Search Results

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 Gliomas? Gliomas are a category of primary brain tumours that arise from glial cells, which provide support and insulation to neurons in the central nervous system. These tumours can occur in both the brain and spinal cord and are classified based on the type of glial cells involved. Gliomas are the most common type of brain tumour in adults and can range from slow-growing to highly aggressive forms. Glioma and Glioblastoma: Advances in Classification and Research In the United States, an estimated 17,000 adults will be diagnosed this year with diffuse glioma , which includes glioblastoma, astrocytoma, and oligodendroglioma . Among these, high-grade gliomas  like glioblastoma have worse prognoses. Glioblastoma is classified  based on its histological characteristics (left) as well as IDH status . “For many years, the Neuro Oncology community has observed significant variation in survival even within traditional classification groups,” said Dr Prem Pillay  from the Singapore Brain Spine Nerves Center .“This was an enormous impetus for researchers to find new markers to better characterize glioma subtypes.” In 2015, two landmark publications , including one from a team of UCSF researchers, found three new tumor markers  that reliably classified glioma patients into distinct groups with notable differences in survival, age at diagnosis, among others.² ³ 2016 World Health Organisation (WHO) Classification Update In 2016, the WHO reorganized their classification system  for adult diffuse glioma  to integrate those molecular features, in addition to others identified since then. The majority of adult diffuse glioma are now classified into the following five groups: Glioblastoma, IDH wildtype  (no mutation) Glioblastoma, IDH mutation Diffuse or anaplastic astrocytoma, IDH wildtype  (no mutation) Diffuse or anaplastic astrocytoma, IDH mutation Oligodendroglioma or anaplastic oligodendroglioma, IDH mutation with 1p19q co-deletion Categorization of adult diffuse glioma, along with characteristics for each of the five subtypes.Image credit: Figure 1 from Molinaro et al. (2019). “By better understanding glioma subtypes, we can help our patients make decisions about treatment,” said Dr Prem Pillay The Future of Brain Tumor Classification Since then, additional markers  have been identified and are in use today to further improve accuracy in prognoses for certain gliomas. A comprehensive overview of molecular features that are also associated with patient outcome and/or treatment response includes the following: TERT and ATRX mutations  affecting telomere maintenance Tumor methylation profile Methylation of the MGMT promoter CDKN2A and/or CDKN2B deletion H3 K27M mutation In the last decade, identifying such molecular features  and their associated pathways has provided mechanistic insight  into how these distinct tumor subtypes form and their potential response to targeted therapy . For instance, researchers recently identified a protein subunit  that activates mutated TERT promoters , which is currently under investigation as a potential therapeutic target. As we continue to identify additional markers, proposed changes to the WHO guidelines  remains an ongoing topic of discussion. The cIMPACT-NOW  (the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy ), was created to assess and recommend regular updates to the brain tumor classification system. The discovery of molecular features to better characterize glioma subtypes  has certainly impacted the clinic and continues to shape the direction of research. “Increasingly, molecular analysis of patient samples is becoming a more widespread practice. Identifying a patient’s unique tumor profile is critical not only for diagnosis and prediction of prognoses, but potentially for tailoring treatment to the patient’s specific gene alterations” Identifying Glioma Risk Factors Another recent, significant advance in brain tumor research involves the discovery of 25 inherited variants  that increase the risk of glioma. The majority of these gene alterations are either in or near genes known to be involved in specific cancer-related pathways , providing additional insight into how gliomas develop. In contrast, recent observations suggest that a history of allergies  (or other conditions with heightened immune responses, like asthma and eczema ) is associated with decreased glioma risk . These findings have spurred additional research into characteristics of the immune system  that are involved in glioma pathogenesis and prognosis. Large-scale retrospective and prospective epidemiological studies  to characterize peripheral immune profiles  on the basis of archival DNA  are underway at UCSF to assess how variation amongst patients’ immune profiles impacts glioma risk. Together, these findings combined with the discoveries of changes within the tumors provide a solid foundation for future research into why some people get glioma  and what may be done to help reduce the risk of disease or death  from this disease. Conclusion Gliomas are a complex group of brain tumours that require specialised and multidisciplinary care. Early diagnosis and tailored treatment can significantly improve outcomes and quality of life. At Singapore Brain Spine Nerves Center , we are dedicated to providing expert care for glioma patients, leveraging advanced diagnostic and treatment options. If you or a loved one are experiencing concerning neurological symptoms, schedule a consultation today for comprehensive evaluation and guidance. References: UCSF Brain Tumor Information Cleveland Clinic Brain Tumor Information Singapore Brain Spine Nerves Center

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) Meningioma The Meningioma  is a primary intracranial tumor that is one of the most common benign tumors within the cranium (head). About 40–60% of benign tumors are meningiomas. About 15% of all primary intracranial tumors (both benign and malignant) are meningiomas. Origin:  They originate from the arachnoid cap cells that occur most often at the arachnoid granulations, which are near the midline adjacent to the superior sagittal sinus (the large midline vein of the head). Another location is the tela choroidea in the ventricles. They are therefore intracranial but not intracerebral  (within the head but not in the brain). In other words, they usually occur from the covering of the brain called the dura and not from within the brain. Epidemiology and Characteristics Age:  The peak age is from 40 to 60 years. Sex:  It is more common in females than males. Genetics:  72% of tumors have monosomy 22. Risk factors:  Previous radiation, neurofibromatosis type 2 (NF2). Locations: Cranial (within the head): 90% Spinal canal: 9% Others (neck, parotid, etc.): 1% About 50% are parasagittal and convexity (near the midline and over the lobes of the brain). Grading:  WHO classification I, II, III – from the least to the most aggressive. Pathology:  Meningothelial, fibroblastic, psammomatous, angiomatous, and transitional (most common). Aggressive variants:  They invade the brain, have necrosis, mitosis, papillary features, or are locally recurrent. Malignant:  As above, with metastases. Clinical Features They may be symptomatic or asymptomatic  at the time of discovery.Usual symptoms may include: Headaches Seizures Loss of any of the senses (smell, taste, hearing, vision, sensation) Motor weakness (hemiparesis) Memory loss Language problems (dysphasia, aphasia) Some people with these tumors are mistakenly diagnosed with dementia, strokes, or psychiatric problems . Diagnostic Tests This includes a thorough neurological examination  followed by brain scanning. In emergencies, a CT of the brain with contrast  can be done quickly. An MRI of the brain with gadolinium  is the definitive test. The appearance of a meningioma on these tests is usually unique or characteristic enough for an accurate diagnosis most of the time.There are exceptions where a biopsy with tissue examination  is still needed. Biopsy A biopsy is not mandatory  for the diagnosis of a meningioma. MRI with gadolinium and CT of the brain  can be fairly clear in determining the diagnosis of a meningioma.The presence of an intracranial but extracerebral enhancing tumor with a dural tail  is a classical finding. A biopsy can be done by: Stereotactic computer-aided biopsy , where a needle is guided to the tumor after detailed computer planning based on pre-surgical imaging and using a stereotactic frame. Frameless stereotaxis , using a system like the StealthStation  or Robotic Guidance . Surgery Microsurgery  using a high-definition microscope and microinstruments is the latest type of surgery for meningiomas. CAN/CAM (Computer Aided Neurosurgery / Computer Aided Microsurgery)  and VR technology  can also be used. Lasers, “Super-Lasers”, CUSAs / Ultrasonic beams, the Malis technique  can be used for tumor removal.The StealthStation  and other neuro-navigation systems  are useful in allowing a minimally invasive approach  in the removal of these tumors. Radiosurgery Radiosurgery refers to computer-planned, accurately focused high energy beams  used for non-invasive tumor treatment. Radiosurgery has been shown to be effective for meningiomas.Modern systems include: Gamma Knife Novalis systems with Photon Beams Proton Beam Treatment methods: Single session Multiple sessions : Known as SRT (stereotactic radiation therapy)  or FSR (fractionated stereotactic radiosurgery) New forms include MicroRadiosurgery  and Proton Beam Therapy . Combined Treatment Combined Microsurgery and Radiosurgery (CMR)  uses both modalities for treating large, difficult-to-remove, or dangerously located meningiomas.This can be a lower risk protocol  for complete tumor removal, especially in higher risk patients . Recent Advances Molecular Profiling Molecular profiling has revolutionised meningioma diagnosis and classification. The 2021 WHO classification  now incorporates molecular features alongside histological grading. Key molecular alterations include: NF2 mutations : Found in ~60% of sporadic meningiomas TRAF7, KLF4, AKT1, SMO mutations : Common in non-NF2 mutated meningiomas SMARCE1 mutations : Associated with clear cell meningiomas BAP1, SMARCB1 mutations : Linked to high-grade meningiomas DNA methylation profiling  helps identify clinically relevant subgroups beyond traditional histological grading. Neuroimaging Recent imaging advances include: Arterial spin labelling and dynamic susceptibility contrast-enhanced MRI : Assess tumor vascularity and guide preoperative embolisation. MR spectroscopy and PET-MRI : Help distinguish meningiomas from malignant mimics. Perfusion imaging : Provides insight into tumor grade and recurrence potential. Machine learning algorithms : Predict tumor consistency and behaviour based on imaging features. Treatment Advances Surgical Approaches Minimally invasive techniques Endoscopic and keyhole approaches reduce morbidity and improve cosmetic results. Intraoperative imaging and navigation Enhance resection while preserving critical structures. Fluorescence-guided surgery Techniques like 5-ALA fluorescence  help visualise tumour margins. Radiation Therapy Stereotactic radiosurgery (SRS) Increasingly used for small to medium-sized tumors, especially near eloquent areas. Fractionated stereotactic radiotherapy (FSRT) Offers precision for larger tumors or those near critical structures. Proton beam therapy Reduces radiation exposure to surrounding healthy tissue. Systemic Therapies Although systemic therapies have shown limited historical efficacy, new developments include: Targeted therapies Inhibitors of molecular pathways (e.g., mTOR, VEGF, SMO) are in trials. Immunotherapy Checkpoint inhibitors and immunomodulatory treatments under investigation, especially for high-grade meningiomas. Peptide Receptor Radionuclide Therapy (PRRT) PRRT  is emerging as a treatment for refractory meningiomas: A Phase II trial using 177LD  showed 78% of patients were progression-free at 6 months. It targets somatostatin receptors , highly expressed in meningiomas. Personalised Meningioma Therapy The integration of molecular profiling and imaging supports personalised treatment strategies : Risk stratification Molecular features help identify high-risk patients and guide adjuvant therapy. Treatment selection Some molecular subtypes may respond differently to therapies. Latest Research Research areas showing promise: Liquid biopsy techniques Non-invasive methods for tumor characterization and monitoring are under investigation. Novel targeted therapies targeting specific molecular alterations (e.g., NF2 pathway inhibitors) are in development. Artificial intelligence Machine learning algorithms may enhance diagnosis, treatment planning, and outcome prediction. Conclusions The field of meningioma diagnosis and treatment is rapidly evolving. Molecular profiling and advanced imaging techniques are refining our ability to classify and prognosticate these tumors. While surgery and radiation therapy remain the mainstays of treatment, emerging targeted therapies and innovative approaches like PRRT offer new options for patients with refractory disease. As our understanding of meningioma biology deepens, the path towards truly personalized treatment strategies becomes clearer, holding the promise of improved outcomes for patients with these challenging tumors.

What are Pineoblastomas? Pineoblastomas is a pineal region tumor that are best thought of as primitive neuroectodermal tumors (PNET) located in the pineal region and thus they closely resemble (both on imaging and on histology) medulloblastomas, retinoblastomas and supratentorial PNETs. Epidemiology Median age at diagnosis of 5.5 years 1). Pineoblastomas are the most agressive pineal parenchymal tumour and account for a substantial proportion of such tumours (24-50%). They are typically found in young children, with both sexes being equally affected (in contrast to the male predominance seen in pineal germinomas). There is a well established association with hereditary retinoblastomas. Patients with hereditary (bliateral) retinoblastoma 5-15% develop midline (suprasellar or pineal) neuroblastic tumours. Such cases are sometimes referred to as trilateral retinoblastoma. Clinical features Pineoblastomas are typically large and almost always associated with obstructive hydrocephalus, due to compression on the aqueduct. Compression of the tectal plate may also result in the Parinaud syndrome. Pathology The tumour originates from neuroectodermal cells. It is the least differentiated pineal cell tumours, with pineocytomas and pineal parenchymal tumour with intermediate differentiation representing better differentiated tumours along the same spectrum. Pineoblastomas are considered WHO grade IV tumours. The tumours are composed of tightly packed small round blue cells (high nuclear to cytoplasmic ratio) which in turn determines their imaging appearances Diagnosis Radiographic features Pineoblastomas tend to be large poorly defined masses, with frequent CSF seeding at presentation. They have a tendency to directly involve adjacent brain structures, which helps distinguish them from other pineal tumours which tend to be better circumscribed. Computed Tomography ( CT ) Scan The solid component tends to be slightly hyperdense compared to adjacent brain due to high cellularity. This is a characteristic shared by other small round blue cell tumours such as PNET and medulloblastoma. Classically, they are described as having peripherally disperse or “exploded” calcification (Mnemonic: blasted calcification), similar to pineocytomas. In contrast pineal germinomas tend to engulf pineal calcification. Magnetic Resonance Imaging ( MRI ) Scan Pineoblastomas tend to appear as sizable (>4 cm) irregular masses often with evidence of invasion into adjacent brain 6,9. Typical signal characteristics include : T1: isointense to hypointense to adjacent brain T2 isointense to adjacent brain areas of cyst formation or necrosis may be present T1 C+ (Gd): vivid heterogenous enhancement DWI/ADC restricted diffusion due to dense cellular packing ADC values are typically ~400-800 mm2/s ADC values can aid in differentiation of pineoblastoma/PNET from germ cell tumors in a population of children with pineal masses 2). Central necrosis is sometimes present which can make the mass appear centrally cystic and thus can roughly mimic a pineal cyst, although the latter should have a smooth thin wall Screening of the whole neural axis is necessary as CSF seeding is seen in 45% of cases. Differential diagnosis General imaging differential considerations include: other pineal parenchymal tumours pineocytoma: mature well-differentiated tumor: smaller and better circumscribed pineal parenchymal tumour with intermediate differentiation papillary tumour of the pineal region germ cell tumours germinoma marked male predominance engulfed calcification ADC values are typically much higher (~1000-2000 mm2/s 7) embryonal carcinoma choriocarcinoma teratoma: may contain fat pineal cyst thin (<2mm) wall astrocytoma of pineal gland metastasis medulloblastoma Imaging is very similar located in the vermis rather than pineal region but can be difficult to distinguish if very high in the vermis and very large Treatment Treatment is usually a combination of surgery including Stereotactic Image guided Biopsy, VP shunting or endoscopic third ventriculostomy -for hydrocephalus; Microsurgery for tumor removal, chemotherapy and radiation including Stereotactic Radiotherapy and Proton therapy stated Dr Prem Pillay , a Neurosurgeon who specializes in treating Pineal tumors including Pineoblastoma (He is currently Medical Director of the Singapore Brain Spine Nerves Center and was previously Chief Resident in Neurosurgery at the Cleveland Clinic, USA and fellow at MD Anderson Cancer Center and the Hospital for Sick Children, Toronto). Outcome They are the most aggressive and highest grade tumour among pineal parenchymal tumours. Prone to CSF seeding, which is present in 15% of patients at the time of diagnosis. Aggressive tumor resection was associated with improved survival only in older pediatric patients. Radiotherapy was more effective in patients receiving surgery. Age-stratified approaches might allow for improved disease management of pediatric pineoblastoma 3). The role of surgery and adjuvant radiotherapy on overall survival remains to be defined 4). Case series A total of 211 pediatric (age 0-17 yr) histologically confirmed pineoblastoma patients diagnosed between 2004 and 2015 were queried from the National Cancer Database. Wilcoxon rank-sum statistics and chi-squared analyses were used to compare continuous and categorical variables, respectively. Univariable and multivariable Cox regressions were used to evaluate the prognostic impact of covariates. Propensity-score matching was used to balance baseline characteristics. Older patients (age ≥ 4 yr) experienced improved overall survival compared to younger patients (age < 4 yr) (hazard ratio [HR] = 0.41; 95% CI 0.25-0.66). Older patients (adjusted odds ratio [aOR] = 5.21; 95% CI 2.61-10.78) and those residing in high-income regions (aOR = 3.16; 95% CI 1.21-8.61) received radiotherapy more frequently. Radiotherapy was independently associated with improved survival in older (adjusted HR [aHR] = 0.31; 95% CI 0.12-0.87) but not younger (aHR = 0.64; 95% CI 0.20-1.90) patients. The benefits of radiotherapy were more pronounced in patients receiving surgery than in those not receiving surgery (aHR [surgical patients] = 0.23; 95% CI 0.08-0.65; aHR [nonsurgical patients] = 0.46; 95% CI 0.22-0.97). Older patients experienced improved outcomes associated with aggressive resection (P = .041); extent of resection was not associated with survival in younger patients (P = .880). Aggressive tumor resection was associated with improved survival only in older pediatric patients. Radiotherapy was more effective in patients receiving surgery. Age-stratified approaches might allow for improved disease management of pediatric pineoblastoma 5). Using the Surveillance, Epidemiology, and End Results (SEER) cancer registry, Selvanathan et al., investigated clinical and pathological factors associated with outcome in paediatric pineoblastomas. Paediatric patients (< 16 years old) with pineoblastomas diagnosed between 1990 and 2007 were identified from the SEER database. Kaplan-Meier survival analysis and Cox models were used to examine the effect of variables on overall survival. The variables analysed included patient’s age at diagnosis, gender, race, tumour spread and size, surgical resection and the use of adjuvant radiotherapy. Seventy-eight patients were identified from the database. Twelve patients were excluded as 11 had no surgery and one patient was excluded as the surgical status was unknown. Analysis of the remaining 66 patients revealed a median age at diagnosis of 5.5 years. Three patients underwent biopsy. Seventeen patients underwent full and partial resection, respectively. A further 46 patients underwent surgery the nature of which was not recorded. Thirty-nine patients (59.1%) received adjuvant radiotherapy. Eight patients (12.1%) had both surgery (full or partial resection) and radiotherapy. The median overall survival was 40.5 months. Univariate analysis demonstrated that older age at diagnosis was the only positive predictor of overall survival. This study represents the largest analysis of paediatric pineoblastomas to date. The only clinically relevant prognostic factor was older age at diagnosis. The role of surgery and adjuvant radiotherapy on overall survival remains to be defined 6). Conclusion Pineoblastoma, though rare and aggressive, can be managed effectively with early diagnosis and a tailored treatment plan. At Singapore Brain Spine Nerves Center, we are dedicated to providing expert, compassionate care for patients facing complex conditions like pineoblastoma. If you or a loved one are experiencing concerning neurological symptoms, seek professional medical evaluation promptly. Early intervention is crucial to achieving the best possible outcomes. Visit the Singapore Brain Spine Nerves Center for comprehensive support and personalised treatments. References 1) , 4) , 6) Selvanathan SK, Richards O, Alli S, Elliott M, Tyagi AK, Chumas PD. Outcome and prognostic features in paediatric pineoblastomas: analysis of cases from the Surveillance, Epidemiology, and End Results registry (1990-2007). Acta Neurochir (Wien). 2019 May 18. doi: 10.1007/s00701-019-03909-1. [Epub ahead of print] PubMed PMID: 31104125. 2) Choudhri AF, Whitehead MT, Siddiqui A, Klimo P Jr, Boop FA. Diffusion characteristics of pediatric pineal tumors. Neuroradiol J. 2015 Apr;28(2):209-16. doi: 10.1177/1971400915581741. Epub 2015 May 11. PubMed PMID: 25963154. 3) , 5) Jin MC, Prolo LM, Wu A, Azad TD, Shi S, Rodrigues AJ, Soltys SG, Pollom EL, Li G, Hiniker SM, Grant GA. Patterns of Care and Age-Specific Impact of Extent of Resection and Adjuvant Radiotherapy in Pediatric Pineoblastoma. Neurosurgery. 2020 Feb 28. pii: nyaa023. doi: 10.1093/neuros/nyaa023. [Epub ahead of print] PubMed PMID: 32110805.

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) Medulloblastoma Medulloblastoma (MB) is an embryonic tumor of the neuroepithelial tissue and the most frequent primary pediatric solid malignancy. MB represents a heterogeneous group of cerebellar tumors characterized clinically by increased intracranial pressure and cerebellar dysfunction, with the most common presenting symptoms being headache, vomiting, and ataxia. Epidemiology MB is the most common malignant brain tumor in childhood. Annual incidence is estimated at 1/909,000 in Europe, 1.5/100,00 in the USA said Dr Prem Pillay , a Neurosurgeon who specializes in treating Medulloblastomas ( He trained at the Cleveland Clinic,USA and the Hospital for Sick Children, Toronto). Males are more affected than females. Clinic Description Age of disease onset is variable and can occur in patients ranging in age from the newborn period to adulthood (peak age at presentation is children 3-6 years, with only 25% of patients being between 15 and 44 years). The most common presenting symptoms are headache, vomiting, and ataxia. Additional features that may be observed include lethargy, motor or cranial nerve impairment, gaze palsy, visual impairment due to hydrocephalia, vertigo/hearing loss, behavioral changes/irritability, and extracranial pain (e.g. back pain in those with spinal metastases). Around 30% of pediatric cases present with metastases at diagnosis. Most metastases occur within the central nervous system by seeding via the cerebrospinal fluid (cranial or spinal), while spread to extracranial organs (e.g. bone marrow, liver, lungs) is very rare at diagnosis. In a minority of patients, MB is associated with Gorlin syndrome, familial adenomatous polyposis (FAP; the association of FAP and MB is referred to as the Turcot syndrome with polyposis) or with Li-Fraumeni Syndrome (see these terms). Increased susceptibility to certain tumors (neuroblastoma), hematological malignancies (acute lymphoblastic leukemia, acute myeloid leukemia) or disorders caused by mutations in genes encoding components of the RAS signaling pathway (Noonan syndrome or neurofibromatosis-Noonan syndrome) have been reported in MB (see these terms). Etiology and Molecular Genetics To date, the exact etiology of MB is still unknown but genomic data has identified multiple candidate genes that contribute to the pathogenesis of different subgroups of MB. This includes an inhibitor of the sonic hedgehog pathway SUFU (10q24.32), the RNA helicase DDX3X (Xp11.3-p11.23), chromatin regulators KDM6A (Xp11.2) and N-CoR complex genes BCOR (Xp11.4), and the Parkinson’s disease genes KMT2D (12q13.12), SMARCA4 (19p13.3), MYCN (2p24.3), and TP53 (17p13.1). Diagnostic Methods MB occurs in the vermis and 20% occurs in the hemispheres of the cerebellum. Histologically, MB is characterized by small, round cells that stain blue with haematoxylin spectrum and appearance ranges from tumors with extensive nodularity to those with large cell/anaplastic features. Apart from classical MB, four histological variants of MB are recognized: anaplastic MB, large cell MB, MB with extensive nodularity, and desmoplastic/nodular MB. Differential diagnosis Differential diagnosis includes other brain tumors (ependymoma, glial tumor, atypical teratoid rhabdoid tumor; see these terms) and other causes of cerebellar alterations (infectious or cystic lesions, hemorrhages). Management and treatment Initially, patients need to be checked for increased intracranial pressure. The best current treatment is gross total resection of the Tumor using Microsurgery assisted with Computer aided Image guided technology, Ultrasonic tumor removal systems, Lasers, Microinstruments with Neuromonitoring particularly of brainstem signals followed by good ICU care stated Dr Prem Pillay who specializes in brain tumors including Medulloblastomas. The postoperative treatment depends on age, histological variant, and result of staging assessments. In children older than 3-5 years, craniospinal irradiation including Stereotactic Radiotherapy with MicroMLC technology can be applied. In younger children, brain sparing therapies avoiding irradiation can be administered in very specific constellations. Latest Advances Advances in Diagnosis : Molecular Subgrouping One of the most significant advances in medulloblastoma diagnosis has been the identification and characterization of molecular subgroups. Medulloblastomas are now classified into four main subgroups based on their molecular profiles: WNT SHH (Sonic Hedgehog) Group 3 Group 4 This classification has important implications for prognosis and treatment planning. For example, WNT tumors generally have the best prognosis, while Group 3 tumors tend to have the worst outcomes.Improved Imaging Techniques Improved Imaging Techniques Researchers are developing new imaging methods to diagnose and monitor medulloblastomas more accurately. A recent study demonstrated that combining MRI scanning with machine learning could potentially identify medulloblastoma subtypes without the need for invasive biopsies. This approach could significantly reduce diagnostic wait times from 3-4 weeks to just 10 minutes.Liquid Biopsies Liquid Biopsies Ongoing research is exploring the use of liquid biopsies (analyzing tumor DNA in cerebrospinal fluid, or blood ) to diagnose and monitor medulloblastomas non-invasively. This technique could provide real-time information about tumor genetics and treatment response. Advances in Treatment : Risk Adapted Therapy Treatment protocols are increasingly tailored based on both clinical risk factors and molecular subgroup. This approach allows for de-escalation of therapy in lower-risk patients to reduce long-term side effects, while maintaining or intensifying treatment for high-risk groups. Reduced Radiation Therapy For standard-risk patients, reducing craniospinal irradiation (CSI) from 36 Gy to 23.4 Gy, combined with oral and iv anti tumor agents , has shown similar survival outcomes with potentially fewer cognitive side effects. However, further reduction to 18 Gy resulted in poorer outcomes, particularly for Group 4 tumors. Proton Beam Therapy The use of proton beam therapy for CSI and tumor bed boost is becoming more common. This technique can deliver precise radiation doses while sparing surrounding healthy tissue, potentially reducing long-term side effects. Novel Chemotherapy Approaches Recent studies have explored new chemotherapy regimens and timing: The addition of a radiosensitizer showed improved outcomes for Group 3 patients in a post-hoc analysis of the ACNS0332 study Neoadjuvant anti tumor agents before surgery is being investigated to potentially improve surgical outcomes and neuropsychological function Immunotherapy Several immunotherapy approaches are being studied for medulloblastoma: Adoptive T-cell therapy combined with PD-1 inhibitors is being tested in a clinical trial for relapsed Group 4 medulloblastoma An mRNA cancer vaccine is being developed to reprogram the immune system to attack medulloblastoma cells Targeted Therapies Researchers are identifying new molecular targets for medulloblastoma treatment: An anti tumor agent originally developed for pancreatic cancer has shown promise in preclinical models of Group 3 medulloblastoma Targeting specific regions of the EP300/CBP proteins, particularly the bromodomain, has demonstrated anti-tumor activity in Group 3 medulloblastoma cells Infant Treatment Protocols For infants (typically defined as under 4 years old), treatment approaches aim to delay or avoid radiation therapy due to its severe cognitive effects. Current strategies include: High-dose anti tumor agents with stem cell rescue Intrathecal and intravenous anti tumor agents Combinations of these approaches Future Directions Further refinement of molecular subgrouping and identification of targetable mutations within subgroups. Development of more effective and less toxic targeted therapies. Optimization of immunotherapy approaches for medulloblastoma. Improvement of treatment strategies for infants and young children to minimize long-term cognitive effects. Integration of liquid biopsy techniques for real-time monitoring of treatment response and tumor evolution. These advances in diagnosis and treatment offer hope for improved outcomes and quality of life for patients with medulloblastoma and other PNETs. However, continued research is needed to address the challenges posed by these aggressive pediatric brain tumors. *The Hospital for Sick Children Toronto, Canada is one of the leading Pediatric and Childrens Cancer Centers in the world including for the treatment of Pediatric Brain Tumors. MD Anderson is one of the leading Cancer Centers in the USA and Globally. Conclusion Medulloblastoma and PNET are challenging tumours that require prompt and expert care. Early diagnosis and a multidisciplinary treatment approach are essential for improving outcomes and quality of life. If you or a loved one experiences persistent neurological symptoms seek immediate evaluation. Visit the Singapore Brain Spine Nerves Center for specialised care and support.

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 Primary Central Nervous System (CNS) Lymphoma ? Primary Central Nervous System (CNS) Lymphoma is a malignant, or high-grade brain tumor of B cell origin. A CNS Lymphoma can occur in both immuno-competent patients as well as patients with immunodeficiency (eg. HIV positive). Who Gets Affected? Age/Sex:  The mean age is about 50 years except for HIV+ve or immuno-deficient patients who are mostly in the late 20s. What Brings Them to the Clinic? Presentation:  Headaches, seizures, blurred vision, cranial neuropathy and focal neurological symptoms (hemiparesis, aphasia etc). How is It Diagnosed? Diagnosis: MRI is the diagnostic modality of choice. The tumor shows intense contrast enhancement with gadolinium. The lesions are usually cerebral and single in about 2/3rds of patients. HIV+ve patients usually have multiple lesions. The use of steroids prior to imaging may cause the lesion to temporarily disappear, hindering diagnosis. Stereotactic Biopsy or Image-guided craniotomy and biopsy is usually needed for histopathological diagnosis. The therapeutic role of aggressive surgical resection is limited. What Are the Treatment Options? Treatment:  Image-guided /Computer-aided Craniotomy and aggressive tumor resection is rarely done as it can make patients worse and does not have a major impact on survival. The exception is for large tumors with mass effect and impending herniation. Radiation has an important role as primary CNS lymphoma is very radiosensitive. Stereotactic radiation and NeuroTomotherapy are more advanced forms of radiation. Chemotherapy especially intrathecal chemotherapy through an Ommaya reservoir is a mainstay of treatment. MTX (methothrexate) is the agent of choices. Conclusion Primary CNS lymphoma is a rare yet aggressive condition requiring timely diagnosis and specialised treatment. If you or a loved one experiences persistent neurological symptoms, it is crucial to seek medical attention immediately. At Singapore Brain Spine Nerves Center, our experienced team is dedicated to providing comprehensive and personalised care for patients with primary CNS lymphoma. Contact us today for expert consultation and compassionate support.

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) Craniopharyngiomas are benign brain tumors (not a cancer). They can affect children and adults. Craniopharyngiomas usually grow near the base of the brain, just above the pituitary gland. The pituitary gland makes hormones that control important body functions. Craniopharyngiomas do not usually spread. Because they grow close to the pituitary gland, they can cause changes in the way that it works. Symptoms of craniopharyngiomas include: changes in hormone levels. In adults this might cause difficulty getting an erection and irregular periods. It can also cause growth problems in children and diabetes loss of eyesight headaches a build up of pressure in and around the brain, which can cause feeling or being sick Symptoms can develop suddenly, which means that you feel unwell quickly or they can develop more slowly. How common it is Craniopharyngiomas are not common tumors. In children, between 6 and 13 out of every 100 brain tumors (6 to 13%) are craniopharyngiomas. And in adults, between 1 and 3 out of every 100 brain tumors (1 to 3%) are craniopharyngiomas. What tests will I have? To find out what is causing your symptoms our Neurosurgeon will arrange for you to have some tests. The tests you might have include: blood tests to look at the levels of hormones MRI brain scan or CT brain scan eye examinations including Fundal examination of the optic nerve a biopsy As well as finding out whether you have a tumor, the tests check the size of the tumor and its location. Treatment According to Dr Prem Pillay a Singapore Neurosurgeon, (trained at the Cleveland Clinic -USA,MD Anderson Cancer Center-USA and the Hospital for Sick Children, Toronto) an expert on Craniopharyngiomas, microsurgery either through a craniotomy or through Endoscopic surgery through the nose to attempt complete tumor removal is usually recommended. In patients where the tumor cannot be completely removed safely or where patients decline surgery Radiotherapy especially more advanced methods like Stereotactic Radiotherapy using Micro MLC technology or Radiosurgery can be used. Proton Therapy is another advanced technology that can be used. Hormone replacement therapy may be needed if there are changes in the levels of hormones. Surgery Specifics A brain specialist surgeon (neurosurgeon) removes all the tumor or just a part depending on where the tumor is. Some tumors are close to important parts of the brain such as the optic nerve and the hypothalamus. These tumors cannot usually be completely removed. The side effects you might have after the operation include: changes in the hormone levels high blood sugar levels (diabetes) changes in vision weight gain behaviour changes Radiotherapy If there is residual tumor you may have Stereotactic radiotherapy after surgery. This is to try to stop the tumor from coming back. You might also have radiotherapy if the tumor comes back. For small tumors, you might have stereotactic radiotherapy or radiosurgery. Both treatments target high doses of radiotherapy to the tumor. Some people may also have a type of radiotherapy called proton beam therapy. It uses high energy or low energy proton beams to the tumor. Hormone replacement Many people with a craniopharyngioma have changes in their hormone levels. This is due to either the tumor itself or as a side effect of treatment. You might need to take hormone replacement therapy to help with this. The type of hormone you take depends on your individual needs. Follow up You have regular appointments with your doctor after treatment finishes. Your doctor examines you at each appointment. They ask how you are feeling, whether you have had any symptoms or side effects and if you are worried about anything. You might also have MRI scans on some visits. How often you have check ups depends on your individual situation. Most people have a check up every 6 to 12 months, for up to 5 years. Coping with craniopharyngioma Coping with a diagnosis of a brain tumor can be difficult, both practically and emotionally. It can be especially difficult when you have a uncommon tumor. Being well informed about the type of tumor you have, and its treatment can make it easier to cope. Craniopharyngiomas are rare malformational tumours of low histological malignancy arising along the craniopharyngeal duct. The two histological subtypes, adamantinomatous craniopharyngioma (ACP) and papillary craniopharyngioma (PCP), differ in genesis and age distribution. ACPs are diagnosed with a bimodal peak of incidence (5–15 years and 45–60 years), whereas PCPs are restricted to adults mainly in the fifth and sixth decades of life. ACPs are driven by somatic mutations in CTNNB1 (encoding β-catenin) that affect β-catenin stability and are predominantly cystic in appearance. PCPs frequently harbour somatic BRAFV600E mutations and are typically solid tumours. Clinical manifestations due to increased intracranial pressure, visual impairment and endocrine deficiencies should prompt imaging investigations, preferentially MRI. Treatment comprises neurosurgery and radiotherapy; intracystic chemotherapy is used in monocystic ACP. Although long-term survival is high, quality of life and neuropsychological function are frequently impaired due to the close anatomical proximity to the optic chiasm, hypothalamus and pituitary gland. Indeed, hypothalamic involvement and treatment-related hypothalamic lesions frequently result in hypothalamic obesity, physical fatigue and psychosocial deficits. Given the rarity of these tumours, efforts to optimize infrastructure and international collaboration should be research priorities. Dr Prem Pillay a Neurosurgeon who specializes in the treatment of these brain tumors agrees and notes that advances in Neurosurgery and Neurosciences including Molecular biology and Genetics will help achieve better results for those with this disease. Conclusion Craniopharyngiomas, though benign, can have profound effects on health due to their location and potential to disrupt critical brain functions. Early diagnosis and a multidisciplinary approach to treatment are key to optimising outcomes. If you or your loved one is experiencing symptoms suggestive of a brain tumour, seek medical advice promptly. Visit the Singapore Brain Spine Nerves Center for expert care tailored to your needs and a comprehensive treatment plan designed for your journey to recovery. References Singapore Brain Spine Nerves Center Protocols and information Cancer UK information

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 a Glioblastomas Multiforme (GBM)? By definition, a glioblastoma multiforme (GBM) tumor is considered a grade IV tumor. This high-grade astrocytoma group is represented by the glioblastoma multiforme and variants. the gliosarcoma and giant cell glioblastoma. A malignant astrocytoma that contains areas of dead tumor cells (necrosis) is called a glioblastoma multiforme. GBM represents about 30 percent of all primary brain tumors and about-50 percent of the astrocytomas. It is more common in older adults and it affects more men than women. Nine percent of childhood brain tumors are glioblastomas. How does it affect a person and how is it Diagnosed? Because of its aggressive nature and fast growing ability, the first symptoms are usually due to increased pressure in the brain. Headaches, seizures, memory loss, limb weakness, speech difficulties and behavioral changes are among the most common presenting symptoms. The first procedure for most GBMs is either Craniotomy (awake or asleep) with image guided microsurgery to remove the tumor and obtain tumor for analysis including molecular genetic profiling, or a Stereotactic or Neuroendoscopic biopsy for just diagnosis. Robotic assistance and Computer guided Image guidance may be used to improve accuracy and safety. What are the Latest Diagnostic Methods for GBMs? New methods for diagnosing GBMs include Molecular Genetic tests based on fluid from the Brain called CSF (Cerebrospinal Fluid) or from the Blood and this is called Liquid Biopsy. These tests may also be particularly useful for following up the results of treatments such as surgery,advanced radiation including Radiosurgery (Linac, Gamma Knife,Proton), and Targeted Molecules. They are also useful in finding actionable targets unique to the GBM and choosing appropriate molecular treatments that can cause tumor cell death or apoptosis. What are the Latest Treatments for GBMs? Surgery alone is usually not enough to control the GBM because of its aggressive nature whereby its cells quickly infiltrate throughout the brain. Advances in Surgery include Immunoflorescense microscopy to visualize malignant brain tumor cell clusters and lasers/Ultrasonics for maximizing tumor resection (complete and supra-maximal). Thus, radiation therapy including advanced Radiosurgery (LINAC-Photons, Gamma Knife, Proton/Carbon Therapy) almost always follows surgery or biopsy to attempt to control the spread of the cells. Targeted Molecular Therapies are also used to treat this tumor. Latest Treatments : Targeted Therapies for GBM and Gliomas Targeted therapies for glioblastoma multiforme (GBM) and gliomas are based on molecular genetic analysis of the tumors, aiming to inhibit specific pathways and proteins that are critical for tumor growth and survival. These therapies are designed to minimize off-target toxicities in normal cells, contrasting with conventional cytotoxic chemotherapy. Key Molecular Targets Epidermal Growth Factor Receptor (EGFR) EGFR Amplification EGFR is amplified in many GBMs, particularly in the classical subtype. Targeting EGFR with inhibitors has shown potential and improved survival but the effectiveness can be limited due to tumor heterogeneity and resistance mechanisms. Vascular Endothelial Growth Factor (VEGF ) VEGF Inhibitors Is a notable example of a clinically approved targeted therapy for progressive recurrent GBM. It works by inhibiting angiogenesis, which is crucial for tumor growth. p53 Pathway p53 Restoration Efforts have been made to restore the function of p53, a tumor suppressor, by inhibiting negative regulatory proteins such as MDM2 and MDM4. This approach aims to neutralize defective MDM2 and MDM4 produced by amplification in GBM patients. Neurotrophic Tyrosine Receptor Kinases (NTRK): NTRK Fusion NTRK gene fusions, though rare in glioblastoma, have shown significant response to targeted therapies which have been effective in treating infantile GBM and other NTRK fusion-positive tumors. IDH Mutations IDH Inhibitors For IDH1/2-mutant gliomas, targeted therapies  have been  to stop the growth of tumor cells by blocking specific enzymes needed for cell growth. FGFR-TACC Fusions FGFR Inhibitors have demonstrated antitumor activity in recurrent GBM with FGFR-TACC gene fusions. These drugs are being studied in ongoing clinical trials. Challenges and Future Directions Tumor Heterogeneity The heterogeneity of glioblastoma poses a significant challenge in achieving consistent success with targeted therapeutic strategies. Tumors often develop resistance mechanisms, limiting the effectiveness of targeted therapies. Personalized Medicine The use of molecular profiling to determine individualized treatment plans is becoming increasingly important. This approach involves analyzing the tumor’s genetic makeup to identify specific targets for therapy. Combination Therapies Combining targeted therapies with other treatments, such as chemotherapy and immunotherapy, may offer improved clinical outcomes. This approach aims to overcome the limitations of single-agent therapies. Tumor Treatment Fields (TTF) This is new and non-invasive technique where an external device is used to create alternating electric Fields that pulse through the scalp and disrupt the GBM tumor cells so they stop dividing and/or cause cell death. In summary, targeted therapies for GBM and gliomas are evolving rapidly, with ongoing research focusing on identifying and inhibiting specific molecular pathways that drive tumor growth and survival. Despite challenges, these therapies hold promise for improving treatment outcomes for patients with these aggressive brain cancers. Dr Prem Pillay remains optimistic that the intense research into these tumors will allow improved survival outcomes. Conclusion Glioblastoma Multiforme is a highly aggressive brain tumour requiring prompt and expert medical attention. If you or your loved one is experiencing concerning neurological symptoms, early evaluation and intervention can make a critical difference. Visit Singapore Brain Spine Nerves Center for compassionate, evidence-based care tailored to your journey with GBM. References Protocols of the Singapore Brain Spine Nerves Center Tumor Treating Fields Therapy for Glioblastoma. O Rominyi et al. Brit J of Cancer 124-697, 2021 Proton Therapy for Glioblastoma MD Anderson Cancer Center https://www.mdanderson.org/publications/cancer-newsline/proton-therapy-for-glioblastoma.h35-1589046.html

An ependymoma is a primary central nervous system (CNS) tumor. This means it begins in the brain or spinal cord. What are the grades of ependymomas? Ependymomas are grouped in three grades based on their characteristics. Within each grade, are different ependymoma subtypes. Molecular testing is used to help identify subtypes that are related to location and disease characteristics. The Image on the right shows the MRI of an ependymoma in the spine. Credit: NCI-CONNECT Staff Grade I ependymomas are low grade tumors. This means the tumor cells grow slowly. The subtypes include subependymoma and myxopapillary ependymoma. Both are more common in adults than in children. Myxopapillary tumors usually occur in the spine. Grade II ependymomas are low grade tumors and can occur in either the brain or the spine. Grade III ependymomas are malignant (cancerous). This means they are fast-growing tumors. The subtypes include anaplastic ependymomas. These most often occur in the brain, but can also occur in the spine. Who is diagnosed with ependymomas? Ependymomas occur in both children and adults. Ependymomas in the lower half of the brain are more common among children. Ependymomas in the spine are more common among adults. Ependymomas occur more often in males than females. They are most common in white and non-hispanic people. What causes ependymomas? The cause of ependymomas is not known. Where do ependymomas form? Ependymomas can form anywhere in the CNS. Ependymomas often occur near the ventricles in the brain and the central canal of the spinal cord. On rare occasions, ependymomas can form outside the CNS, such as in the ovaries. Ependymomas develop from ependymal cells (called radial glial cells). Ependymal cells are one of three types of glial cells that support the CNS. Do ependymomas spread? Ependymomas rarely spread outside the CNS. But ependymomas can spread to other areas of the CNS through cerebrospinal fluid (CSF). What are symptoms of an ependymoma? Symptoms related to an ependymoma depend on the tumor’s location. People with an ependymoma in the brain may have headaches, nausea, vomiting and dizziness. People with an ependymoma in the spine may have back pain, numbness and weakness in their arms, legs or trunk, problems with sexual, and urinary or bowel problems. What are treatment options for ependymomas? The first treatment for an ependymoma is surgery, if possible. The goal of surgery is to obtain tissue to determine the tumor type and to remove as much tumor as possible without causing more symptoms for the person. Microsurgery is usually used with fine microinstruments and using Computer Aided Image Guided Neuronavigation for accuracy and precision in tumor removal explains Dr Prem Pillay a US, Canadian trained Singapore Neurosurgeon (Cleveland Clinic-USA, MD Anderson Cancer Center USA, Hospital for Sick Children,Toronto). After surgery, if there is residual or recurrent tumor there are other treatments for ependymomas. These treatments may include radiation including Stereotactic Radiotherapy or Radiosurgery, Medical therapy or clinical trials explains Dr Prem Pillay. Proton therapy is also another possible option. Clinical trials, with new medical therapy, targeted therapy, or immunotherapy, may also be available and can be a possible treatment option. Treatments are decided by the patient’s healthcare team based on the patient’s age, remaining tumor after surgery, tumor type, and tumor location. Conclusion Ependymomas, though rare, require prompt diagnosis and expert care to manage effectively. With advances in surgical techniques and radiotherapy, many patients achieve good outcomes. If you or your loved one are experiencing symptoms suggestive of a brain or spinal cord tumour, early evaluation is crucial. Visit the Singapore Brain Spine Nerves Center for comprehensive care tailored to your needs. Our specialists are here to support you at every step of your journey.

A quick guide to common neurological conditions and what they mean. The brain and nerves play a vital role in controlling movement, memory, and daily functions. When changes occur, it can be concerning. Symptoms such as persistent headaches, numbness, or difficulty with speech may indicate an underlying neurological condition. Understanding these conditions can help in recognising early signs and seeking appropriate medical advice. At Singapore Brain Spine and Nerves Centre , we provide information on various neurological conditions, from common disorders to more complex medical conditions. This blog aims to offer insights into symptoms, causes, and management options available. A:  Acoustic Neuromas - A benign tumor in the nerve that connects the ear to the brain Acromegaly - A disorder marked by progressive enlargement of the head, face, hands, feet and thorax, due to the excessive secretion of growth hormone. Agnosia - Absence of the ability to recognize the form and nature of persons and things. Amnesia - Loss of memory caused by brain damage or by severe emotional trauma Anencephaly - Absence of the greater part of the brain, skull and scalp. Aphasia - Difficulty with or loss of the use of language; failure to understand the written, printed or spoken word not related to intelligence, but to specific lesions in the brain. Aneurysm - Dilation of an artery, formed by a circumscribed enlargement of its wall. Apoplexy - A condition in which there is bleeding into an organ or blood flow to an organ has ceased. Arteriovenous Malformation - Tangle of abnormal and poorly formed blood vessels (arteries and veins) with an innate propensity to bleed. Astrocytoma - Tumor within the brain or spinal cord made up of astrocytes; ranges from slow-growing to rapid-growing Ataxia - A loss of voluntary muscle coordination. B: Bell’s Palsy - Paralysis of facial muscles (usually one side) due to a facial nerve damage or dysfunction. Brown-Sequard’s Syndrome - Loss of sensation and function on one side of the body; often caused by a spinal cord tumor or trauma to the spinal cord. C: Carcinoma -  A malignant growth of epithelial or gland cells; a synonymous term for cancer. Chorea- A disorder, typically occurring in childhood, characterised by irregular, spasmodic involuntary movements of the limbs or facial muscles. Craniopharyngioma -A benign tumoUr arising from the embryonic duct in the pituitary gland Craniosynostosis- Premature closure of cranial sutures, limiting or distorting the growth of the skull. D:  Dystonia Musculorum Deformans- An affliction marked by muscular contractions producing distortions of the spine and hips. E: Epilepsy-  Disorder characterized by repeated seizures caused by abnormal electrical discharges in the brain. G:  Glioblastoma - A rapidly growing tumor composed of primitive glial cells, mainly arising from astrocytes. Glioma - A tumor formed by glial cells. H: Hemangioma - An accumulation of multiple, dilated blood vessels in the skin. Hemianopia - Loss of vision of one-half of the visual field as a result of a stroke or brain injury; also known as hemianopsia. Hemiplegia -  Paralysis of one side of the body. Hydrocephalus -  A condition, often congenital, marked by abnormal and excessive accumulation of cerebrospinal fluid in the cerebral ventricles; results in dilated ventricles. In infants and young children, this condition often causes the head to enlarge.  L : Leukodystrophy -  Disturbance of the white matter of the brain; white matter is a component of the central nervous system and helps transmits signals through the regions of the brain. M :   Medulloblastoma - Malignant brain tumor composed of medulloblasts, which are cells that develop in the fourth ventricle of the brain.  Meningioma - A firm, often vascular, tumor arising from the coverings of the brain; the most common primary brain tumor. Meningitis - An infection or inflammation of the membranes covering the brain and spinal cord MyopathyAny disease of muscle. N: Neuroblastoma - Malignant tumour arising from nerve tissue; commonly found in infants and children. Neuroma - A tumour or new growth largely made up of nerve fibers and connective tissue. Neuropathy- Any functional or pathologic disturbance in the peripheral nervous system. O: Oligodendroglioma- A growth of new cells derived from the oligodendroglia. P: Paraplegia-  Paralysis of the lower part of the body, including the legs. Q: Quadriplegia - Paralysis of all four limbs; also known as tetraplegia S: Spina Bifida - A congenital defect of the spine marked by the absence of a portion of the spine. Syringomyelia- A condition in which a fluid-filled cavity or cyst forms in the spinal cord. T: Trigeminal Neuralgia- Disorder that causes trigeminal nerve pain in the face; also known as tic douloureux.   The nervous system affects every part of the body. Neurological conditions may impact movement, sensation, and cognitive function. Some conditions, such as Bell’s palsy and epilepsy , affect specific nerves, while others, including aneurysms and glioblastomas , involve changes in brain structure. Recognising symptoms early may assist in determining the next steps for care. If you or a loved one experience unexplained neurological symptoms, seeking medical evaluation can provide clarity. At Singapore Brain Spine and Nerves Centre , we are committed to providing professional medical care and support. If you have concerns, consult a healthcare professional to understand more about your neurological health.

What are EMG and NCS (Electromyogram and Nerve Conduction Studies)? Electromyograms (EMG) and Nerve Conduction Studies (NCS) are diagnostic tests used to assess the health and function of muscles and the nerves that control them. These tests help identify conditions that affect the peripheral nervous system, which includes the nerves outside the brain and spinal cord. EMG and NCS are often performed together to provide a comprehensive evaluation of neuromuscular disorders, helping to pinpoint the cause of symptoms such as pain, weakness, or numbness. Types of Tests: EMG and NCS EMG and NCS each serve a distinct purpose, complementing one another to provide a thorough assessment of nerve and muscle function. Electromyogram (EMG): This test evaluates the electrical activity of muscles at rest and during contraction. A small needle electrode is inserted into the muscle to measure electrical signals generated by muscle fibres. Abnormal activity may indicate muscle damage or nerve disorders affecting muscle function. Nerve Conduction Studies (NCS): NCS measures how well and how quickly electrical signals travel along a nerve. Small electrodes are placed on the skin over the nerve and muscles being tested, and a mild electrical stimulus is applied. Delayed or weakened signals can indicate nerve damage or dysfunction. Benefits of EMG and NCS EMG and NCS offer several advantages as diagnostic tools, including: Accurate Diagnosis:  These tests provide precise information about the location and severity of nerve or muscle dysfunction. Early Detection:  Conditions affecting the peripheral nervous system can be detected early, allowing timely treatment. Non-Invasive Option (NCS):  NCS is entirely non-invasive, with no needles involved. Guidance for Treatment:  Results from EMG and NCS help guide treatment decisions, including therapy, medication, or surgery. Symptoms and Conditions Assessed with EMG and NCS EMG and NCS are used to diagnose a range of conditions that affect nerves and muscles. These include: Nerve Compression or Injury:  Conditions such as carpal tunnel syndrome, sciatica, or nerve entrapment syndromes. Peripheral Neuropathy:  Nerve damage caused by diabetes, autoimmune diseases, or infections. Muscle Disorders:  Such as muscular dystrophy, myositis, or other conditions causing muscle weakness or wasting. Radiculopathy:  Nerve root compression in the spine, often due to herniated discs. Motor Neuron Diseases:  Including amyotrophic lateral sclerosis (ALS). Unexplained Symptoms:  Such as chronic pain, numbness, tingling, or muscle spasms. Diagnosis and Testing Process Diagnosis: A thorough clinical evaluation and history are essential before proceeding with EMG and NCS. The diagnostic process typically includes: Medical History and Physical Examination:  To evaluate symptoms, reflexes, and muscle strength. Discussion of Symptoms:  Including their onset, duration, and severity. Preliminary Testing:  Imaging studies, such as X-rays or MRI, may sometimes precede EMG and NCS to identify structural causes of symptoms. Testing Process: Nerve Conduction Studies (NCS): Electrodes are placed on the skin to stimulate the nerves and record their response. The test is painless apart from a mild tingling sensation during the electrical stimulus. Electromyogram (EMG): A fine needle electrode is inserted into specific muscles to assess their electrical activity. This may cause mild discomfort, but the procedure is generally well tolerated. Duration and Recovery: Both tests typically take 30 to 60 minutes, depending on the areas being evaluated. Normal activities can be resumed immediately after the procedure. Conclusion EMG and NCS are valuable diagnostic tools for identifying and managing neuromuscular disorders. By providing detailed insights into nerve and muscle function, these tests enable healthcare professionals to determine the underlying cause of symptoms and develop effective treatment plans. If you are experiencing persistent pain, weakness, or numbness, consult with our specialists to see if EMG and NCS testing are appropriate for you.

What is Spine and Peripheral Nerve Surgery? Spine and peripheral nerve surgery encompasses a range of specialised surgical techniques designed to treat conditions affecting the spine and the network of peripheral nerves that extend throughout the body. These surgeries aim to relieve pain, restore function, and improve quality of life by addressing issues such as nerve compression, spinal instability, or tumours. Depending on the condition, these procedures may involve minimally invasive techniques or more extensive surgical interventions. Types of Spine and Peripheral Nerve Surgery Spine and peripheral nerve surgeries are tailored to treat specific conditions and address unique patient needs. Common types include: Spine Surgery Discectomy and Microdiscectomy:  Removal of part or all of a herniated disc to relieve pressure on a nerve and alleviate pain. Spinal Fusion:  Stabilises the spine by fusing two or more vertebrae together, often performed for degenerative disc disease or spinal instability. Laminectomy:  Removes part of the vertebra (lamina) to relieve pressure on the spinal cord or nerves, commonly used for spinal stenosis. Disc Replacement Surgery:  Replaces damaged spinal discs with artificial ones to preserve motion and reduce pain. Peripheral Nerve Surgery Nerve Decompression:  Frees compressed nerves, such as in carpal tunnel syndrome, to restore normal function and relieve symptoms. Nerve Repair or Grafting:  Treats nerve damage or severed nerves by suturing or grafting healthy nerve tissue to restore function. Neurolysis:  Removes scar tissue around a nerve to reduce irritation and restore proper nerve function. Tumour Resection:  Surgical removal of benign or malignant growths affecting peripheral nerves or the spine. Benefits of Spine and Peripheral Nerve Surgery Spine and peripheral nerve surgeries offer several advantages for individuals suffering from chronic pain or neurological deficits. Benefits include: Relief from Chronic Pain:  Reduces or eliminates pain caused by nerve compression, herniated discs, or spinal instability. Improved Mobility and Function:  Restores movement and strength by addressing the underlying causes of symptoms. Preventing Further Damage:  Timely intervention can prevent the worsening of nerve damage or spinal conditions. Minimally Invasive Options:  For many conditions, smaller incisions and advanced techniques reduce recovery time and minimise risks. Enhanced Quality of Life:  Alleviating pain and restoring function enables patients to resume daily activities with greater ease and comfort. Symptoms and Conditions Treated with Spine and Peripheral Nerve Surgery These surgical approaches are used to treat a wide range of conditions, including: Herniated or Bulging Discs:  Causing nerve compression and radiating pain, often in the lower back or neck. Spinal Stenosis:  Narrowing of the spinal canal, leading to nerve compression and symptoms such as sciatica or leg weakness. Spondylolisthesis:  A condition where one vertebra slips forward over another, causing instability and nerve irritation. Peripheral Nerve Injuries:  Trauma or compression affecting nerves, leading to pain, numbness, or weakness. Nerve Entrapment Syndromes:  Conditions such as carpal tunnel syndrome or cubital tunnel syndrome caused by nerve compression. Spinal or Nerve Tumours:  Growths affecting the spinal cord, vertebrae, or peripheral nerves. Diagnosis and Treatment Process Diagnosis: Accurate diagnosis is essential to determine the need for surgery and the most appropriate treatment plan. Steps include: Medical History and Physical Examination:  To assess symptoms, muscle strength, reflexes, and nerve function. Imaging Studies:  MRI, CT, or X-rays to identify structural abnormalities, nerve compression, or tumours. Nerve Conduction Studies and Electromyography (EMG):  Evaluate the function of peripheral nerves and muscles to pinpoint areas of damage. Treatment: The treatment process for spine and peripheral nerve surgery typically involves: Preoperative Planning:  Detailed imaging and analysis to create a customised surgical plan tailored to the patient’s condition and anatomy. Surgical Procedure:  Depending on the condition, the procedure may involve minimally invasive techniques, nerve decompression, or tumour removal. Postoperative Care:  Includes physical therapy and rehabilitation to help patients regain strength, mobility, and function. Follow-up appointments are crucial for monitoring recovery and addressing any concerns. Conclusion Spine and peripheral nerve surgery plays a vital role in restoring function, relieving pain, and improving the lives of patients with spinal or nerve-related conditions. Whether addressing herniated discs, nerve injuries, or tumours, these procedures offer effective solutions for a range of complex issues. If you are experiencing chronic pain or neurological symptoms, schedule a consultation with us today to explore your treatment options.

What is Neurovascular Surgery? Neurovascular surgery is a specialised field of medicine focused on diagnosing and treating conditions affecting the blood vessels in the brain and spinal cord. These procedures address problems such as aneurysms, strokes, arteriovenous malformations (AVMs), and other vascular abnormalities that can have life-threatening or debilitating consequences. By using advanced techniques and tools, neurovascular surgery aims to restore normal blood flow, prevent complications, and improve patients' quality of life. Types of Neurovascular Surgery Neurovascular surgery encompasses a range of procedures tailored to the specific condition and needs of the patient. Common types include: Aneurysm Clipping: A surgical procedure where a tiny metal clip is placed at the base of a brain aneurysm to prevent it from rupturing or bleeding further. Endovascular Coiling: A minimally invasive procedure that uses a catheter to insert tiny coils into an aneurysm, promoting clotting and preventing blood flow into the weakened area. Arteriovenous Malformation (AVM) Resection: Surgical removal of abnormal tangles of blood vessels to prevent haemorrhage and alleviate pressure on the surrounding brain tissue. Carotid Endarterectomy: A procedure to remove plaque build-up in the carotid arteries, reducing the risk of stroke by restoring blood flow to the brain. Stent-Assisted Treatments: Stents may be used to treat narrowed arteries or support other interventions such as coiling in complex aneurysm cases. Cerebral Bypass Surgery: Involves creating a detour for blood flow around a blocked or damaged artery, restoring adequate blood supply to the brain. Benefits of Neurovascular Surgery Neurovascular surgery offers significant benefits for patients with complex vascular conditions, including: Improved Outcomes:  These procedures can prevent life-threatening complications such as strokes or aneurysm rupture. Symptom Relief:  Many neurovascular surgeries alleviate symptoms such as headaches, weakness, or seizures caused by vascular abnormalities. Minimally Invasive Options:  Endovascular techniques involve smaller incisions and shorter recovery times compared to traditional open surgeries. Customised Approaches:  Treatment plans are tailored to the patient’s specific condition, ensuring optimal care and outcomes. Symptoms and Conditions Treated with Neurovascular Surgery Neurovascular surgery is used to manage a wide variety of conditions, including: Aneurysms:  Bulging or weakened areas in blood vessel walls that can rupture and cause bleeding in the brain. Strokes:  Caused by blocked or burst blood vessels, leading to brain damage. Arteriovenous Malformations (AVMs):  Abnormal tangles of arteries and veins that disrupt normal blood flow. Carotid Artery Disease:  Narrowing of the carotid arteries that increases the risk of stroke. Cavernous Malformations:  Clusters of abnormal blood vessels in the brain or spinal cord, often causing seizures or neurological symptoms. Vascular Tumours:  Abnormal growths involving blood vessels in the brain or spinal cord. Diagnosis and Treatment Process Diagnosis: A thorough evaluation is essential to determine the appropriate neurovascular surgical approach. Diagnostic steps include: Medical History and Physical Examination:  To assess symptoms and identify any neurological deficits. Imaging Studies:  Tests such as CT scans, MRI, or cerebral angiography provide detailed images of the brain’s blood vessels, helping pinpoint abnormalities. Functional Assessments:  Neurological exams and cognitive tests may be performed to evaluate the impact of the vascular condition. Treatment : The neurovascular surgery process involves the following steps: Preoperative Planning:  Detailed imaging and discussions with a multidisciplinary team are used to develop an individualised treatment plan. Surgical Procedure:  Depending on the condition, open or minimally invasive techniques are employed to address the vascular abnormality. Postoperative Care:  Patients undergo monitoring and rehabilitation, which may include physical therapy, speech therapy, or occupational therapy to regain function and prevent complications. Conclusion Neurovascular surgery plays a crucial role in treating complex conditions of the brain and spinal cord, improving both survival and quality of life. With advanced techniques and a personalised approach, patients can benefit from safer, more effective treatments that address their unique needs. If you or a loved one are facing a neurovascular condition, schedule a consultation with us today to explore your treatment options.