accuracy, resolution, and usability of these interfaces. The future of BCIs is brimming with possibilities. As the technology continues to evolve, we can expect to see even more groundbreaking advancements in the years to come. From restoring lost function to enhancing human capabilities, BCIs have the potential to reshape our understanding of the brain and revolutionize the way we interact with the world around us. This article is just a glimpse into the exciting world of BCIs. As research and development continue, we can expect even more remarkable breakthroughs in this field, pushing the boundaries of human-machine interaction and unlocking the full potential of the human mind. References Learn more:1. [Brain-computer interface: trend, challenges, and threats | Brain Informatics | Full Text]( https://braininformatics.springeropen.com/articles/10.1186/s40708-023-00199-3)2 . [Neuron devices: emerging prospects in neural interfaces and recognition | Microsystems & Nanoengineering]( https://www.nature.com/articles/s41378-022-00453-4)3 . [The year of brain-computer interfaces | Nature Electronics]( https://www.nature.com/articles/s41928-023-01041-8 )

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA)\ What is the Gamma Knife? The Gamma Knife is a specialized medical device used to treat brain disorders, particularly tumors and other abnormalities. Despite its name, it doesn’t involve any actual cutting. Instead, it uses focused beams of Gamma Rays to target and treat specific areas within the brain. This non-invasive technique is known as stereotactic radiosurgery. The Gamma Knife is highly precise, allowing doctors to treat brain conditions without the need for traditional surgery. Dr Prem Pillay, spearheaded the setting up of the first Gamma Knife Center in Singapore and the Region (South East Asia and South Asia). He currently treats patients with the latest Gamma Knife which uses Robotic assistance. Conditions Treated with Gamma Knife The Gamma Knife is primarily used to treat a variety of brain conditions, including: Brain Tumors Both benign (non-cancerous) such as Meningiomas, Acoustic Neuromas, Pituitary Tumors and malignant (cancerous) tumors can be treated. Arteriovenous Malformations (AVMs) These are abnormal tangles of blood vessels in the brain. Trigeminal Neuralgia A chronic pain condition affecting the trigeminal nerve in the face. Acoustic Neuromas Non-cancerous tumors that develop on the nerve leading from the inner ear to the brain. Metastatic Brain Cancers Cancers that have spread to the brain from other parts of the body such as Lung Cancer, Breast Cancer, Colon Cancer and many other primary cancers. Advantages Over Surgery and Other Treatments The Gamma Knife offers several advantages over traditional surgery and other treatment methods: Non-Invasive There’s no need for incisions, which reduces the risk of infection and other surgical complications. Precision The treatment targets only the affected area, minimizing damage to surrounding healthy tissue. Outpatient Procedure Most patients can go home the same day, avoiding a hospital stay. Minimal Recovery Time Patients typically experience a quicker recovery compared to conventional surgery. Less Painful Since there are no cuts or stitches, patients usually experience less pain and discomfort. Treatment Steps Here’s what a typical Gamma Knife treatment involves: Consultation The process begins with a consultation with Dr Prem Pillay,a Neurosurgeon and Gamma Knife specialist who evaluates whether Gamma Knife treatment is appropriate for your condition. Preparation On the day of treatment, a lightweight frame is attached to your head to keep it still during the procedure. This ensures precision targeting. Imaging Detailed imaging scans (such as MRI and/or CT) are taken to pinpoint the exact location of the area to be treated. Treatment Planning Using advanced software with 3 D modelling of the Brain and the tumor or lesion, Dr Pillay and his team,. plan how to deliver the radiation beams most effectively and safely with high precision. Treatment Session You’ll lie on a bed that slides into the Gamma Knife machine. The machine delivers focused radiation beams to the targeted area in your brain. Robotic assistance is used to improve the accuracy of the treatment. Dr Prem will monitor the treatment from then adjacent control room where muliptle computer screens show the real time dose output of gamma rays and video imaging of the patient. Post-Treatment Once treatment is complete, the stereotactic frame is removed and you can usually return home shortly afterward. Why People with Brain Tumors Should Consider This Treatment Gamma Knife radio surgery is particularly beneficial for individuals with brain tumors and AVMs because it offers an effective alternative to traditional surgery with fewer risks and side effects. It’s especially useful for treating tumors and AVMS in hard-to-reach areas of the brain or for patients who cannot undergo conventional surgery due to health reasons. It is also useful for patients with Trigeminal Neuralgia. Post-Treatment Care After undergoing Gamma Knife treatment, patients should follow these general guidelines: Follow-Up Appointments Regular check-ups with your doctor are crucial to monitor your progress and assess any changes in your condition. Rest and Recovery Although recovery time is minimal, it’s important to rest and avoid strenuous activities for a few days after treatment. Report Symptoms Any unusual symptoms or side effects should be reported to your healthcare provider immediately. Lifestyle Adjustments Depending on your condition, you may need to make certain lifestyle adjustments as advised by your doctor. Conclusion The Gamma Knife represents a significant advancement in treating brain disorders with its precision and non-invasive approach. It offers hope and effective treatment options for those dealing with challenging conditions like brain tumors, AVMs and Trigeminal Neuralgia providing an alternative that minimizes risks while maximizing outcomes.

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Historical Origins Robotics in neurosurgery represents a groundbreaking technological advancement that began in 1985, marking the first practical application of robotic systems in surgical procedures[1]. The Zeiss MKM Robotic Microscope and the Surgiscope in the early 2000-2010 period were also groundbreaking. The field has since evolved dramatically, driven by the need for increased precision, minimally invasive techniques, and enhanced surgical capabilities. Types of Robotic Systems Surgical Control Approaches Neurosurgical robotic systems can be categorised into three primary control methods: Surgeon Supervised Systems Preplanned surgical procedures Neurosurgeon plots robotic arm movements beforehand Robot performs predetermined movements NeuroSurgeon provides direct oversight[1] Telesurgical Robots NeuroSurgeon controls surgical movements remotely Real-time control from a separate console Includes haptic feedback and live video transmission Enables surgery from outside the operating room[1] Shared Control System Collaborative interaction between robot and Neurosurgeon NeuroSurgeon maintains primary movement control Robot provides stabilizing forces[1] Notable Robotic Neurosurgery Platforms and Systems Advanced Robotic Systems include: NeuroArm: First MRI-compatible neurosurgical robot (launched 2008) ROSA ONE Brain: Provides minimally invasive brain procedures Renaissance Robotic System: Offers high dexterity for deep brain procedures CyberKnife: Pioneering radiosurgery platform[1][2][3] NDR Spine Robotics for Discoplasty and other Spine procedures Robotic Radiosurgery for Brain and Spine Tumors and Cancers Da Vinici Robotics for selective Brain and Spine Surgery Clinical Applications and Primary Neurosurgical Uses Robotic systems excel in several critical neurosurgical domains: Precise Anatomical Localation Stabilizing Surgical Instruments Deep Brain Target Access Spinal Pedicle Screw Placement Stereotactic Procedures Minimally Invasive Brain Interventions[3][4] Specific Procedural Applications Epilepsy surgery Deep brain stimulation Stereotactic biopsies Electrode placement Tumor removal Laser ablation procedures[4] Technological Advantages Key Benefits Unprecedented Precision: Sub-millimeter accuracy Minimally Invasive Techniques Reduced Surgical Trauma Shorter Procedure Times Lower Infection Risks Enhanced Surgical Planning[2][4] Limitations and Ethical Considerations Technical Challenges Potential view obstruction during surgery Limited tactile dexterity Image acquisition distortions Mechanical design constraints[5] Ethical Concerns Potential reduction in surgeon’s manual skills High technological costs Unequal global access to advanced technology Risk of over-reliance on robotic systems[5] Future Perspectives and Emerging Trends Machine Learning Integration Enhanced Autonomous Capabilities Improved Human-Robot Collaboration Expanded Procedural Applications More Sophisticated Sensory Feedback[6] Future Trends in Robotics in Neurosurgery Neurosurgical robotics is expected to become increasingly sophisticated, with potential multi-robot systems collaborating during complex procedures. The future likely involves more nuanced, adaptive robotic platforms that can handle intricate neurological interventions[6]. Dr Prem Pillay believes that future neurosurgical teams will include humanoid robotic assistants ( AI embodied) working with human Neurosurgeons using smart tools to remove brain tumors and brain cancers; correct spinal problems, and using finer tools and devices to replace diseased, injured or missing parts of the nervous system (Brain and Spinal Cord). Robotic neurosurgery represents a transformative technological frontier, balancing remarkable precision with ongoing technological challenges. As research continues, these systems promise to revolutionize neurological interventions, offering unprecedented surgical capabilities while maintaining critical human expertise. Citations: [1] https://pmc.ncbi.nlm.nih.gov/articles/PMC11588608/ [2] https://www.escatec.com/blog/9-leading-companies-developing-robotic-neurosurgery-technology [3] https://pmc.ncbi.nlm.nih.gov/articles/PMC9479589/ [4] https://www.seattlechildrens.org/clinics/neurosciences/services/robot-assisted-neurosurgery/ [5] https://www.int-res.com/articles/esep2021/21/e021p025.pdf [6] https://thejns.org/focus/view/journals/neurosurg-focus/42/5/article-pE1.xml [7] https://www.zimmerbiomet.com/en/products-and-solutions/zb-edge/robotics/rosa-brain.html [8] https://jnis.bmj.com/content/10/1/78

The Definition of Dementia Dementia is a general term used to describe progressive and neurodegenerative diseases in which alterations in the chemical composition of the brain compromise one’s cognitive ability. Specifically, dementia is characterized by a decline in mental ability severe enough to interfere with everyday activities. Dementia is sometimes incorrectly referred to as “senility” or “senile dementia” reflecting the widespread but incorrect belief that dementia is a normal part of aging. At this time, there is no cure or remedy for any type of dementia, including Alzheimer’s disease. The only thing that existing medication can do is lessen symptoms and delay disease progression in some people and, in the interim, help support their mood and quality of life. Cortical vs. Subcortical Dementia While these classifications are not always used, some physicians find it helpful to classify dementia into one of two groups, depending on the initial brain area that is primarily affected.There will typically be visible physical changes in the brain wherever the damage is, such as atrophy or shrinkage. The definition of cortical dementia is that it is a type of dementia that primarily targets the brain’s gray matter (in the cortex). Cortical dementia typically causes difficulties with language (such as word-finding or understanding others), social behaviors, and memory. Examples include Frontotemporal dementia, Creutzfeldt-Jakob disease, and Alzheimer’s disease. Subcortical dementia targets the parts of the brain underneath the cortex, and are linked to the white matter of the brain. Subcortical dementias are more likely to impact personality and thought processes. Language and memory tend to be largely unaffected in the early stages of these conditions. Parkinson’s, Huntington’s disease, and AIDS dementia complex are subcortical dementias. Typically, categorizing dementia as cortical or subcortical is of less value than determining the specific type of dementia someone is experiencing, as different types of dementia have unique symptoms, causes, and prognosis. Alzheimer’s Disease (AD) Alzheimer disease is by far the most prevalent form of dementia, accounting for 60 to 80 % of all individuals with dementia. This chronic illness predominantly afflicts people in the 65+ age bracket, with the exception of “early onset” Alzheimer’s,rendering it the sixth leading cause of mortality in America. Almost 6 million people in the United States are estimated to have Alzheimer’s disease, and this number is expected to grow dramatically with the aging of our population. Alzheimer’s Disease Signs and Symptoms The first signs of Alzheimer’s disease include issues with memory, typically having difficulty recalling people’s names. These initial signs are commonly referred to as mild cognitive impairment (MCI). With Alzheimer’s, these symptoms progress to the point that the individual needs incrementally more assistance with everyday tasks and gradually becomes more dependent. Other symptoms of Alzheimer’s disease include: Confusion and disorientation Language and communication difficulties Advanced memory loss Agitation and possible combativeness Possible sleeplessness and wandering Repetitive talking Stages of Alzheimer’s Disease Alzheimer’s disease is sometimes broken down into three stages: mild, moderate, and severe. In the mild stage , it is typical for the individual to: Start wandering, at first mostly inside the home Experience difficulty managing finances independently Repeat phrases and questions In the moderate stage , the individual can experience symptoms such as: Impairment in their reasoning skills Language issues Confused thought patterns Difficulty recognizing familiar faces Difficulty learning new things In the advanced stages , people typically: Lose their ability to communicate effectively Become completely dependent on others Often become bed ridden Experience body systems shutting down Causes of Alzheimer’s Disease Scientists are still working to determine exactly what causes Alzheimer’s disease. Like other types of dementia, Alzheimer’s seems to be brought on by progressive death of brain cells that happens over time, causing parts of the brain to shrink. Scientists also attribute Alzheimer’s disease to genetic mutations as well as environmental and lifestyle factors. See our article on Alzheimer’s risks, causes, and prevention for more detailed information. PART II Vascular Dementia (VD) Vascular dementia, usually results from a succession of small strokes, is also referred to as a post-stroke or multi-infarct dementia. It ranks only second to AD as the most prevalent dementia, accounting for approximately 10% of all dementia cases. Strokes can cause a weakening of the blood flow to the brain, which in turn brings about confusion and the failure to think or speak clearly. When the brain is starved of oxygen and nutrients, brain cells start to weaken and die. Vascular Dementia Signs and Symptoms Like Alzheimer’s, vascular dementia symptoms can vary across a wide range and depend largely on how bad the blood vessel damage is and what portion of the brain is impacted. After a stroke, patients can experience symptoms like confusion, difficulty speaking, disorientation, and the inability to focus. Compared to Alzheimer’s, vascular dementia primarily affects judgment or ability to make decisions, as opposed to memory. Following one or more strokes, vascular dementia may also be characterized by physical symptoms like vision or speech problems and weakness in limbs, but these symptoms might get better with rehabilitation. Causes of Vascular Dementia Vascular dementia is primarily caused by strokes, causing the brain to go without nutrients for an extended period of time. When this blockage occurs, it leaves the brain partially or severely damaged. Another cause is the constricting of blood vessels or the prevalence of damaged blood cells. Those with heart conditions, Diabetes, high blood pressure, or high cholesterol may be at greater risk of developing vascular dementia. Treatment and Prognosis of Vascular Dementia There are currently no approved medical therapy for the treatment of vascular dementia. There is, however, some evidence that certain medical therapy used to treat the symptoms of Alzheimer’s disease may provide some benefit to those with vascular dementia. The most important thing you can do for now is control the risk factors that contributed to the dementia in the first place (e.g. blood pressure or cholesterol levels). Individuals with vascular dementia live for about 5 years on average after their symptoms begin. Dementia with Lewy Bodies (LBD) Dementia with Lewy Body (LBD) is the third most prevalent type of dementia, after Alzheimer’s and vascular dementia. Individuals with LBD experience both deficits in their memory and difficulty thinking. At first, the LBD symptoms look similar to Alzheimer’s. As LBD progresses, the disease acquires its own set of symptoms, notably a blank facial expression, tremors, difficulties walking and hallucinations. Lewy Body Dementia Signs and Symptoms Symptoms of LBD worsen over time and include memory loss, difficulty planning and executing functions, paying attention, and making decisions, and problems completing and following through on routines. Difficulties with visual perception and visual hallucinations are also common, as are concentration difficulties, restlessness, sleeplessness, and spontaneous, Parkinson’s-like tremors. Individuals with LBD may also experience depression and/or apathy, or loss of motivation. Causes of Lewy Body Dementia LBD is caused by an abnormal buildup of proteins called alpha-synuclein that get lumped into clusters known as Lewy Bodies and affect chemicals in the brain. People with LBD have plaques and tangles, associated with Alzheimer’s disease, in their brains as well. In LBD, the part of the brain that is affected the most is the center cortex, associated with thinking, memory, and movement. Treatment and Prognosis of Lewy Body Dementia Though there is currently no cure for LBD, existing medications can help manage some symptoms of the disease. These medications are called cholinesterase inhibitors (used to treat AD) and they can help if a person with LBD is experiencing memory problems. Examples of these medications include Donepezil, Rivastigmine and Galantamine. If a person with LBD has movement problems, medications used for Parkinson’s disease, such as Levodopa (L-dopa), may be recommended. Sleep problems can also be managed by sleep medications including melatonin. The disease lasts an average of 5 to 7 years from the time of diagnosis to death, but depending on the person, it can last anywhere from 2 to 20 years. Mixed Dementia Mixed dementia is a term used when Alzheimer’s and other dementias co-exist in the same person. In the most common type of mixed dementia, the protein deposits linked to Alzheimer’s disease co-exist with the blood vessel problems associated with vascular dementia. Alzheimer’s disease also is likely to co-exist with Lewy Body Dementia. In some cases, a person might display brain changes characteristic of all 3 types of dementia. It is not known how many people have mixed dementia, as it may often be misdiagnosed as a single type, but autopsies suggest that the condition may be much more prevalent than previously thought. Mixed Dementia Signs and Symptoms Symptoms of mixed dementia likely vary, as they will depend on the changes in the brain and the brain regions that are affected. Symptoms in many cases resemble Alzheimer’s disease or another type of dementia. In other cases, a person’s symptoms might more clearly suggest that they are experiencing more than one type of dementia. Causes of Mixed Dementia The causes of mixed dementia depend on the mix of symptoms they are experiencing. In most cases, mixed dementia seems to be caused by the abnormal protein build up linked to Alzheimer’s disease in addition to blood vessel linked to vascular dementia. It is not known why some individuals experience more than one type of dementia, but it is thought that those with more than one type may experience worse brain damage. Mixed Dementia Treatment and Prognosis As most people with mixed dementia are mistakenly diagnosed with a single type of dementia, physicians often prescribe medication based on the type of dementia that’s been diagnosed. No medications are approved by the U.S. Food and Drug Administration (FDA) to treat mixed dementia specifically. However, if your loved one is experiencing symptoms that most resemble Alzheimer’s disease, Alzheimer’s medications may provide some help with some of their symptoms. As vascular dementia is one of the most common co-occurring forms of dementia, it cannot hurt to control vascular risk factors like high blood pressure and cholesterol. It is hard to provide a disease duration for mixed dementias as experiences can vary a great deal depending on the unique combination of diseases, as well as age and coexisting health conditions. Parkinson’s Disease Dementia An estimated 50 to 80 percent of those with Parkinson’s eventually develop dementia as their disease worsens. The average duration of time from a Parkinson’s diagnosis to the development of dementia is about 10 years. Parkinson’s Dementia Symptoms Parkinson’s disease dementia impairs one’s ability to think and reason clearly. Symptoms include: Changes in memory, concentration, and judgment Difficulty interpreting visual information Muffled speech Rapid eye movement (REM) sleep disorder Visual hallucinations, delusions, and paranoia Depression, irritability, anxiety, and sleep disturbances Possible daytime drowsiness Causes of Parkinson’s Disease Dementia Some factors at the time of a Parkinson’s diagnosis might increase individuals’ likelihood of developing dementia, including older age, more severe motor symptoms, and mild cognitive impairment (MCI). People may also be more at risk if they experience hallucinations, excessive daytime drowsiness, and Parkinson’s symptoms of postural instability and gait disturbance, which can include freezing mid-step, shuffling the feet, and problems with balance and falls. Treatment and Prognosis of Parkinson’s Disease Dementia There are currently no treatments to slow or stop the cognitive decline caused by Parkinson’s disease dementia. Current strategies focus on helping with certain symptoms.  Like other types of dementia, Parkinson’s disease dementia gets progressively worse with time, though the rate of progression can vary from person to person. Frontotemporal Dementia (FTD) Frontotemporal dementia involves a diverse group of uncommon disorders that directly affect the frontal temporal lobes of the brain. As a result, one’s personality, behavior, and language begin to show radical decline. The brain typically shrinks due to atrophy. Typically, people are diagnosed with Frontotemporal dementia when they are in their 40’s, much earlier than Alzheimer’s disease is usually diagnosed. Frontotemporal Dementia Signs and Symptoms People with FTD typically exhibit changes in behavior and personality. The symptoms can include: Inappropriate behaviors Loss of interpersonal skills like empathy Lack of judgment and inhibition Apathy Repetitive compulsive behaviors A decline in personal hygiene Changes in eating habits, usually overeating Oral exploration and consumption of inedible objects Lack of awareness of thinking or behavioral changes Speech and language problems Movement problems (more rare) Causes of Frontotemporal Dementia In FTD, the frontal and temporal lobes of the brain atrophy or shrink. Some genetic mutations have also been linked to certain subtypes of frontotemporal dementia. However, more than 50% of those who develop frontotemporal dementia have no family history of the disease. In some cases, the disease seems to result from pick cells or pick bodies that develop inside the nerve cells in the brain. These cells have an abnormal amount of a protein known as Tau. There are no known risk factors for FTD other than a family history of dementia. Treatment and Prognosis of Frontotemporal Dementia Like Alzheimer’s and other types of dementia, there is no cure for frontotemporal dementia. There are also no treatments to slow down the progression of FTD. There are medical therapies that might help ease behavioral symptoms like irritability, depression, and agitation. The speed of decline will vary, but symptoms of FTD tend to progress at a rapid, steady rate. Individuals with frontotemporal dementia can survive anywhere between 2 and 15 years with the disease. Creutzfeldt-Jakob Disease (CJD) Creutzfeldt-Jakob Disease is an extremely rare brain disorder in which the brain breaks down. Once contracted, usually around age 60, most people die within a year. The disease destroys brain cells, and then begins to look like a sponge. It affects approximately one person out of every one million people per year worldwide, with about 300 cases per year in the U.S. Signs and Symptoms of Creutzfeldt-Jakob Disease In the early stages of the disease, individuals experience failing memory, behavioral changes, poor coordination and visual impairment. People with CJD may also experience insomnia, depression, or unusual sensations. As it progresses, individuals may experience worsened mental deterioration, involuntary or jerky movements, muscle weakness, blindness, and coma. Pneumonia and other infections often occur in the later stages of the disease and can lead to death. Causes of Creutzfeldt-Jakob Disease Causes for this type of dementia have yet to be discovered. What is known is that the disease begins when prion proteins begin to accumulate in the brain and then begin to mutate. Familial CJD results from prion protein genes that guarantee that an individual will develop CJD. CJD Treatment and Prognosis Since there is no cure for CJD, current treatment focuses on alleviating symptoms and making the individual as comfortable as possible.  Towards the end of the disease, changing the person’s position frequently can keep him or her comfortable and prevent bedsores. Catheters can be used to drain urine if the individual cannot control bladder function, and intravenous fluids and artificial feeding can also be used. Normal-Pressure Hydrocephalus (NPH) Normal-Pressure Hydrocephalus is a condition that is characterized by abnormal buildup of fluid in the brain. In a healthy being, the cerebrospinal fluid (CSF) is able to circulate around the brain and the spinal cord. Those with NPH have an abnormal build-up of CSF in the brain’s cavities, causing the ventricles to enlarge and putting pressure on the brain. When this happens, the brain has difficulty controlling basic function such as speaking and memory. NPH primarily affects individuals over age 60. Normal-Pressure Hydrocephalus Signs and Symptoms Signs and symptoms for this condition include those that are typical only of NPH patients. Frequent urination, gait disturbance, and mild dementia are among those. Individuals with NPH also feel like their feet are glued to the floor, causing difficulty with walking. This is different from Parkinson’s in which the individual will likely experience tremors. Also, in comparison to Alzheimer’s disease, individuals with NPH will not have memory loss or confusion until the later stages.

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Selection Criteria Deep brain stimulation (DBS) has become a standard treatment for advanced Parkinson’s disease (PD), but selecting the right candidates is crucial for optimal outcomes. Traditional selection criteria, such as those outlined in the Core Assessment Program for Surgical Interventional Therapies in Parkinson’s Disease (CAPSIT-PD), are considered outdated due to advances in understanding PD’s heterogeneity. Current practices emphasize a comprehensive assessment of both motor and non-motor symptoms, including genetic and phenotypic characterisation, to better predict surgical outcomes. An interdisciplinary team often reviews potential candidates to evaluate the risk-benefit profile, ensuring realistic expectations are set 7 . Currently too few patients are receiving DBS globally states Dr Prem Pillay because of the lack of trained Neuro Specialists, Equipment costs and availability,and patient access to specialized Neuro Centers. Targets The subthalamic nucleus (STN) and globus pallidus internus (GPi) are the primary targets for DBS in PD. Both targets have shown similar efficacy in improving motor symptoms, but they differ in their impact on medication reduction and mood. STN DBS allows for a greater reduction in dopaminergic medication but may negatively affect speech and mood, whereas GPi DBS is associated with better mood outcomes. Emerging targets, such as the pedunculopontine nucleus and the caudal zona incerta, show promise for addressing specific symptoms like axial symptoms and tremor. Methods and Techniques The DBS procedure involves precise localization of the target area, often using ventriculography and/or high definition MRI (Magnetic Resonance Imaging ) and intraoperative neuronal microrecording to ensure accurate placement. In leading Neuro centers for example, DBS is typically performed bilaterally in a single session with awake anesthesia, using frame-based techniques and microelectrode recordings for final lead positioning. Advances in neuroimaging are expected to further refine targeting accuracy. Results DBS has been shown to significantly improve motor function and quality of life in PD patients, with benefits sustained even in advanced stages of the disease. A meta-analysis of randomized controlled trials indicates that both STN and GPi DBS provide similar motor benefits, although STN DBS allows for a greater reduction in medication. However, axial symptoms such as speech and balance may not improve as much and can sometimes worsen post-surgery. Future Innovations of Brain Stimulation of Parkinson's Disease The future of DBS in PD includes the development of adaptive DBS systems, such as closed-loop approaches that adjust stimulation in real-time based on patient needs. New hardware with directional stimulation capabilities and advanced imaging techniques are being explored to enhance precision and efficacy. Research is also focused on identifying new brain targets and refining programming strategies to address treatment-resistant symptoms. Conclusion Deep brain stimulation remains a highly effective treatment for Parkinson’s disease, with ongoing innovations aimed at improving patient outcomes. Careful patient selection, precise targeting, and advanced programming are essential for maximizing the benefits of DBS. Dr Prem Pillay explains that future advancements in technology and methodology hold promise for further enhancing the efficacy and scope of this treatment. Apart from Parkinsons disease , patients with morbid obesity, treatment resistant depression and other functional conditions may benefit from the techniques and technologies used for Parkinsons disease in the near future. References 1.An update on best practice of deep brain stimulation in Parkinson’s diseaseCareful patient selection, individualized target localization, and evaluation of stimulation parameters are crucial requirements for optimal results in deep brain stimulation for Parkinson’s disease. 2019·106Citations·C. Hartmann et al.· Therapeutic Advances in Neurological Disorders 2.Deep brain stimulation of the subthalamic nucleus for Parkinson’s disease: methodologic aspects and clinical criteria.Proper selection of patients and accuracy in targeting the subthalamic nucleus (STN) are crucial for achieving the best possible results in Parkinson’s disease deep brain stimulation. 2000·242Citations·A. Benabid et al.· Neurology 3.Deep brain stimulation for Parkinson’s disease: meta-analysis of results of randomized trials at varying lengths of follow-up.Motor benefits of GPi and STN DBS for Parkinson’s disease are similar, but STN stimulation allows for greater medication reduction and better mood compared to GPi stimulation. 2017·84Citations·A. Mansouri et al.· Journal of neurosurgery 4.Deep Brain Stimulation Selection Criteria for Parkinson’s Disease: Time to Go beyond CAPSIT-PDRethinking the selection process for DBS in Parkinson’s disease should include a broad assessment of non-motor symptoms, quantitative measurement of gait, posture, and balance, and in-depth genotypic and phenotypic characterization. 2020·33Citations·C. Artusi et al.· Journal of Clinical Medicine 2022·3Citations·F. Mancini et al.· Journal of neurosurgical sciences 6.The latest evidence on target selection in deep brain stimulation for Parkinson’s diseaseSTN and GPi DBS both improve motor scores in Parkinson’s disease, but STN DBS has more negative effects on speech and mood, while GPi DBS has less impact on speech and mood. 2014·44Citations·T. Lukins et al.· Journal of Clinical Neuroscience 7.Current Practice and the Future of Deep Brain Stimulation Therapy in Parkinson’s DiseaseDBS therapy for Parkinson’s disease is effective, with subthalamic nucleus and globus pallidus internus targets being the most widely used, and research focuses on improving symptom control and efficiency of stimulation delivery. 2017·25Citations·L. Almeida et al.· Seminars in Neurology 2022·10Citations·Carina França et al.· Arquivos de Neuro-Psiquiatria 9.Deep Brain Stimulation in Movement Disorders: From Experimental Surgery to Evidence‐Based TherapyDBS has shown better motor, nonmotor, and quality-of-life outcomes for patients with fluctuating Parkinson’s disease, disabling dystonia, tremors, and refractory Gilles de la Tourette syndrome. 2019·135Citations·P. Krack et al.· 10.Deep brain stimulation for Parkinson’s disease: Patient selection and evaluationDeep brain stimulation for Parkinson’s disease requires proper patient selection and evaluation using the Core Assessment Program for Surgical Interventions and Transplantation in Parkinson’s Disease (CAPSIT-PD). Movement Disorders 2002·172Citations·A. Lang et al.·

Brain Checks and Scan Most people undergo regular health check-ups  throughout their lives—such as school health checks, employment screenings, and executive health checks . These tests are effective in screening for conditions like diabetes, hypertension, high cholesterol, kidney disease, heart disease, and some cancer markers . However, these general health checks  are often inadequate for detecting brain conditions . The brain is the most important organ , responsible for thinking, movement, and overall body function . Unfortunately, it is also vulnerable to diseases such as: Cerebrovascular disease (stroke-causing blood vessel blockages or bleeding) Brain tumors, including brain cancer Epilepsy and other seizure disorders Brain infections Dementia and memory loss conditions Neurodegenerative diseases such as Parkinson’s disease Increasingly, younger individuals are being diagnosed with brain-related diseases . Early detection  can make a significant difference in treatment , preventing long-term brain damage, which is difficult to reverse . Who Should Get a Brain Check? A Brain Check  is recommended for individuals experiencing any of the following symptoms: Persistent and severe headaches Dizziness, vertigo, or spinning sensations Seizures, including epilepsy Sudden weakness in the limbs Loss of consciousness Sudden loss of senses (hearing, vision, smell, taste, or touch) Difficulty understanding speech or expressing oneself Tremors or uncontrollable movements of the hands and limbs Memory problems and forgetfulness What is Done During a Brain Check? A Specialist Brain Check  involves a consultation with a Brain Specialist at a Brain Center . The Process Includes: Detailed Medical History  – Assessment of current and past health conditions . Physical Examination  – Evaluates gait, movement, speech, hearing, vision, sensation, strength, and reflexes . S pecialist Brain Scans & Tests  – Ordered based on clinical findings  for accurate diagnosis . What Are the Specialist Brain Scans and Tests? Your Brain Specialist  may recommend the following brain imaging and diagnostic tests : Imaging Scans MRI (Magnetic Resonance Imaging) of the Brain CT (Computed Tomography) of the Brain PET (Positron Emission Tomography) Brain Scans, including PET-MRI Brain Function & Neurological Tests NeuroMetrics & PsychoMetrics Digital Brain Function Tests EEG (Electroencephalogram), including Video EEG Blood Vessel & Circulatory Tests Cerebral Angiograms, including CT Angiogram, MR Angiogram, and Catheter Angiograms Hearing & Balance Tests Audiograms and Vestibular Function Tests ( This is not an exhaustive list. Your Brain Specialist will determine the necessary tests based on your symptoms and clinical diagnosis. ) Specialist Brain Care at Singapore Brain Spine Centre At Singapore Brain Spine Centre , we provide: ✅ Comprehensive Brain Health Assessments ✅ Advanced Brain Imaging (MRI, CT, PET Scans) ✅ Specialist Neurological Tests for Accurate Diagnosis Prioritise Your Brain Health, Book a Brain Check Today If you are experiencing persistent headaches, dizziness, memory issues, or unexplained neurological symptoms , early diagnosis can be life-changing . 📞 Schedule a consultation today  at Singapore Brain Spine Centre  and take a proactive step toward better brain health.

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Brain Arteriovenous Malformations (AVMs) and Dural Arteriovenous Fistulas (DAVFs)  are potentially serious cerebrovascular conditions that can have significant bleeding causing brain damage (strokes) that can result in weakness, numbness, loss of senses, speech problems (aphasia, dysphasia), paralysis, coma and death. This summary will provide an overview of these conditions, including their presentation, diagnosis, treatments, and less invasive treatment methods. Brain Arteriovenous Malformations (AVMs) Presentation Brain AVMs are abnormal connections between arteries and veins in the brain, bypassing the normal capillary bed. They account for 10-15% of all intracranial vascular malformations[1]. AVMs can present with various symptoms, including: – Sudden, severe headaches – Seizures – Neurological deficits (e.g., weakness, numbness, vision problems) – Cognitive changes (forgetfulness and memory problems, loss of focus, difficulty with complex tasks or executive function) However, many AVMs are asymptomatic and are discovered incidentally during brain imaging for other reasons[4]. Diagnosis The diagnosis of brain AVMs typically involves several imaging techniques: Computed Tomography (CT): Often the initial imaging modality, especially in emergency situations[1] as they can show the location of bleeding. Magnetic Resonance Imaging (MRI) Provides detailed images of brain tissue and can show subtle changes related to AVMs[1]. CT Angiography (CTA) and MR Angiography (MRA) These techniques can provide additional vascular details and are often used in conjunction with other imaging modalities[4]. They are less invasive than formal Cerebral catheter Angiography. Cerebral Angiography Considered the gold standard for AVM diagnosis. It provides detailed information about the location, size, and vascular architecture of the AVM[1]. Treatment The treatment of brain AVMs aims to reduce the risk of hemorrhage and alleviate symptoms. Treatment options include: Surgical Resection Involves removing the AVM through open brain surgery. This is often the preferred treatment for accessible AVMs[1]. Smaller openings and  Advanced Microscopes using florescence together with brain mapping and tractography / connectomes identification can allow safer and more accurate surgery. Endovascular Embolization A minimally invasive procedure where embolic agents such as Onyx, PHIL and others are injected through a catheter to block blood flow to the AVM[6]. Stereotactic Radiosurgery A no Surgery Non-Invasive technology; Uses focused radiation to gradually close off the abnormal blood vessels over time[4].The latest systems use Robotics and Micro (MLC) Radiosurgery for higher accuracy and safety. These can often be done as Day Procedures. Conservative Management For some low-risk AVMs, observation and medical management of symptoms may be appropriate[7]. Dural Arteriovenous Fistulas (DAVFs) Presentation DAVFs are abnormal connections between arteries and veins within the dura mater, the protective covering of the brain and spinal cord[8]. Symptoms can vary depending on the location and severity of the DAVF: – Pulsatile tinnitus (rhythmic sound in the ear) – Headaches – Visual disturbances – Neurological deficits – In severe cases, intracranial hemorrhage or seizures[8] Diagnosis The diagnosis of DAVFs involves similar imaging techniques to those used for AVMs: MRI and MRA: Can detect abnormal blood flow patterns and enlarged blood vessels[5]. CT and CTA: Useful for identifying bony involvement and vascular anatomy[5]. Cerebral Angiography: The definitive diagnostic tool, providing detailed information about the fistula’s location, feeding arteries, and draining veins[5][9]. Treatment Treatment of DAVFs depends on their classification (e.g., Borden or Cognard systems) and associated risks. Options include: Endovascular Embolization Often the first-line treatment, involving the injection of embolic agents to occlude the fistula[9]. Microsurgery Used when endovascular treatment is not feasible or unsuccessful[10]. Stereotactic Radiosurgery Can be effective for certain types of DAVFs, especially those in challenging locations[3]. Conservative Management For low-risk DAVFs, observation and symptom management may be appropriate[8]. Less Invasive Treatment Methods Recent advancements have led to the development of less invasive treatment options for both AVMs and DAVFs: Endovascular Techniques Liquid Embolic Agents Modern agents like Onyx, PHIL (Precipitating Hydrophobic Injectable Liquid), and Squid offer improved control and effectiveness in embolization procedures[9]. Detachable Coils Used in combination with liquid embolic agents for more complex cases[9]. Flow Diverters In special scenarios, devices like the Pipeline Embolization Device can be used to treat certain types of fistulas[9]. Stereotactic Radiosurgery (SRS) SRS has emerged as an effective and safe alternative to conventional surgery for some AVMs and DAVFs[3]. It offers several advantages: – Non-invasive procedure – Lower risk of complications compared to open surgery – Effective for deep-seated or surgically inaccessible lesions – Can be used in combination with other treatment modalities Multimodal Approach For complex cases, a combination of treatment methods may be employed. For example, endovascular embolization may be used to reduce the size of an AVM before surgical resection or radiosurgery[6]. Conclusion Brain AVMs and DAVFs are complex cerebrovascular conditions that require careful evaluation and individualised treatment planning explains Dr Prem Pillay, an AVM/DAVF expert. While traditional surgical approaches remain important, less invasive techniques such as advanced endovascular procedures and stereotactic radiosurgery have expanded the treatment options available to patients. These newer methods offer the potential for reduced procedural risks and improved outcomes in selected cases. As research continues, ongoing advances in imaging technology, embolisation techniques, and radiosurgery are likely to further refine and improve the management of these challenging vascular lesions. The choice of treatment should be based on factors such as the patient’s age, overall health, lesion characteristics, and the expertise of the treating team. If you or your loved ones have an AVM/DAVF, you are most welcome to contact us for an opinion or guidance from our Expert and his team. We are able to design a personalized treatment that has the highest potential success rate and lowest risk rate based on the latest medical evidence and years of experience. Citations: [1] https://www.mayoclinic.org/diseases-conditions/brain-avm/diagnosis-treatment/drc-20350265 [2] https://www.spandidos-publications.com/10.3892/etm.2014.2122 [3] https://www.e-neurofunction.org/m/journal/view.php?number=354 [4] https://www.msdmanuals.com/home/brain-spinal-cord-and-nerve-disorders/stroke/brain-arteriovenous-malformations-avms [5] https://pubmed.ncbi.nlm.nih.gov/19172609/ [6] https://evtoday.com/articles/2015-feb/cerebral-avms-and-dural-avfs-pathology-and-management [7] https://my.clevelandclinic.org/health/diseases/16755-arteriovenous-malformation-avm [8] https://www.mayoclinic.org/diseases-conditions/dural-arteriovenous-fistulas/symptoms-causes/syc-20364280 [9] https://pmc.ncbi.nlm.nih.gov/articles/PMC7213517/ [10] https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/dural-arteriovenous-fistula