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The evolution of supramarginal tumor resection in to supra‑complete surgery according to the DiVA protocol. (A) the T1‑weighted MR‑scans show a contrast agent enhancing space occupying lesion at the occipital horn on the left side (left image). The tumor was preoperatively segmented and the data sent to the neuronavigation (right image series). (B) white light microscopy is depicted in the upper row and 5‑ALA fluorescence microscopy in the lower row. The left column depicts the point in surgery following resection of the primary tumor bulk, represented by a distinct 5‑ALA signal. Following resection of the tumor bulk, vague 5‑ALA fluorescence can be identified in the depth of the resection cavity (middle column). Conventional glioma surgery would entail ending the surgery at this point. Supramarginal resection would entail additional, unspecific peritumoral resection. In contrast, supra‑complete surgery as a further refinement to conventional supramarginal resection entails selective resection of the vague 5‑ALA fluorescence positive areas until no signal is detected any longer (right column). (C) the intraoperative T1‑weighted MR‑scan with contrast agent administration confirms the planned extent of resection (left image); there is no pathological contrast agent enhancement detectable any longer. Superimposition of these intraoperative images with the original segmentation demonstrates resection beyond the contrast agent enhancing areas in terms of a tailored supramarginal resection (right image series). Conclusion Supra marginal and supra complete surgery represents a promising advancement in glioma treatment, combining precision, innovation, and patient-centred care. At Singapore Brain Spine Nerves Center, our multidisciplinary team utilises advanced technology and expertise to deliver optimal outcomes while prioritising the preservation of brain function. If you or your loved one is exploring advanced surgical options for gliomas, consult our experienced specialists to learn how these techniques can be tailored to your unique needs.

Making Neurosurgery more effective and safe Neurosurgery refers to surgery of the brain, spine and nerves. Micro-Neurosurgery is the use of an operating Microscope to allow smaller openings to be made to reach brain, spine and nerve problems and to aid delicate surgery on these parts to cure a disease. The latest generation of microscopes is now digital rather than analogue A craniotomy is done to treat various problems in the brain such as brain tumours, anerysms, blood clots, abscesses and head injuries. The goal of neurosurgery is to effectively treat the brain or spine disease completely with minimal side-effects. Currently, brain and spine surgery is made more effective and safer with the use of computer digital (CAN/CAM) technology. This provides sophisticated navigational information to the neurosurgeon through a special microscope to guide precision and delicacy in brain and spine surgery. The Procedure of Computer Aided Neurosurgery Special stickers (Fiducial markers) will be stuck on to your head or spine in the areas of your problem/lesion. You will then go for a special MRI or CT scan that will be used for the surgical planning (your earlier MRI was for diagnostic purposes). During the scan various cuts of your head/spine are imaged in different views (top/bottom, front/back, side/side). After the scan you will rest in your room till the time of your surgery. Please note that the stickers on your head should not be removed. It can only be removed by your Neurosurgeon in the Operating Room (OR). The images from the CT or MRI scans are saved onto a digital audio tape or optical disc which is transferred to the Computer Station in the OR. Once the images are loaded onto the computer workstation, your whole head or spine is reconstructed in 3-dimensions (3-D). The lesion in your brain (tumor, abscess, blood clot etc) and critical areas of the brain/spine eg. blood vessels, the optic nerve can be similarly reconstructed in 3-dimensions. Your Neurosurgeon can determine the safest access to your lesion with minimal damage to critical brain/spine areas. This allows him to make a smaller opening (craniotomy) in your brain or smaller spinal access. You will be brought to the OR and met by your surgical team (your Neurosurgeon, his neuroanaesthetist and the neuronurse). Once you have been put to sleep, a special probe is used to touch the various parts of your head/spine to register your position in space with that of the 3-D computer image. By this means, your Neurosurgeon will know at any point of time where he is in your brain/spine during the surgery. The most advanced digital microscope is integrated to a computer workstation (Zeiss NC-4 with the StealthStation). Robotic brain micro-surgery is also available (Surgiscope). Using CAN/CAM technology, your brain/spine surgery is now: more accurate less invasive safer with minimal damage to critical normal brain or spinal nerves. After surgery you may be in the ICU, and then can be discharged usually within 24-72 hours. With any type of surgery the most common risks are internal bleeding, infection and anaesthetic risks. Conclusion Computer-Aided Neurosurgery and Computer-Aided Microsurgery represent the future of brain and spine surgery, combining advanced technology with surgical expertise to achieve exceptional results. At Singapore Brain Spine Nerves Center, we are proud to offer these advanced techniques, ensuring precision, safety, and improved outcomes for our patients. If you or your loved one requires surgical intervention for a brain or spine condition, consult our experienced team to learn how CAN and CAM can transform your treatment experience.

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) Radiosurgery represents the future of radiation therapy.  When applied to the brain and spine we have termed it Stereotactic Radiosurgery as it can create the effects of surgery without any incisions or scars and is a Day Procedure which is Non Invasive.  Forms of high precision radiation, (also called radiosurgery, stereotactic radiotherapy or fractionated stereotactic radiosurgery) include Gamma knife , X-knife, Cyberknife, Novalis and Proton Therapy . Neuro Radiosurgery allows real-time image-guided precision radiation treatment to tumors of the brain and spine.  Intensity Modulation (IMRT) and the presence of a MicroMultileaf Collimator (MMLC) allow accurate shaping of the energy beams to each unique tumor volume and an effective dose to be given. Radiosurgery can be used to treat most Brain Tumors including: Meningioma Acoustic Neuroma Neuromas and Schanommas of other nerves including Spine nerves, Hypoglossal nerve, Accessory Nerve and other cranial nerves Pituitary Tumors Gliomas including Glioblastoma Multiforme, Neurocytoma, GanglionGlioma Chordomas Chondrosarcoma Brainstem Gliomas in Children Blood Vessel problems such as AVM (Arterio Venous Malformations), Cavernous Malformation, AV Fistulas Conclusion Radiosurgery is a groundbreaking treatment option that combines precision, efficacy, and convenience, making it an excellent choice for brain and spine conditions. At Singapore Brain Spine Nerves Center, we are dedicated to providing the latest treatment options, including radiosurgery, to improve patient outcomes and quality of life. If you or a loved one is considering radiosurgery, consult our experienced team for personalised guidance and care. Visit the Singapore Brain Spine Nerves Center today to explore how radiosurgery can be part of your treatment journey.

Imagine being able to talk to your doctors during brain tumor surgery without pain and give them immediate feedback while they operate.  That’s exactly what happens during an awake craniotomy. A craniotomy is a type of Micro surgery where a small piece of the skull is temporarily removed to access the brain. In an awake craniotomy, the patient is gently woken up during surgery. This highly specialized surgical procedure requires a team approach led by an experienced neurosurgeon and a neuroanesthesiologist. To learn more, we spoke to neurosurgeon Dr Prem Pillay from the Singapore  Brain Spine Nerves Center.   What’s the benefit of being awake during brain tumor surgery? Our goal is to remove as much of the tumor as possible, as safely as possible. When a tumor is near an area of the brain that controls critical functions — such as speech, language or movement, an awake craniotomy is the best way to identify and safely preserve those abilities. We know where certain functions are generally located on the brain’s surface. But below the surface, bundles of nerves pass through the brain to the spinal cord and throughout the body. We have to map these nerves to understand which ones are connected to key functions, so that we can avoid them as we remove the tumor. Damaging critical nerves could cause permanent disability. We also use other tools to map the brain including Computer aided Neuro Navigation of the Brain, but mapping nerves during an awake craniotomy is the only way to obtain immediate feedback during surgery. Which patients are candidates for awake craniotomies? Awake craniotomies are frequently, but not always used for gliomas (including glioblastoma, astrocytomas and oligodendrogliomas),ependymomas ,Neurocytomas and some Brain metastases. These brain tumors especially the Gliomas occur at the frontal and temporallobes, which control speech and motor function. The patient also has to feel comfortable with the idea of waking up during surgery. Apatient with severe symptoms may not be able to effectively contribute to the neurological exams during surgery. A neuropsychologicalevaluation can help determine if the patient has deficits or would be a good candidate for this procedure. Frequently Asked Questions How is it possible to wake up during brain surgery without feeling pain? Brain tissue doesn’t have any pain fibers, so while you may feel pressure or vibrations from the surgery, you shouldn’t feel pain. We use a local anesthetic (similar to those used at a dentist’s office) to numb the muscles, skin and bone that the surgeon has to cut through to get to the brain. What should I expect when I wake up during surgery? When you wake up, you’ll hear the neuroanesthesiologist reassuring  you. You won’t be able to move your head, but the neuroanesthesiology team will make you as comfortable as possible and stay with you the entire time. How long will I be awake? You could be awake for 45 minutes to several hours, depending on how big your tumor is, where it’s located and the type of symptoms you hadbefore surgery. What happens while I’m awake? While you’re awake, you’ll be an essential participant in the most critical part of the surgery. You’ll help map your own brain function through a series of simple neurological exams. The neurosurgeon will stimulate part of your brain near the tumor by sending a light electrical current down the central nervous system. At the same time, the Neuro Psychologist /neuroanesthesiologist will give you some simple verbal tasks to see if the stimulation affected yourneurological function. For example, you may be shown flashcards with common objects. If you suddenly can’t name an object or can’t get any words out at all, the neurosurgeon will know the area they’ve stimulated is connected to a critical speech area. Even when you’re not actively mapping, you’ll talk to the neuroanesthesiologist and neurosurgeon, who are in constant communication throughout the surgery. This is important for ensuring a safer surgery, with the best possible outcomes. When will you put me back to sleep? We’ll put you back to sleep after we’ve collected as much helpful  information as possible from the neurological exam. You’ll be asleep as the incision is closed, and you’ll wake up again when the Brain Micro surgery is completely over. How can I prepare for an awake craniotomy? Before surgery, you’ll meet with the neurosurgeon, neuro psychologist and neuroanesthesiologist. We’ll explain what to expect and answer your questions. We’ll take time to get to know you and learn what’s important to you. This will help us personalize your neurological exam and talk about things you care about during surgery, which will help you stay awake and actively participating in the mapping process longer. It’ll also help us build trust, which is important for asurgical procedure like this. We’re most likely to get the best possible outcome when you feel safe, supported and fully engaged. So don’t be afraid to ask questions and share your concerns at your initial appointment and while you’re awake during your craniotomy. Conclusion Awake craniotomy is a remarkable advancement in neurosurgery, offering hope to patients with brain tumours located in challenging areas. By preserving vital functions, this procedure ensures the best possible quality of life post-surgery. At Singapore Brain Spine Nerves Center, we provide expert care and guidance for patients considering awake craniotomy. If you or your loved one has been diagnosed with a brain tumour, consult our team to learn more about this advanced treatment option and how it can be tailored to your unique needs. ReferencesMD Anderson Cancer Center : Awake Craniotomy information Cleveland Clinic Brain Tumor Center : Awake Craniotomy information/Protocols Singapore Brain Spine Nerves Center : Awake Craniotomy Protocol

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) Proton Therapy Proton therapy is the latest and most advanced form of radiation treatment that uses a beam of protons to deliver radiation precisely and effectively to tumors while sparing normal tissues. Proton therapy is a type of radiation therapy that uses a beam of protons to treat cancer and some noncancerous tumors. Protons are positively charged particles that can damage the DNA of cells and stop their reproduction, thus killing them. Proton therapy has some advantages over current types of radiation therapy, such as X-rays, because protons can be more precisely controlled to target the tumor and spare the surrounding healthy tissue. Proton therapy may cause fewer side effects than traditional radiation. It is not widely available except in advanced overseas centers such as MD Anderson Cancer Center in Texas, USA states Dr Prem Pillay, a Singapore Neurosurgeon who was a Fellow in Neurosurgical Oncology (Brain and Spine Tumors) at MD Anderson Cancer Center and is now practising at the Singapore Brain-Spine-Nerves Center at the Mt Elizabeth Medical Center in Singapore. Fortunately for patients in our part of Asia, Proton therapy is now available at Mt Elizabeth Hospitals, in Singapore. How proton therapy is performed Proton therapy is performed using a particle accelerator that produces a beam of protons. The beam is shaped and directed by magnets and computers to match the size and shape of the tumor. The patient lies on a table that can be moved and rotated to adjust the position of the beam. The treatment usually lasts for several minutes and may be given in small doses (fractionation) daily for a few weeks to improve results and reduce side effects. What tumors can Proton Therapy Treat? Proton therapy may be used to treat various types of brain, spine, breast, eye, esophageal, head and neck, liver, lung, lymphoma, pancreatic, prostate, sarcoma, chordomas, gliomas. It may also be used to treat children, who are more sensitive to radiation damage. Proton therapy may be used alone or in combination with other treatments, such as surgery and chemotherapy. Proton therapy may also be used if a tumor remains or comes back after traditional X-ray radiation. Brain tumors that can be treated include malignant gliomas such as glioblastomas, astrocytomas, ependymomas, aggressive pituitary tumors, meningiomas, and brain cancer/metastases that have spread to the brain from the breast, lung, and other primary sites. Skull base tumors such as chordoma, chondrosarcoma, adenocarcinoma, and squamous cell carcinoma, to name a few, can also potentially be treated with proton therapy. Spine tumors and cancer can also be treated. Proton therapy can target tumors with sub-millimeter precision while sparing nearby healthy tissues and minimizing side effects. Standard radiation therapy Standard radiation therapy has evolved and improved over the years and is effective in controlling many cancers. However, because X-ray beams are composed of primary photons and secondary electrons, they deposit their energy along the path of the beam, to the targeted tumor and beyond, and deliver radiation to healthy tissues before and after the tumor site. This radiation “exit dose” may cause health issues later because it can damage the normal tissue or organs near the tumor or area of concern. Advantage of Proton Therapy The advantage of proton therapy (also called proton beam therapy) is that the physician can control where the proton releases the bulk of its cancer-fighting energy. As the protons move through the body, they slow down and interact with electrons, and release energy. The point where the highest energy release occurs is the “Bragg peak.” A physician can designate the Bragg peak’s location, causing the most damage to the targeted tumor cells. A proton beam conforms to the shape and depth of a tumor while sparing healthy tissues and organs. Comparison with standard radiation therapy Standard radiation therapy has evolved and improved over the years and is effective in controlling many cancers. However, because X-ray beams are composed of primary photons and secondary electrons, they deposit their energy along the path of the beam, to the targeted tumor and beyond, and deliver radiation to healthy tissues before and after the tumor site. This radiation “exit dose” may cause health issues later because it can damage the normal tissue or organs near the tumor or area of concern. How proton therapy works The advantage of proton therapy (also called proton beam therapy) is that the physician can control where the proton releases the bulk of its cancer-fighting energy. As the protons move through the body, they slow down and interact with electrons, and release energy. The point where the highest energy release occurs is the “Bragg peak.” A physician can designate the Bragg peak’s location, causing the most damage to the targeted tumor cells. A proton beam conforms to the shape and depth of a tumor while sparing healthy tissues and organs. How Dose Proton Therapy actually work? The best way to understand how proton therapy works is to take a look at the physics and engineering inside the proton accelerator, or the synchrotron, and the beam delivery system. The proton begins its journey at the ion source. Within fractions of a second, hydrogen atoms are separated into negatively charged electrons and positively charged protons. The protons are injected via a vacuum tube into a linear accelerator and in only a few microseconds, the protons’ energy reaches 7 million electron volts. Proton beams stay in the vacuum tube as they enter the synchrotron, where acceleration increases their energy to a total of 70 million to 250 million electron volts, enough to place them at any depth within the patient’s body. After leaving the synchrotron, the protons move through a beam-transport system comprised of a series of magnets that shape, focus and direct the proton beam to the appropriate treatment room. To ensure that each patient receives the prescribed treatment safely and efficiently, the facility is controlled by a network of computers and safety systems. The gantry can revolve around the patient, allowing the beam to be delivered through many angles. As protons come through the nozzle, a custom-made device (the aperture) shapes the beam of protons, and another custom-made device (the compensator) shapes the protons into three dimensions, delivering them to the depth of the tumor. At maximum energy, a proton beam travels 125,000 miles per second, which is equivalent to the two-thirds the speed of light. Pencil beam and intensity modulated proton therapy The team at MD Anderson Proton Therapy Center has continued to expand ways to use proton therapy to benefit patients. The team pioneered pencil beam proton therapy, also called scanning beam, and intensity modulated proton therapy (IMPT). The techniques are now available to other treatment centers said Dr Prem Pillay. Pencil beam technology and IMPT build on the benefits of proton therapy. With a proton beam just millimeters wide, these advanced forms of proton therapy combine precision and effectiveness, offering unmatched ability to treat a patient’s tumor and minimizing the effect on a patient’s quality of life – during and after treatment. They rely on complex treatment planning systems and an intricate number of magnets to aim a narrow proton beam and essentially “paint” a radiation dose layer by layer. Pencil beam is very effective in treating the most complex tumors, like those in the Brain, Spine,eye, and cancers in children, while leaving healthy tissue and other critical areas unharmed. IMPT is best used to deliver a potent and precise dose of protons to complex or concave-shaped tumors that may be adjacent to the spinal cord or embedded head and neck or skull base below the brain or around brain critical structures. References: 1.Towards effective and efficient patient-specific quality assurance for spot scanning proton therapyX Ronald Zhu 1 , Yupeng Li 2 , Dennis Mackin 3 , Heng Li 4 , Falk Poenisch 5 , Andrew K Lee 6 , Anita Mahajan 7 , Steven J Frank 8 , Michael T Gillin 9 , Narayan Sahoo 10 , Xiaodong Zhang 11Cancers (Basel) 2015 Apr 10;7(2):631-47.Affiliations : MD Anderson Cancer Center 2.Proton Therapy for Head and Neck Cancer: A 12-Year, Single-Institution ExperienceG Brandon Gunn 1 , Adam S Garden 1 , Rong Ye 2 , Noveen Ausat 1 , Kristina R Dahlstrom 3 , William H Morrison 1 , C David Fuller 1 , Jack Phan 1 , Jay P Reddy 1 , Shalin J Shah 1 , Lauren L Mayo 1 , Stephen G Chun 1 , Gregory M Chronowski 1 , Amy C Moreno 1 , Jeffery N Myers 3 , Ehab Y Hanna 3 , Bita Esmaeli 4 , Maura L Gillison 5 , Renata Ferrarotto 5 , Katherine A Hutcheson 3 , Mark S Chambers 3 , Lawrence E Ginsberg 6 , Adel K El-Naggar 7 , David I Rosenthal 1 , Xiaorong Ronald Zhu 8 , Steven J Frank 1Int J Part Ther. 2021 Jun 25;8(1):108-118.

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 are Tumour Treating Fields Therapy? Tumour Treating Fields (TTFields) represent an innovative approach to treating brain cancer, particularly glioblastoma multiforme (GBM), one of the most aggressive forms of brain cancer. This non-invasive treatment modality uses alternating electric fields to disrupt cancer cell division and inhibit tumor growth. Mechanism of Action Tumour Treating Fields Therapy work by delivering low-intensity, intermediate frequency (200 kHz) alternating electric fields to the tumour region through transducer arrays placed on the patient’s scalp. It is a painless non invasive treatment without any surgery and is best carried out by a Neurosurgical Oncologist. These electric fields interfere with the mitotic process of cancer cells in several ways: Disruption of microtubule formation during mitosis Interference with proper chromosome alignment Disruption of the mitotic spindle Dielectrophoretic movement of polar macromolecules and organelles during cytokinesis These effects lead to mitotic arrest, abnormal chromosome segregation, and ultimately, cancer cell death. Clinical Application The TTFields device, known commercially as Optune, was approved by the FDA in 2011 for recurrent GBM and in 2015 for newly diagnosed GBM The treatment involves the patient wearing a portable device that generates the electric fields. Four transducer arrays are placed on the shaved scalp and connected to a field generator, which the patient carries in a backpack or shoulder bag. Efficacy The EF-14 phase III clinical trial demonstrated the efficacy of TTFields in newly diagnosed GBM patients. When combined with maintenance temozolomide chemotherapy, TTFields significantly improved both progression-free survival and overall survival compared to temozolomide alone The median overall survival increased representing a significant improvement in a cancer with historically poor outcomes Patient Experience and Side Effects TTFields therapy requires a significant commitment from patients, as the device should be worn for at least 18 hours per day for optimal effect. The main side effect is mild to moderate skin irritation beneath the transducer arrays, which occurs in about half of the patients. However, compared to traditional cancer treatments, TTFields have a favorable side effect profile, with no systemic side effects reported Ongoing Research and Future Directions Current research is exploring the potential of TTFields in other brain cancers and solid tumors. Clinical trials are underway for: Low-grade gliomas Brain metastases : cancers that spread to the brain from primary sites such as the lung, breast, colon, kidney and other organs Meningiomas Pancreatic cancer Ovarian cancer Lung cancer Researchers are also investigating combinations of TTFields with other treatment modalities, such as immunotherapy and targeted therapies, to potentially enhance their efficacy Conclusion Tumor Treating Fields represent a significant advancement in brain cancer treatment, offering a novel approach with proven efficacy and minimal side effects. As research continues, TTFields may become an increasingly important component of brain cancer treatment strategies, potentially extending to other types of cancer as well. The non-invasive nature and favorable side effect profile make it an attractive option for patients who may not tolerate more aggressive treatments. However, challenges remain in terms of patient compliance, cost, and the need for further research to optimize its use. As our understanding of TTFields grows and technology improves, we can expect to see refinements in the application of this therapy and potentially broader adoption across various cancer types. The development and success of TTFields therapy underscores the importance of exploring innovative approaches to cancer treatment, particularly for difficult-to-treat cancers like glioblastoma. It serves as an example of how thinking outside the traditional treatment paradigms can lead to meaningful advances in patient care and outcomes. At Singapore Brain Spine Nerves Center , we provide expert guidance and support to patients exploring innovative therapies like TTFT. If you or a loved one are considering advanced treatment options, consult our team to learn more about how TTFT can be integrated into your care plan. *MD Anderson Cancer Center, USA is the leading Hospital and Center for Cancer in the USA and Globally)

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) What is the Parkinson's Disease? Parkinson’s disease is a brain disorder that leads to shaking , stiffness , and difficulty with walking, balance, and coordination . Parkinson’s symptoms usually begin gradually  and get worse over time. As the disease progresses, people may have difficulty walking  and talking . They may also experience mental and behavioural changes , sleep problems , depression , memory difficulties , and fatigue . Both men and women can have Parkinson’s disease. However, the disease affects about 50 percent more men than women . One clear risk factor for Parkinson’s is age . Although most people develop the disease around age 60 , about 5 to 10 percent  of people have early-onset Parkinson’s , which begins before age 50 . Early-onset forms are often, but not always, inherited and may be linked to specific gene mutations . What causes Parkinson’s disease? Parkinson’s disease occurs when nerve cells (neurons)  in the area of the brain that controls movement become impaired or die . Normally, these neurons produce dopamine , a critical brain chemical. When they are lost or impaired, dopamine levels drop, causing the movement problems  associated with Parkinson’s. People with Parkinson’s also lose nerve endings that produce norepinephrine , which controls many automatic body functions  like heart rate and blood pressure. The loss of norepinephrine may explain non-movement symptoms , such as: Fatigue Irregular blood pressure Slow digestion Sudden blood pressure drops when standing up Many brain cells of people with Parkinson’s contain Lewy bodies —unusual clumps of the protein alpha-synuclein . Scientists are studying how this protein and certain genetic mutations  relate to Parkinson’s and Lewy body dementia . While some cases are hereditary or linked to genetic mutations , most cases occur randomly  and do not run in families. Many researchers believe Parkinson’s results from a combination of genetic and environmental factors , including toxin exposure . Symptoms of Parkinson’s disease Parkinson’s disease has four main symptoms: Tremor  (in hands, arms, legs, jaw, or head) Stiffness  of the limbs and trunk Slowness of movement Impaired balance and coordination , sometimes leading to falls Other symptoms may include: Depression and emotional changes Difficulty swallowing, chewing, and speaking Urinary problems or constipation Skin problems Sleep disruptions Symptoms and progression vary among individuals. Early symptoms can be subtle  and are often dismissed as normal ageing . There are no definitive medical tests for Parkinson’s, making diagnosis challenging. Early signs may include: Mild tremors Difficulty rising from a chair Soft speech Small, cramped handwriting Loss of facial expression or arm swing Parkinsonian gait: leaning forward, small steps, reduced arm swing Trouble initiating or continuing movement Symptoms typically begin on one side  of the body, eventually affecting both—though often more severely on the original side. Many people also report early non-motor symptoms , such as: Sleep problems Constipation Reduced sense of smell Restless legs Diagnosis of Parkinson’s disease Advanced neuroimaging with PET of the brain Many disorders mimic Parkinson’s symptoms. When caused by other factors, these are termed parkinsonism. Some may initially be misdiagnosed, but specific tests and responses to medication help distinguish them. There are currently no blood or lab tests  to diagnose non-genetic Parkinson’s. Diagnosis is based on: Medical history Neurological examination Improvement with medication , a key hallmark of Parkinson’s Treatment of Parkinson’s disease While there is no cure , treatment can relieve symptoms  through medications , surgery , and therapies . Medicines for Parkinson’s disease Medications may: Increase dopamine levels Affect other brain chemicals Control non-motor symptoms Main therapy involves dopamine-replacement drugs , usually taken with medications to reduce side effects  (nausea, vomiting, low blood pressure, restlessness). Warning:  Patients should never stop medication  without consulting their doctor. Abruptly stopping can cause serious complications , such as immobility  or breathing difficulties . Other medications include: Dopamine agonists  – mimic dopamine MAO-B inhibitors  – slow dopamine breakdown COMT inhibitors  – help dopamine persist Amantadine  – an old antiviral that reduces involuntary movements Anticholinergics  – reduce tremors and rigidity Deep brain stimulation (DBS) For patients not responding well to medication, DBS  may be appropriate. This involves: Implanting electrodes  into the brain Connecting them to a small device  implanted in the chest Painlessly stimulating the brain  to relieve tremor , slowness , and rigidity DBS is an established treatment  for advanced Parkinson’s.— Dr Prem Pillay , Singapore neurosurgeon trained at the Cleveland Clinic-USA , now Medical Director at Singapore Brain Spine Nerves Center Other therapies Supportive therapies include: Physical, occupational, and speech therapy Neuropsychological assessment and support Aquatic physiotherapy Table tennis for Parkinson’s disease  – helps with muscle coordination and balance Healthy diet and quality sleep Conclusion Parkinson’s disease is a complex condition, but with early diagnosis and tailored treatments, individuals can continue to lead fulfilling lives. If you or your loved one are experiencing symptoms such as tremors or changes in movement, consult a healthcare professional promptly. For expert care and support, contact the Singapore Brain Spine Nerves Center today. References and acknowledgements National Institutes of Health – USA Singapore Brain Spine Nerves Center Table Tennis for Good Foundation

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) What is Trigeminal Neuralgias? The 5th cranial nerve also known as the trigeminal nerve is the nerve that supplies feeling and movement to the face. Trigeminal neuralgia is a troublesome pain in the face that may be caused by a tumor pressing on the trigeminal nerve or a blood vessel that presses on the trigeminal nerve. In some patients the cause cannot be determined. In 5% of patients, trigeminal neuralgia may be associated with multiple sclerosis. How is Trigeminal Neuralgia Diagnosed? Trigeminal Neuralgia is diagnosed by the clinical symptoms of pain in the face that is quite disturbing and can be triggered by hot or cold food/drinks, brushing the teeth, air blowing on the face or touching the face. The pain can have a nerve irritation quality which includes being tingly, burning, electric zapping in nature and sometimes so severe that people have to stop their activities and sit still or lie down. It may involve the forehead, cheek or chin area. It can come and go randomly. Dr Prem Pillay usually does an MRI of the Brain to make sure there is no tumor such as a meningioma or acoustic neuroma pressing the trigeminal nerve and causing face pain. Blood vessels touching the Trigeminal Nerve can also be visualised on MRI. Treatment of trigeminal neuralgia Stereotactic radiosurgery Gamma Knife A no open surgery  method that is non-invasive, effective, precise , and lower risk  than surgery. It is a day treatment  for most patients. Other minimally invasive procedures Radiofrequency electrocoagulation Glycerol injection Balloon compression of the Gasserian ganglion Microvascular decompression (MVD) A surgery  where an opening is made in the skull behind the ear , and microsurgery  is done to find the root cause of trigeminal nerve compression .This is usually a blood vessel , which is then elevated off the nerve  and kept there using a Teflon patch . Stereotactic surgery / Gamma Knife for trigeminal neuralgia Stereotactic radiosurgical treatment  of trigeminal neuralgia is the most recent  and least invasive  neurosurgical option.It is the treatment least likely to cause complications , as no surgical opening  is made, avoiding the major risks of surgery such as: Infection Bleeding Death Also, the risk of facial numbness  and new facial sensations (dysesthesias)  is much lower  than with other surgical procedures. Suitable candidate Any patient with trigeminal neuralgia who has: Failed medical therapies  (due to lack of pain relief or undesirable side effects) Older patients  or those with other medical conditions Previously undergone failed surgical procedures … is an excellent candidate  for stereotactic radiosurgery / Gamma Knife . Gamma Knife or LINAC radiosurgery? Both the Linear Accelerator (LINAC)  and the Gamma Knife  are used in stereotactic radiosurgery . The Gamma Knife  is a highly precise system  with good results in the hands of experienced neurosurgeons . It is a day treatment . How does stereotactic radiosurgery / Gamma Knife work to treat trigeminal neuralgia? Stereotactic radiosurgery / Gamma Knife delivers a high dose of gamma rays in one session  to the target lesion  with scalpel-like precision , causing minimal damage to surrounding tissue . The target  is the trigeminal nerve  near where it exits the brain. A stereotactic frame or navigation box  is fixed to the patient’s head. It is a day-surgery procedure . The patient can return to normal activities  immediately after treatment. 4 stages of stereotactic radiosurgery treatment Stage 1 A navigation box  is firmly fixed to the patient’s head.This allows for precision and accuracy  during treatment. Stage 2 The patient undergoes a treatment planning MRI  of the brain. Stage 3 The neurosurgeon and team  (radiation oncologist and physicist) use 3D computer imaging  to: Plan the treatment Determine the radiation dose The neurosurgeon  is the leader of the team , as he is the brain expert . Stage 4 The patient lies down on the treatment couch for the radiosurgery session , which is: Painless Non-invasive After treatment, the navigation box is removed , and the patient usually goes home the same day . What are the results? Studies done in Sweden, the USA, Japan and Singapore show that good pain relief is obtained in the majority of people with Trigeminal Neuralgia. Conclusion Trigeminal Neuralgia is a debilitating condition that requires a tailored approach for effective management. Early diagnosis and treatment can make a significant difference in reducing pain and restoring quality of life. If you or someone you know is experiencing symptoms of trigeminal neuralgia, consult the specialists at Singapore Brain Spine Nerves Center for compassionate and comprehensive care. Let us guide you on your journey to pain relief and improved well-being.

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Your headache symptoms can help your doctor determine its cause and the appropriate treatment. Most headaches aren’t the result of a serious illness, but some may result from a life-threatening condition requiring emergency care. Headaches are generally classified by cause: Primary headaches: A primary headache is caused by overactivity of or problems with pain-sensitive structures in your head. A primary headache isn’t a symptom of an underlying disease. Chemical activity in your brain, the nerves or blood vessels surrounding your skull, or the muscles of your head and neck (or some combination of these factors) can play a role in primary headaches. Some people may also carry genes that make them more likely to develop such headaches. The most common primary headaches are: Cluster headache Migraine Migraine with aura Tension headache Trigeminal autonomic cephalalgia (TAC), such as cluster headache and paroxysmal hemicrania A few headache patterns also are generally considered types of primary headache, but are less common. These headaches have distinct features, such as an unusual duration or pain associated with a certain activity. Although generally considered primary, each could be a symptom of an underlying disease. They include: Chronic daily headaches (for example, chronic migraine, chronic tension-type headache, or hemicranias continua) Cough headaches Exercise headaches Sex headaches Some primary headaches can be triggered by lifestyle factors, including: Alcohol, particularly red wine Certain foods, such as processed meats that contain nitrates Changes in sleep or lack of sleep Poor posture Skipped meals Stress Secondary headaches A secondary headache is a symptom of a disease that can activate the pain-sensitive nerves of the head. Any number of conditions — varying greatly in severity — may cause secondary headaches. Possible causes of secondary headaches include: Acute sinusitis (sinus infection) Arterial tears (carotid or vertebral dissections) Blood clot (venous thrombosis) within the brain — separate from stroke Brain aneurysm (a bulge in an artery in your brain) Brain AVM (arteriovenous malformation) — an abnormal formation of brain blood vessels Brain tumor Carbon monoxide poisoning Chiari malformation (structural problem at the base of your skull) Concussion Dehydration Dental problems Ear infection (middle ear) Encephalitis (brain inflammation) Giant cell arteritis (inflammation of the lining of the arteries) Glaucoma (acute angle closure glaucoma) Hangovers High blood pressure (hypertension) Influenza (flu) and other febrile (fever) illnesses Intracranial hematoma Medications to treat other disorders Meningitis Monosodium glutamate (MSG) Overuse of pain medication Panic attacks and panic disorder Post-concussion syndrome Pressure from tight headgear, such as a helmet or goggles Pseudotumor cerebri Stroke Toxoplasmosis Trigeminal neuralgia (as well as other neuralgias, all involving irritation of certain nerves connecting the face and brain) Some types of secondary headaches include: External compression headaches (a result of pressure-causing headgear) Ice cream headaches (commonly called brain freeze) Medication overuse headaches (caused by overuse of pain medication) Sinus headaches (caused by inflammation and congestion in sinus cavities) Spinal headaches (caused by low pressure or volume of cerebrospinal fluid, possibly the result of spontaneous cerebrospinal fluid leak, spinal tap or spinal anesthesia) Thunderclap headaches (a group of disorders that involves sudden, severe headaches with multiple causes) Dr Prem Pillay, an Expert on Headaches recommends that if they are severe and /or persistent that you have a consult which may include a Neurological examination and imaging including MRI of the Brain. Serious problems such as Brain Tumor or a ruptured Brain Aneurysm or Arterio Venous Malformation are not common but if not detected early have serious life changing consequences. Conclusion Headaches are a common yet diverse condition that can significantly impact the quality of life. Understanding the type and cause of headaches is essential for effective management. At Singapore Brain Spine Nerves Center, our team offers expert evaluation and tailored treatment plans for all types of headaches. If you or a loved one are struggling with recurring or severe headaches, seek professional medical advice to improve your comfort and well-being. Visit the Singapore Brain Spine Nerves Center today to learn more.

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) What Are Cerebral Cavernous Malformations? Cerebral cavernous malformations (CCMs) , also known as cavernous hemangiomas , cavernous angiomas , or cavernomas , are abnormal clusters of blood vessels  in the brain or spinal cord [1][3]. Dr Prem Pillay  explains that these lesions are characterised by their distinctive appearance , resembling small mulberries , and are composed of closely packed, thin-walled blood vessels  [5]. CCMs contain slow-moving or clotted blood  and lack the normal junctions with surrounding cells, leading to potential leakage into adjacent tissues  [1]. Unlike tumours, CCMs do not exhibit endothelial hyperplasia  and are considered vascular malformations rather than neoplasms  [1]. These lesions can vary in size but are typically less than 1 centimetre in diameter  [5].They can be found in various locations within the central nervous system, including the white matter of the brain , the cerebral cortex , and the spinal cord  [1] Causes and Genetic Factors The aetiology of CCMs  is complex and can be attributed to both sporadic occurrences  and genetic factors . In many cases, CCMs develop sporadically as single lesions  without a clear hereditary component [5]. However, a significant proportion of cases are associated with specific genetic mutations . Genetic Basis of Cavernomas / CCMs CCMs can be inherited in an autosomal dominant  pattern, caused by mutations in three primary genes: CCM1 (KRIT1) CCM2 (MGC4607 or malcavernin) CCM3 (PDCD10)  [1] These genes play crucial roles in maintaining the integrity of blood vessels .Mutations leading to loss of function  in these genes are believed to be responsible for the formation of CCMs [1]. The “second hit mutation” theory  suggests that a combination of inherited and acquired mutations  may contribute to the development of multiple lesions  in some patients [1]. Diagnosis of CCMs / Cavernomas Accurate diagnosis of CCMs is essential for proper management and treatment planning . Common diagnostic methods include: Magnetic Resonance Imaging (MRI) MRI is the gold standard  for diagnosing CCMs. On T2-weighted images , CCMs typically appear as high-signal lesions  [1]. Gradient-echo  or susceptibility-weighted sequences  can enhance the detection of small or multiple lesions. Computed Tomography (CT) CT may show CCMs as areas of increased density , often with calcifications . MRI is preferred due to superior soft tissue contrast  and ability to detect smaller lesions  [1]. Angiography CCMs are angiographically occult  and do not appear on conventional angiograms [3]. Cerebral angiograms  are useful to distinguish CCMs from small arteriovenous malformations (AVMs)  or concurrent AVMs/AV fistulas . Genetic Testing For patients with a family history  or multiple lesions , genetic testing for CCM1, CCM2, and CCM3  can confirm diagnosis and guide management [3]. Treatment Options The management of CCMs is tailored to each patient’s presentation , lesion location , and symptoms .As a Cavernoma expert , Dr Prem Pillay  offers a comprehensive treatment approach using the latest advancements  in neurosurgery  and radiosurgery . Conservative Management For asymptomatic lesions  or those in deep, eloquent brain areas , a watchful waiting approach  may be appropriate.This includes: Regular MRI monitoring  to track growth or changes [6] Lifestyle modification guidance  and identifying potential triggers  to reduce risk Microsurgical Resection Surgical removal is the definitive treatment  for symptomatic CCMs, particularly those causing recurrent haemorrhages  or intractable seizures  [8]. Dr Prem Pillay  employs state-of-the-art techniques to maximise safety and efficacy: Frameless stereotaxy  for precise lesion localisation Intraoperative functional MRI  to map critical brain areas Computer image-guided surgical navigation  for optimal planning [7] The goal is complete resection  while preserving healthy tissue — shown to provide excellent outcomes in epilepsy control  and haemorrhage prevention  [8]. Stereotactic Radiosurgery (SRS) For deep-seated lesions  in eloquent areas or for patients unfit for surgery , SRS is a valuable alternative [8]. Uses highly focused radiation beams  to target CCMs precisely Reduces risk of future haemorrhages Performed with Gamma Knife  or LINAC Radiosurgery  using robotic assistance Day procedure : scarless, painless, and involves no cutting Medical Management While there is no medication to treat CCMs directly , symptom management includes: Anticonvulsants  for seizure control Pain management  for headaches Steroids  to reduce perilesional oedema when indicated [4] Ongoing Research and Future Directions As a Neurosurgeon with CCM expertise , Dr Prem Pillay  actively follows cutting-edge research to improve outcomes. Current focus areas include: Novel pharmacological agents  targeting CCM signalling pathways Advanced imaging techniques  for better lesion characterisation Minimally invasive surgical approaches  for deep lesions Conclusions Cerebral cavernous malformations  are complex vascular lesions that require expert management .With many years of experience and access to advanced technology , Dr Prem Pillay  delivers the highest standard of care  — from accurate diagnosis to tailored treatments. If you or a loved one has been diagnosed with a CCM , we encourage you to consult with our specialised team .Together, we can create a comprehensive treatment strategy  tailored to your unique needs and goals. Citations [1] https://en.wikipedia.org/wiki/Cavernous_hemangioma [2] https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/cavernous-malformations [3] https://www.ninds.nih.gov/health-information/disorders/cerebral-cavernous-malformations [4] https://www.healthline.com/health/cavernous-hemangioma [5] https://www.mayoclinic.org/diseases-conditions/cavernous-malformations/symptoms-causes/syc-20360941 [6] https://my.clevelandclinic.org/health/diseases/21594-cavernous-hemangioma [7] https://www.mountsinai.org/locations/cerebrovascular-center/conditions/vascular-malformations/cavernomas [8] https://pmc.ncbi.nlm.nih.gov/articles/PMC4300037/ [9] https://www.mayoclinic.org/diseases-conditions/cavernous-malformations/diagnosis-treatment/drc-20360942

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Spot a Stroke: BE FAST Stroke  remains a leading cause of death and long-term disability worldwide, including Singapore and Asia, affecting over 10 million people annually  [4]. However, recent breakthroughs in diagnosis, treatment, and rehabilitation  offer new hope for patients and their families. This summary provides an overview of the latest advances in stroke care , emphasising the critical importance of rapid intervention  and highlighting promising new approaches  to improve outcomes. Understanding Stroke A stroke  occurs when there is a disruption of blood flow to the brain , either due to a blockage (ischaemic stroke)  or a rupture of a blood vessel (haemorrhagic stroke)  [4]. This interruption deprives brain cells of oxygen, causing damage and potential cell death. The effects of a stroke can vary widely depending on the location and extent of the brain injury . Ischaemic stroke  needs to be quickly identified and treated with anti-platelet and anti-coagulant therapy  and endovascular therapy . Patients with TIAs  and RINDs  should be effectively screened with MRA  and DSA  for treatable carotid artery stenosis . Patients with haemorrhage from brain AVMs, aneurysms, cavernomas, and dural AV fistulas  should be diagnosed early with CT, MRI, and DSA . Some patients require early surgery including microsurgery . Selected patients will benefit from endovascular therapy  including embolisation, coiling, flow diverters , and others from stereotactic radiosurgery . The Urgency of Stroke Treatment One of the most critical factors in stroke treatment is time . The phrase “time is brain”  underscores the importance of rapid intervention to limit cerebral damage [1]. Recent research has reinforced the need for urgent action, even when symptoms appear to resolve quickly. Transient Ischaemic Attacks (TIAs) New guidelines emphasise that even brief stroke symptoms , lasting less than an hour (known as transient ischaemic attacks  or TIAs ), require immediate medical attention  [7]. These “warning strokes” can precede a full-blown stroke and should be treated as medical emergencies . Advances in Stroke Diagnosis Early and accurate diagnosis is crucial for effective stroke treatment. Recent technological advancements have improved our ability to quickly identify and characterise strokes. Portable MRI Technology Researchers have developed a portable MRI machine  that can be brought to a patient’s bedside, potentially reducing delays in diagnosis [4]. This innovation allows for faster imaging and could significantly improve the speed of stroke diagnosis and treatment initiation. Cutting-Edge Stroke Treatments The landscape of stroke treatment has evolved rapidly in recent years, with several groundbreaking approaches  showing promise. Endovascular Interventions Mechanical thrombectomy , a procedure to remove blood clots from large vessels in the brain, has emerged as a highly effective treatment  for certain types of ischaemic strokes [5]. Bleeding from AVMs  can be treated with endovascular embolisation . Aneurysms  can be occluded with platinum coils  or excluded from circulation with flow diverters . Subdural haematomas  can be treated using endovascular embolisation  of the middle meningeal artery . Thrombolysis Intravenous thrombolysis  with recombinant tissue plasminogen activator (rt-PA)  remains a cornerstone  of acute ischaemic stroke treatment [1].Recent studies have explored: Extending the time window  for treatment Alternative thrombolytic agents  like tenecteplase  [8] Brain Stimulation Techniques Non-invasive brain stimulation , such as: Repetitive transcranial magnetic stimulation (rTMS) Transcranial direct current stimulation (tDCS) …are being studied for their potential to enhance motor recovery  after stroke [6]. Neuroprotective Strategies Research is ongoing into neuroprotective therapies  that could be administered early — potentially even before imaging  — to limit brain damage in stroke patients [1]. Rehabilitation and Recovery Stroke rehabilitation has seen significant advancements, with new technologies and approaches offering hope for improved recovery. Brain-Computer Interfaces (BCIs) BCIs  are emerging as a promising tool for rehabilitation, allowing patients to control external devices  using brain signals  [10]. This may help stimulate neuroplasticity  and improve motor function recovery . Virtual Reality and Robotics Virtual reality  and robot-assisted therapies  are being integrated into rehabilitation programmes, offering new ways to engage patients and provide intensive, targeted therapy  [6][10]. Personalised Rehabilitation There is a growing emphasis on tailoring rehabilitation strategies to individual patients , considering: Stroke type Stroke location Patient’s specific deficits and goals [3] Prevention and Secondary Stroke Risk Reduction Blood Pressure Management Recent research highlights the importance of personalised blood pressure management  in the acute phase after a stroke [4]. Optimal targets may vary by patient. Antiplatelet Therapy Dual antiplatelet therapy  (aspirin + clopidogrel) has shown promise in preventing recurrent strokes  in certain high-risk patients [8]. Lifestyle Modifications Encouraging: Healthy diet Regular exercise Smoking cessation …remains a cornerstone  of stroke prevention. Future Directions in Stroke Care The field of stroke care is rapidly evolving, with several exciting areas of research underway: Cell therapies Stem cell treatments for stroke recovery show potential for improving motor function  [10]. Artificial intelligence AI is being explored to enhance diagnosis, treatment selection, and outcome prediction . Telemedicine and telerehabilitation Expanding access to specialised care , especially in underserved regions  [6]. Combination therapies Integrating techniques like brain stimulation  with robotic rehab  and traditional therapy [6]. The landscape of stroke care is rapidly evolving, with new technologies  and treatment approaches  offering hope for improved outcomes. From faster diagnosis  and more effective acute interventions  to innovative rehabilitation techniques , these advancements are transforming the way we approach stroke care. However, the most critical factor  remains rapid recognition and response to symptoms . Public education  about warning signs and the importance of immediate medical attention  is crucial. Remember: If you or someone you know experiences symptoms of a stroke , even if they seem to resolve quickly, seek emergency medical care immediately . Every minute counts  in preserving brain function and improving recovery. Stroke Care with Singapore Brain Spine Center With many years of experience in diagnosing strokes 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 stroke, we welcome you to seek consultation with our specialised team. Together, we can develop a comprehensive, evidence-based, and personalised treatment strategy  that addresses your unique needs and aims to provide the best chance for a positive outcome . References [1] https://pmc.ncbi.nlm.nih.gov/articles/PMC1448697/ [2] https://www.mayoclinic.org/diseases-conditions/stroke/diagnosis-treatment/drc-20350119 [3] https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2024.1402729/full [4] https://www.yalemedicine.org/news/3-stroke-breakthroughs [5] https://bmjmedicine.bmj.com/content/2/1/e000407 [6] https://pmc.ncbi.nlm.nih.gov/articles/PMC10650295/ [7] https://www.stroke.org/en/news/2023/01/19/stroke-symptoms-require-emergency-treatment-even-if-they-quickly-disappear-new-report-says [8] https://pmc.ncbi.nlm.nih.gov/articles/PMC8407466/ [9] https://www.ihi.europa.eu/news-events/newsroom/umbrella-project-sets-sights-stroke-care-revolution [10] https://pmc.ncbi.nlm.nih.gov/articles/PMC10761524/

Dr. Prem Pillay , Singapore Brain Spine Nerves Center, Singapore Senior Consultant Neurosurgeon with super speciality training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) Epilepsy is a disorder of the brain characterised by repeated seizures. A seizure  is usually defined as a sudden alteration of behaviour due to a temporary change in the electrical functioning of the brain. Normally, the brain continuously generates tiny electrical impulses in an orderly pattern. These impulses travel along neurons, the network of nerve cells in the brain and throughout the whole body via chemical messengers called neurotransmitters. In epilepsy, the brain’s electrical rhythms have a tendency to become imbalanced, resulting in recurrent seizures. In patients with seizures, the normal electrical pattern is disrupted by sudden and synchronised bursts of electrical energy that may briefly affect their consciousness, movements or sensations. Epilepsy  is usually diagnosed after a person has had at least two seizures  that were not caused by some known medical condition, such as alcohol withdrawal or extremely low blood sugar. If seizures arise from a specific area of the brain, then the initial symptoms of the seizure often reflect the functions of that area. The right half of the brain controls the left side  of the body, and the left half controls the right side . For example, if a seizure starts from the right side of the brain in the area that controls movement in the thumb, then the seizure may begin with jerking of the left thumb or hand. Types of Seizures Seizures vary so much that epilepsy specialists frequently reclassify seizure types. Typically, seizures belong in one of two basic categories: Primary generalised seizures Begin with a widespread electrical discharge involving both sides of the brain at once. Partial seizures Begin with an electrical discharge in one limited area of the brain. Epilepsy  in which the seizures begin from both sides of the brain at the same time is called primary generalised epilepsy . Hereditary factors  are important in primary generalised epilepsy, which is more likely to involve genetic factors than partial epilepsy  — a condition in which the seizures arise from a limited area of the brain. Some partial seizures  are related to head injury, brain infection, stroke or tumour , but in most cases, the cause is unknown. One question that is used to further classify partial seizures is whether consciousness  (the ability to respond and remember) is impaired or preserved. Factors That May Increase Seizure Risk Stress Sleep deprivation or fatigue Insufficient food intake Alcohol use or drug abuse Failure to take prescribed anticonvulsant medical therapy About half of the people  who have one seizure without a clear cause will have another one, usually within six months. A person is twice as likely  to have another seizure if there is a known brain injury or other type of brain abnormality. If the patient has two seizures, there is about an 80 percent chance  of having more. If the first seizure occurred at the time of an injury or infection in the brain, it is more likely the patient will develop epilepsy than if the seizure did not happen at the time of injury or infection. Prevalence and Incidence According to the Epilepsy Foundation , epilepsy affects three million people in the U.S.  and 50 million worldwide . Seizures may be tied to a brain injury or genetics , but for 70 percent of patients , the cause is unknown. 10 percent  of people will have seizures in their lifetime. More than 300,000 children  under the age of 15 have epilepsy, with 90,000  of them having seizures that cannot be adequately treated. The onset rate increases with age, particularly in cases of stroke, brain tumours, or Alzheimer’s disease . Over 570,000 adults  over 65 suffer from the disorder. More men  than women have epilepsy. Children and adolescents  are more likely to have epilepsy of unknown or genetic origin. Brain injury or infection  can cause epilepsy at any age. The Epilepsy Foundation reports: 70 percent  of children and adults with newly diagnosed epilepsy can enter remission after five years without a seizure while on medication. 75 percent  of people who are seizure-free on medication can eventually be weaned off it. 20 percent  of patients have intractable seizures  — seizures that do not respond to treatment. Epilepsy Risk Factors Premature birth or low birth weight Trauma during birth (such as lack of oxygen) Seizures in the first month of life Abnormal brain structures at birth Bleeding into the brain Abnormal blood vessels in the brain Serious brain injury or lack of oxygen to the brain Brain tumours Infections such as meningitis or encephalitis Stroke Cerebral palsy Mental disabilities Seizures occurring soon after head injury Family history of epilepsy or fever-related seizures Alzheimer’s disease Lengthy febrile seizures Alcohol or drug abuse Diagnosis A doctor diagnoses epilepsy based on symptoms, physical signs , and test results such as: Electroencephalogram (EEG) CT scan (Computed Tomography) MRI (Magnetic Resonance Imaging) Proper diagnosis of both the type of epilepsy  and the type of seizures  is essential, as seizure types are often associated with specific forms of the disorder. Treatment Epilepsy may be treated with: Antiepileptic medical therapy (AEDs) Diet therapy Surgery Medical Therapy Initial treatment for most patients with multiple seizures. Not always needed for a single seizure with low recurrence risk. Controls symptoms, does not cure the condition. Prevents seizures by reducing brain cell excitability. Medication choice  depends on: Seizure type and epilepsy type Side effects Patient’s age, gender, medical history Interactions with other medications Cost Diet Therapy Used in specific forms of epilepsy: Ketogenic diet : High-fat, adequate protein, low-carb diet started in hospital. Modified Atkins diet : Less restrictive, can be started as outpatient. Both reduce seizures in about 50%  of appropriate candidates, mostly children with refractory epilepsy who are not surgical candidates. Medically-Resistant Epilepsy About 30 percent  of patients do not respond to standard therapy. These patients are treated at specialised epilepsy centres  with a multidisciplinary team  that may include: Adult and Paediatric Epileptologists Epilepsy Nurse Practitioners Neurosurgeons EEG Technicians Clinical Neuropsychologists Psychiatrists Radiologists (Neuro & Nuclear Medicine) Dietitians Neuroscience Nurses Surgical Treatment for Epilepsy Patients with refractory epilepsy  may benefit from surgery, especially if seizures come from one area of the brain. The area must be removable without major neurological damage. Pre-Surgical Evaluation Consists of: Phase I (Non-invasive) EEG Video-EEG Monitoring MRI PET scan SPECT scan Neuropsychological Evaluation Functional MRI Wada Test Results help determine if all findings point to a single seizure origin (focus). If so, surgery may be an option. Phase II (Invasive Monitoring) If more clarity is needed, involves: Subdural Electrodes Depth Electrodes StereoEEG Functional Mapping Surgical Procedures Surgical Resections Lesionectomy : Removes abnormal tissue like tumours or cavernous malformations. Lobectomy : Removes a lobe (most commonly, temporal lobe). Multilobar Resection : Removes parts of two or more lobes. Hemispherectomy : Removes or disconnects one hemisphere. Anatomic  or Functional  approaches. Surgical Disconnections Corpus Callosotomy : Cuts the connection between hemispheres to reduce spread. Multiple Subpial Transections (MST) : Disconnects neurons without removing tissue. Stereotactic Radiosurgery Focused radiation like Gamma Knife  is used for deep-seated lesions visible on MRI. Generally used when surgery is too risky. Neuromodulation Vagus Nerve Stimulation (VNS) Electrodes implanted around vagus nerve, generator placed in chest. Reduces seizures in 40–50% of patients. Palliative, improves control, rarely eliminates seizures. Responsive Neurostimulation (RNS) FDA approved in 2014 . Implanted neurostimulator records brain activity and delivers impulses to interrupt seizures. Suitable for patients with one or two focal onset zones. Rarely results in seizure freedom but improves control. Living and Coping with Epilepsy Two life-threatening risks: Tonic-clonic status epilepticus : Prolonged seizure that requires emergency treatment. SUDEP (Sudden Unexplained Death in Epilepsy) : Rare, more common in patients with frequent, uncontrolled seizures. 70–80%  of people can successfully control seizures with treatment.Some rarely think about epilepsy apart from taking medication or doctor visits. Staying well-informed , positive , and engaged  with a healthcare team is essential to leading a full, balanced life . Conclusion Epilepsy is a complex condition that requires a tailored, multidisciplinary approach to care. With proper diagnosis and treatment, many people with epilepsy can achieve excellent seizure control and lead fulfilling lives. At Singapore Brain Spine Nerves Center, our experienced team provides expert guidance and advanced treatments for epilepsy. If you or your loved one is experiencing recurrent seizures, seek professional evaluation to manage the condition effectively. References and Acknowledgements American Association of Neurological Surgeons Singapore Brain Spine Nerves Center Protocols and Information