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Increasing Cases of Head and Neck Pain There are more people suffering from both head and neck pains in our modern age. Dr Prem Pillay, a Spine and Pain specialist has noticed this increase in his practice over the last 10 years. He attributes it so several factors including workstyle and lifestyle changes. Dr Prem observes that our 21st century life is associated with the common use of computers for work and recreation. This includes laptops, desktops, ipads, tablets, smartphones and gameboys. The prolonged sitting and bad posture associated with the use of these devices is contributing to head and neck pain. Starring at a computer screen for hours can also strain the eyes and contribute to headaches states Dr Prem. Common and Less Common Causes of Headaches Common causes of headaches are migraine and tension headaches. Less common causes of headaches include strokes such as sudden bleeding in the brain from a ruptured aneurysm (a balloon like weakness in a brain artery) and brain tumours. Headaches can also start from neck problems. Muscle tension in the both the head and the neck can build up from working with computers and long meetings in the sitting position. Spine Issues and Related Pain Dr Prem has found that there are more people with spine problems including slipped discs who come to him with both headaches and neck pain. A slipped spine disc is the protrusion of a gel like substance between the bones of the spine. This disc is not a bone but a rubbery substance that allows the spine to bend and therefore allows human beings to be flexible and upright. Damage to the spine discs can occur gradually or suddenly. Sudden damage can occur from a car accident or a fall. Gradual damage can occur over time from bad posture, prolonged sitting, carrying heavy objects, impact sports such as road running, and loading sports such as weightlifting. Dr Prem Pillay has noticed that many patients have gradually injured their spines from both their work styles and their recreational activities. This causes the spine discs to come out and irritate the spine nerves. This in turn leads to muscle pulls and aches around the head, neck and low back. Pain in Older Adults In older people other contributing causes include osteoporosis which can cause spine fractures from a minor fall. A few have spine tumors or spine infections such as tuberculosis as the cause of neck and head pain. When to Seek Medical Attention Head and neck pain that continue to bother a person for more than a week should be seen and assessed by a doctor. If there is a sudden severe head and neck pain that is the worst in your life you should immediately seek emergency treatment states Dr Prem. This could be from a type of stroke or a serious brain infection called meningitis. It is a habit for some people to go for massage therapy for their head, neck and back pains that come and go. However if this therapy does not take away the problem after three visits or if it comes back again after three visits you should see a spine/nerve specialist states Dr Prem. A spine and nerve specialist can evaluate your problem and carry out an MRI of the head and spine to determine your problem. Modern Treatment Options Modern treatments for head and neck pain include medications, advanced physiotherapy, advanced spine injections and advanced microsurgery. Dr Prem notes that modern treatments can be effective and safe if carried out by an experienced medical specialist. He illustrates the case of a Mrs Tan who had both head and neck pain. These problems could be not solved by massage therapy or pain medications. A spine and nerve evaluation and MRIs of the head and neck revealed that the source of her problem was weak or injured spine discs. She had a spine injection treatment using a laser like technology as a day procedure with any cutting/surgery. She was able to go home within a few hours of this special spine injection and over the next few weeks had relief of her pain. Advanced physiotherapy was also done to strengthen her spine. Preventive Measures and Final Advice Workstyle and lifestyle adjustments including a proper ergonomic desk and chair and frequent breaks from the sitting position are also useful notes Dr Prem.Prevention of these problems in young people should be more widely taught in the schools, universities and work places states Dr Prem Pillay. Head and neck pains are common yet diverse conditions that can disrupt your daily life. Identifying the cause is key to determining the most effective treatment and finding relief. If you or a loved one are struggling with persistent or severe head and neck pains, schedule a consultation with us today. Let us help you regain comfort and quality of life.

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) Sweaty Palms Sweaty palms refers to excessive sweating of the palms and is also known by the medical term: Hyperhidrosis. People with sweaty palms may also have sweaty armpits and sweaty feet. Why Does Sweaty Palms Occur? Sweaty palms is not caused by any injury, or eating the wrong food or an infection caught from another person. It is caused by an over activity in a part of the nervous system which starts in childhood. The over activity occurs in part of the brain called the hypothalamus and is transmitted to the hands and the feet through a relay system called the sympathetic nervous system. Who Gets Sweaty Palms? Sweaty palms can occur in anyone. It is more common in certain ethnic groups including Chinese and Israelis. However, it can occur at any age. It usually starts in childhood often becoming more obvious in the teenage years. It can run in families with brothers and sisters sharing the problem. However the gene is not a strong one and the likelihood of an affected person’s children having the same problem is not high. How Is Sweaty Palms Medically Treated? Medical treatment for sweaty palms consists of agents to dry up the hand and which have to be topically applied.  Once such agent is called Drichlor or Aluminium Hydroxide.  It is not a cure and has to be used daily.  It can be effective for mild sweaty palms but is not so effective for severe sweaty palms. The hands may feel tight after use. Pills for sweaty palms tend to have side-effects including blurring of vision, dryness of the mouth and difficulty in passing urine.  Most doctors do not recommend them.  Iontophoresis is an electrical treatment for sweaty palms which can reduce sweating for a few days.  The treatment will have to be repeated.  It can be useful for students just before their examinations.  However it is not a cure for sweaty palms. Can Sweaty Palms Be Cured? Yes, sweaty palms can be cured by an operation called Minendoscopic Sympathectomy (MES). This operation interrupts the abnormal increased signals to the hands by precisely burning a nerve relay station called the T2 sympathetic ganglion. This operation is recommended for those who are genuinely troubled by sweaty palms at work and socially and who have not found medical treatment useful. MES is the latest method for the minimally invasive treatment of sweaty palms. Older operations include Video-Endoscopic Syrnpathectomy (VES) and open cervical and transaxillary sympathectomy. How Is The MES Operation Done? The operation is done under general anaesthesia. A tiny nick (about 3mm in diameter) is made in each armpit. It is through this nick that the mini-endoscope (similar to a telescope) is introduced. Through the endoscope the surgeon burns the T2 sympathetic ganglion. The surgery takes approximately 1 hour. At the end of the surgery a single stitch is used to close the nick in the armpit. How Long Do I Have To Stay In Hospital? Generally you come into hospital the night before surgery. The operation is done early the next morning and you can be discharged later that same evening once you have recovered from the general anaesthesia. The other option is to be admitted to Day Surgery in the late morning, have the MES in the afternoon and be discharged the same night. When Can I Return To Work After Surgery? You can return to work the next day after surgery if you want to. Your single stitch in each armpit will be removed about 1 week after surgery. How Much Pain And Discomfort Is There After Surgery? The incisions in your armpit are very small with this method. Pain and discomfort is therefore very much less than the older method. Also the very small nick in the armpit leaves an almost inconspicous scar. What Is The Success Rate For MES Surgery? The success rate is approximately 98% for MES surgery for sweaty palms.

Symptoms, Causes & Treatment Nerves are fragile and can be damaged by pressure, stretching, or cutting. Injury to a nerve can stop signals to and from the brain, causing muscles not to work properly, and a loss of feeling in the injured area. Anatomy Nerves are part of the “electrical wiring” system that carries messages between the brain and the rest of the body. Motor nerves carry messages between the brain and muscles to make the body move. Sensory nerves carry messages between the brain and different parts of the body to signal pain, pressure, and temperature . Nerve with bundles of individual nerve fibers and surrounding sheath. A ring of tissue covers the nerve, protecting it just like the insulation surrounding an electrical cable. Nerves are composed of many fibers, called axons. These axons are separated into bundles within the nerve. The bundles are surrounded by tissue layers, just like the outer tissue layer that surrounds the nerve. Cause of Nerve Injuries Pressure or stretching injuries can cause fibers within the nerve to break. This may interfere with the nerve’s ability to send or receive signals, without damaging the cover. When a nerve is cut, both the nerve and the insulation are severed. Sometimes, the fibers inside the nerve break while the insulation remains intact and healthy. If the insulation has not been cut, the end of the fiber farthest from the brain dies. The end that is closest to the brain does not die. After some time, it may begin to heal. New fibers may grow beneath the intact insulating tissue until it reaches a muscle or sensory receptor. If both the nerve and insulation have been severed and the nerve is not fixed, the growing nerve fibers may grow to form a painful nerve scar, or neuroma. Treatment Surgical Treatment Nerve repair with realignment of bundles. The insulation around both ends of the injured nerve is sewn together. The goal in fixing the nerve is to save the insulating cover so that new fibers can grow and the nerve can work again. If a wound is dirty or crushed, surgery may be delayed until the skin has healed. If there has been some loss, leaving a space between the ends of the nerve, it may be necessary to take a piece of nerve (nerve graft) from a donor part of the body to fix the injured nerve. This may cause permanent loss of feeling in the area where the donor nerve graft was taken. Once the insulating covering of the nerve is repaired, the nerve generally begins to heal three or four weeks after the injury. Nerves usually grow one inch every month, depending on the patient’s age and other factors. With an injury to a nerve in the arm above the fingertips, it may take up to a year before feeling returns to the fingertips. The feeling of pins and needles in the fingertips is common during the recovery process. While this can be uncomfortable, it usually passes and is a sign of recovery. Therapy Several things can be done to keep up muscle activity and feeling while waiting for the nerve to heal. Physical therapy will keep joints flexible. If the joints become stiff, they will not work, even after muscles begin to work again. If a sensory nerve has been injured, care must be taken not to burn or cut fingers because there is no feeling in the affected area. With a nerve injury, the brain may need to be “re-educated.” After the nerve has recovered, sensory re-education may be needed to improve feeling to the hand or finger. This involves physician therapy and the appropriate therapy based on the nature of the injury will be recommended by the physician. Factors that may affect results after nerve repair include age, the type of wound and nerve, and location of the injury. Although nerve injuries may create lasting problems for the patient, care by a physician and proper therapy help two out of three patients return to more normal use.

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) Symptoms, Causes & Treatment Ulnar nerve entrapment occurs when the ulnar nerve in the arm becomes compressed or irritated. The ulnar nerve is one of the three main nerves in your arm. It travels from your neck down into your hand, and can be constricted in several places along the way. Depending upon where it occurs, this pressure on the nerve can cause numbness or pain in your elbow, hand, wrist, or fingers. Sometimes the ulnar nerve gets compressed at the wrist, beneath the collarbone, or as it comes out of the spinal cord in the neck. The most common place where the nerve gets compressed is behind the elbow. When the nerve compression occurs at the elbow, it is called “cubital tunnel syndrome” Anatomy At the elbow, the ulnar nerve travels through a tunnel of tissue (the cubital tunnel) that runs under a bump of bone at the inside of your elbow. This bony bump is called the medial epicondyle. The spot where the nerve runs under the medial epicondyle is commonly referred to as the “funny bone.” At the funny bone the nerve is close to your skin, and bumping it causes a shock-like feeling. This illustration of the bones in the shoulder, arm, and hand shows the path of the ulnar nerve. Reproduced from Mundanthanam GJ, Anderson RB, Day C: Ulnar nerve palsy. Orthopaedic Knowledge Online 2009. Accessed August 2011. Beyond the elbow, the ulnar nerve travels under muscles on the inside of your forearm and into your hand on the side of the palm with the little finger. As the nerve enters the hand, it travels through another tunnel (Guyon’s canal). The ulnar nerve gives feeling to the little finger and half of the ring finger. It also controls most of the little muscles in the hand that help with fine movements, and some of the bigger muscles in the forearm that help you make a strong grip. The ulnar nerve gives sensation to the little finger and to half of the ring finger on both the palm and back side of the hand. Causes of Ulnar Nerve Entrapment In many cases of cubital tunnel syndrome, the exact cause is not known. The nerve is especially vulnerable to compression at the elbow because it must travel through a narrow space with very little soft tissue to protect it. The ulnar nerve runs behind the elbow on the inside of the arm. Common Causes of Compression There are several things that can cause pressure on the nerve at the elbow: When your bend your elbow, the ulnar nerve stretches around the boney ridge of the medial epicondyle. Because this can irritate the nerve, keeping your elbow bent for long periods or repeatedly bending your elbow can cause painful symptoms. For example, many people sleep with their elbows bent. This can aggravate symptoms of ulnar nerve compression and cause you to wake up at night with your fingers asleep. In some people, the nerve slides out from behind the medial epicondyle when the elbow is bent. Over time, this sliding back and forth may irritate the nerve. Leaning on your elbow for long periods of time can put pressure on the nerve. Fluid buildup in the elbow can cause swelling that may compress the nerve. A direct blow to the inside of the elbow can cause pain, electric shock sensation, and numbness in the little and ring fingers. This is commonly called “hitting your funny bone.” Sleeping with your elbow bent can aggravate symptoms. Risk Factors Some factors put you more at risk for developing cubital tunnel syndrome. These include: Prior fracture or dislocations of the elbow. Bone spurs/ arthritis of the elbow. Swelling of the elbow joint. Cysts near the elbow joint. Repetitive or prolonged activities that require the elbow to be bent or flexed. Symptoms Cubital tunnel syndrome can cause an aching pain on the inside of the elbow. Most of the symptoms, however, occur in your hand. Ulnar nerve entrapment can give symptoms of “falling asleep” in the ring finger and little finger, especially when your elbow is bent. In some cases, it may be harder to move your fingers in and out, or to manipulate objects. Numbness and tingling in the ring finger and little finger are common symptoms of ulnar nerve entrapment. Often, these symptoms come and go. They happen more often when the elbow is bent, such as when driving or holding the phone. Some people wake up at night because their fingers are numb. Weakening of the grip and difficulty with finger coordination (such as typing or playing an instrument) may occur. These symptoms are usually seen in more severe cases of nerve compression. If the nerve is very compressed or has been compressed for a long time, muscle wasting in the hand can occur. Once this happens, muscle wasting cannot be reversed. For this reason, it is important to see your doctor if symptoms are severe or if they are less severe but have been present for more than 6 weeks. Home Remedies There are many things you can do at home to help relieve symptoms. If your symptoms interfere with normal activities or last more than a few weeks, be sure to schedule an appointment with your doctor. Avoid activities that require you to keep your arm bent for long periods of time. If you use a computer frequently, make sure that your chair is not too low. Do not rest your elbow on the armrest. Avoid leaning on your elbow or putting pressure on the inside of your arm. For example, do not drive with your arm resting on the open window. Keep your elbow straight at night when you are sleeping. This can be done by wrapping a towel around your straight elbow or wearing an elbow pad backwards. Loosely wrapping a towel around your arm with tape can help you remember not to bend your elbow during the night. Doctor Examination Medical History and Physical Examination After discussing your symptoms and medical history, your doctor will examine your arm and hand to determine which nerve is compressed and where it is compressed. Some of the physical examination tests your doctor may do include: Tap over the nerve at the funny bone. If the nerve is irritated, this can cause a shock into the little finger and ring finger — although this can happen when the nerve is normal as well.Check whether the ulnar nerve slides out of normal position when you bend your elbow.Move your neck, shoulder, elbow, and wrist to see if different positions cause symptoms.Check for feeling and strength in your hand and fingers. Tests X-rays These imaging tests provide detailed pictures of dense structures, like bone. Most causes of compression of the ulnar nerve cannot be seen on an x-ray. However, your doctor may take x-rays of your elbow or wrist to look for bone spurs, arthritis, or other places that the bone may be compressing the nerve. Nerve conduction studies. These tests can determine how well the nerve is working and help identify where it is being compressed. Nerves are like “electrical cables” that travel through your body carrying messages between your brain and muscles. When a nerve is not working well, it takes too long for it to conduct. During a nerve conduction test, the nerve is stimulated in one place and the time it takes for there to be a response is measured. Several places along the nerve will be tested and the area where the response takes too long is likely to be the place where the nerve is compressed. Nerve conduction studies can also determine whether the compression is also causing muscle damage. During the test, small needles are put into some of the muscles that the ulnar nerve controls. Muscle involvement is a sign of more severe nerve compression. Treatment Unless your nerve compression has caused a lot of muscle wasting, your doctor will most likely first recommend nonsurgical treatment. Nonsurgical Treatment Anti-inflammatory medicines. If your symptoms have just started, your doctor may recommend an anti-inflammatory medicine, to help reduce swelling around the nerve. Anti-inflammatory injections Injecting anti-inflammatory injections around the ulnar nerve is generally not used because there is a risk of damage to the nerve. Bracing or splinting Your doctor may prescribe a padded brace or split to wear at night to keep your elbow in a straight position. Nerve gliding exercises Some doctors think that exercises to help the ulnar nerve slide through the cubital tunnel at the elbow and the Guyon’s canal at the wrist can improve symptoms. These exercises may also help keep the arm and wrist from getting stiff. Examples of nerve gliding exercises. With your arm in front of you and the elbow straight, curl your wrist and fingers toward your body, then extend them away from you, and then bend your elbow. Surgical Treatment Your doctor may recommend surgery to take pressure off of the nerve if: Nonsurgical methods have not improved your condition. The ulnar nerve is very compressed. Nerve compression has caused muscle wasting. There are a few surgical procedures that will relieve pressure on the ulnar nerve at the elbow. Dr. Prem Pillay your Neurosurgeon (Spine/Nerve Specialist) will talk with you about the option that would be best for you.Microsurgery with a microscope may be recommended for better visualization of the nerve and compressing structures by Dr. Prem. These procedures are most often done on an outpatient basis, but some patients do best with an overnight stay at the hospital. Cubital tunnel release.   In this operation, the ligament “roof” of the cubital tunnel is cut and divided. This increases the size of the tunnel and decreases pressure on the nerve. After the procedure, the ligament begins to heal and new tissue grows across the division. The new growth heals the ligament, and allows more space for the ulnar nerve to slide through. Cubital tunnel release tends to work best when the nerve compression is mild and the nerve does not slide out from behind the bony ridge of the medial epicondyle when the elbow is bent. Ulnar nerve anterior transposition. More commonly, the nerve is moved from its place behind the medial epicondyle to a new place in front of it. This is called an anterior transposition of the ulnar nerve. The nerve can be moved to lie under the skin and fat but on top of the muscle (subcutaneous transposition), within the muscle (intermuscular transposition) or under the muscle (submuscular transposition). Moving the nerve to the front of the medial epicondyle prevents it from getting caught on the bony ridge and stretching when you bend your elbow. For anterior transposition of the ulnar nerve, an incision is made along the inside of the elbow. Medial epicondylectomy Another option to release the nerve is to remove part of the medial epicondyle. Like ulnar nerve transposition, this technique also prevents the nerve from getting caught on the boney ridge and stretching when your elbow is bent. Surgical Recovery Depending on the type of surgery you have, you may need to wear a splint for a few weeks after the operation. A submuscular transposition usually requires a longer time (3 to 6 weeks) in a splint. Dr. Prem may recommend physical therapy exercises to help you regain strength and motion in your arm. He will also talk with you about when it will be safe to return to all your normal activities. Surgical Outcome The results of surgery are generally good. Each method of surgery has a similar success rate for routine cases of nerve compression. If the nerve is very badly compressed or if there is muscle wasting, the nerve may not be able to return to normal and some symptoms may remain even after the surgery. Nerves recover slowly, and it may take a long time to know how well the nerve will do after surgery. Dr. Prem Pillay encourages people with these symptoms to seek advice early and if they need surgery to do it before the nerve is damaged.

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) Symptoms, Causes & Treatment Carpal tunnel syndrome is a common source of hand numbness and pain. It is more common in women than men. Anatomy The carpal tunnel is a narrow, tunnel-like structure in the wrist. The bottom and sides of this tunnel are formed by wrist (carpal) bones. The top of the tunnel is covered by a strong band of connective tissue called the transverse carpal ligament. The median nerve travels from the forearm into the hand through this tunnel in the wrist. The median nerve controls feeling in the palm side of the thumb, index finger, and long fingers. The nerve also controls the muscles around the base of the thumb. The tendons that bend the fingers and thumb also travel through the carpal tunnel. These tendons are called flexor tendons. The carpal tunnel protects the median nerve and flexor tendons that bend the fingers and thumb. Reproduced and adapted from Rodner C., Raissis A., Akelman E.: Carpal Tunnel Syndrome. Orthopaedic Knowledge Online. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2009. Cause Carpal tunnel syndrome occurs when the tissues surrounding the flexor tendons in the wrist swell and put pressure on the median nerve. These tissues are called the synovium. The synovium lubricates the tendons and makes it easier to move the fingers. This swelling of the synovium narrows the confined space of the carpal tunnel and, over time, crowds the nerve. Carpal tunnel syndrome is caused by pressure on the median nerve traveling through the carpal tunnel. Many things contribute to the development of carpal tunnel syndrome: Heredity is the most important factor – carpal tunnels are smaller in some people and this trait can run in families. Hand use over time can play a role. Hormonal changes related to pregnancy can play a role. Age — the disease occurs more frequently in older people. Medical conditions, including diabetes, rheumatoid arthritis and thyroid gland imbalance can play a role. In most cases of carpal tunnel syndrome, there is no single cause. Symptoms Of Carpal Tunnel Syndrome The most common symptoms of carpal tunnel syndrome include: Numbness, tingling and pain in the hand. An electric shock-like feeling mostly in the thumb, index and long fingers. Strange sensations and pain traveling up the arm toward the shoulder Symptoms usually begin gradually, without a specific injury. In most people, symptoms are more severe on the thumb side of the hand. Symptoms may occur at any time. Because many people sleep with their wrists curled, symptoms at night are common and may awaken you from sleep. During the day, symptoms frequently occur when holding something, like a phone or when reading or driving. Moving or shaking the hands often helps decrease symptoms. Symptoms initially come and go, but over time they may become constant. A feeling of clumsiness or weakness can make delicate motions, like buttoning your shirt, difficult. These feelings may cause you to drop things. If the condition is very severe, muscles at the base of the thumb may become visibly wasted. Doctor Examination To determine whether you have carpal tunnel syndrome, your doctor will discuss your symptoms and medical history. He or she will also examine your hand and perform a number of physical tests, such as: Checking for weakness in the muscles around the base of your thumb. Bending and holding your wrists in positions to test for numbness or tingling in your hands. Pressing down on the median nerve in the wrist to see if it causes any numbness or tingling. Tapping along the median nerve in the wrist to see whether tingling is produced in any of the fingers. Testing the feeling in your fingers by lightly touching them when your eyes are closed. Test Electrophysiological tests Electrical testing of median nerve function is often done to help confirm the diagnosis and clarify the best treatment option in your case. X-rays If you have limited wrist motion, your doctor may order x-rays of your wrist. MRI Dr. Prem Pillay, our Neurosurgeon & Spine/Nerve Specialist, may recommend an MRI (Magnetic Resonance Imaging) of the wrist area to assess the reasons for pressure on the median nerve and whether there are other reasons such as a neurofibroma a type of nerve tumor arising from the median nerve as a cause of your problems. Treatment For most people, carpal tunnel syndrome will progressively worsen without some form of treatment. It may, however, be modified or stopped in the early stages. For example, if symptoms are clearly related to an activity or occupation, the condition may not progress if the occupation or activity is stopped or modified. Nonsurgical Treatment If diagnosed and treated early, carpal tunnel syndrome can be relieved without surgery. In cases where the diagnosis is uncertain or the condition is mild to moderate, your doctor will always try simple treatment measures first. Bracing or splinting.  A brace or splint worn at night keeps the wrist in a neutral position. This prevents the nightly irritation to the median nerve that occurs when wrists are curled during sleep. Splints can also be worn during activities that aggravate symptoms. Medications.  Simple medications can help relieve pain. Activity changes.  Changing patterns of hand use to avoid positions and activities that aggravate the symptoms may be helpful. If work requirements cause symptoms, changing or modifying jobs may slow or stop progression of the disease. Steroid injections.  A corticosteroid injection will often provide relief, but symptoms may come back. Surgical Treatment Surgery may be considered if you do not gain relief from nonsurgical treatments. The decision whether to have surgery is based mostly on the severity of your symptoms. In more severe cases, surgery is considered sooner because other nonsurgical treatment options are unlikely to help. In very severe, long-standing cases with constant numbness and wasting of your thumb muscles, surgery may be recommended to prevent irreversible damage. The ligament is cut during surgery. When it heals, there is more room for the nerve and tendons. Surgical technique.  In most cases, carpal tunnel surgery is done on an outpatient basis under local anesthesia. During surgery, a small cut is made in your palm. Dr. Prem Pillay states that a Microscope may be used to improve visualisation of the internal structures. The roof (transverse carpal ligament) of the carpal tunnel is divided. This increases the size of the tunnel and decreases pressure on the nerve. Once the skin is closed, the ligament begins to heal and grow across the division. The new growth heals the ligament and allows more space for the nerve and flexor tendons. Endoscopic method. Some surgeons make a smaller skin incision and use a small camera, called an endoscope, to cut the ligament from the inside of the carpal tunnel. This may speed up recovery. The end results of traditional and endoscopic procedures are the same. Your doctor will discuss the surgical procedure that best meets your needs. Recovery. Right after surgery, you will be instructed to frequently elevate your hand above your heart and move your fingers. This reduces swelling and prevents stiffness. Some pain, swelling, and stiffness can be expected after surgery. You may be required to wear a wrist brace for up to 3 weeks. You may use your hand normally, taking care to avoid significant discomfort. Minor soreness in the palm is common for several months after surgery. Weakness of pinch and grip may persist for up to 6 months. Driving, self-care activities and light lifting and gripping may be permitted soon after surgery. Your doctor will determine when you should return to work and whether there should be any restrictions on your work activities. Complications.  The most common risks from surgery for carpal tunnel syndrome include: Bleeding Infection Nerve injury Long-term outcomes Most patients’ symptoms improve after surgery, but recovery may be gradual. On average, grip and pinch strength return by about 2 months after surgery. Complete recovery may take up to a year. If significant pain and weakness continue for more than 2 months, your physician may instruct you to work with a hand therapist. In long-standing carpal tunnel syndrome, with severe loss of feeling and/or muscle wasting around the base of your thumb, recovery is slower and might not be complete. Carpal tunnel syndrome can occasionally recur and may require additional surgery.Dr. Prem Pillay recommends that those with the hand symptoms mentioned seek advice and help early before severe problems occur.

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) Symptoms, Causes & Treatment The nerves in your body bring information to the brain about the environment (sensory nerves) and messages from the brain to activate muscles (motor nerves). To do this, nerves must pass over, under, around, and through your joints, bones, and muscles. Usually, there is enough room to permit easy passage. Swelling, trauma, or pressure can narrow these openings and squeeze the nerve. When that happens, pain, paralysis, or other dysfunction may result. Symptoms of Burning Thigh Pains A painful, burning sensation on the outer side of the thigh may mean that one of the large sensory nerves to your legs–the lateral femoral cutaneous nerve (LFCN)–is being compressed. This condition is known as meralgia paresthetica (me-ral’-gee-a par-es-thet’-i-ka). Pain on the outer side of the thigh, occasionally extending to the outer side of the kneeA burning sensation, tingling, or numbness in the same areaOccasionally, aching in the groin area or pain spreading across the buttocks.Usually only on one side of the bodyUsually more sensitive to light touch than to firm pressure Diagnosis During a physical examination, Dr Prem Pillay (Nerve/Spine Specialist) will ask about recent surgeries, injury to the hip, or repetitive activities that could irritate the nerve. He will also check for any sensory differences between the affected leg and your other leg. To verify the site of the burning pain, the physician will put some pressure on the nerve to reproduce the sensation. You may need both an abdominal and a pelvic examination to exclude any problems in those areas. X-rays will help identify any bone abnormalities that might be putting pressure on the nerve. If your physician suspects that a growth such as a tumor is the source of the pressure, he or she may ask for a magnetic resonance image (MRI) or a computed tomography (CT) scan. In rare cases, a nerve conduction study may be advised. Restrictive clothing and weight gain are two common reasons for pressure on a nerve. Your physician may ask if you wear a heavy tool belt at work or if you consistently wear a tight corset or girdle. He or she may recommend a weight loss program. Another reason may result from a seatbelt injury during a motor vehicle injury. Treatment Treatments will vary, depending on the source of the pressure. It may take time for the burning pain to stop and, in some cases, numbness will persist despite treatment. The goal is to remove the cause of the compression. This may mean resting from an aggravating activity, losing weight, wearing loose clothing, or using a toolbox instead of wearing a tool belt. In more severe cases, your physician may give you an injection of a corticosteroid preparation to reduce inflammation. This generally relieves the symptoms for some time. In some cases, surgery is needed to release the nerve.

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 brain tumor? Brain tumors are the most common solid tumors in children. Brain and spinal cord tumors account for 1 in 4 childhood cancers. Approximately 4,000 children and adolescents in the U.S. are diagnosed with primary brain tumors each year. Primary brain tumors start in the brain and generally do not spread outside the brain tissue. Most central nervous system cancers are brain tumors. Brain tumors, either malignant or benign, are tumors that originate in the cells of the brain. A tumor is an abnormal growth of tissue. Benign Brain Tumors A benign tumor does not contain cancer cells and usually, once removed, does not recur. Most benign brain tumors have clear borders, meaning they do not invade surrounding tissue. These tumors can, however, cause symptoms similar to cancerous tumors because of their size and location in the brain. Malignant Brain Tumors Malignant brain tumors contain cancer cells. Malignant brain tumors are usually fast growing and invade surrounding tissue. Malignant brain tumors very rarely spread to other areas of the body, but may recur after treatment. Sometimes, brain tumors that are not cancer are called malignant because of their size and location, and the damage they can do to vital functions of the brain. Age and Differences in Tumors Brain tumors can occur at any age. Brain tumors that occur in infants and children are very different from adult brain tumors, both in terms of the type of cells and the responsiveness to treatment. Causes The American Cancer Society states that no apparent reason can be found for the development of brain tumors in children. Brain tumors cannot be directly linked to something the parents or child did or did not do. Recommendations for Treatment In addition, both the American Academy of Pediatrics and the National Cancer Institute recommend that children receive brain cancer diagnosis and treatment by Neurosurgeons that specialize in pediatric brain tumors and cancers. Research studies show a 20% to 40% higher survival rate when children receive such care. Anatomy of the brain The central nervous system (CNS) consists of the brain and spinal cord. The brain is an important organ that controls thought, memory, emotion, touch, motor skills, vision, respirations, temperature, hunger, and every process that regulates our body. The brain can be divided into the cerebrum, the brainstem, and the cerebellum: Cerebrum (front of brain). The cerebrum is composed of the right and left hemispheres. Functions of the cerebrum include: initiation of movement, temperature sensation, touch, vision, hearing, judgment, reasoning, problem solving, emotions, and learning. Brainstem (base of brain). This includes the midbrain, the pons, and the medulla. Functions of this area include: movement of the eyes and mouth, relaying sensory messages (for example, hot, pain, or loud), hunger, respirations, consciousness, cardiac function, body temperature, involuntary muscle movements, sneezing, coughing, vomiting, and swallowing. Cerebellum (back of brain). Located at the back of the head, the cerebellum’s function is to coordinate voluntary muscle movements and to maintain posture, balance, and equilibrium. What causes brain tumours? The majority of pediatric brain tumours have abnormalities of genes involved in cell cycle control, causing uncontrolled cell growth. These abnormalities are caused by alterations directly in the genes, or by chromosome rearrangements that change the function of a gene. Patients with certain genetic conditions (neurofibromatosis, von Hippel-Lindau disease, Li-Fraumeni syndrome, and retinoblastoma) also have an increased risk for developing tumors of the central nervous system. There have also been some reports of children in the same family developing brain tumors who do not have any of these genetic syndromes. Some chemicals may change the structure of a gene that protects the body from diseases and cancer. Research has been investigating parents of children with brain tumors and their past exposure to certain chemicals, including pesticides and petroleum products. Children who have received radiation therapy to the head as part of prior treatment for other malignancies are also at an increased risk for new brain tumors. What are the symptoms of a brain tumor? The following are the most common symptoms of a brain tumor. However, each child may experience symptoms differently. Symptoms vary depending on size and location of tumor. Many symptoms are related to an increase in pressure in or around the brain, except in very young children (whose skull bones have not yet fused together), as there is no spare space in the skull for anything except the delicate tissues of the brain and its fluid. Any tumor, extra tissue, or fluid can cause pressure on the brain and result in the following symptoms: Increased intracranial pressure (ICP). ICP is caused by extra tissue or fluid in the brain. Pressure may increase because one or more of the ventricles that drain cerebrospinal fluid (CSF, the fluid that surrounds the brain and spinal cord) has been blocked, causing the fluid to be trapped in the brain. Increased ICP can cause the following: Headache Vomiting (usually in the morning) Nausea Personality changes Irritability Drowsiness Depression Decreased cardiac and respiratory function and eventually coma if not treated Symptoms of brain tumors in the cerebrum (front of brain) may include: Seizures Visual changes Slurred speech Paralysis or weakness on half of the body or face Increased intracranial pressure (ICP) Drowsiness and/or confusion Personality changes/impaired judgment Short-term memory loss Gait disturbances Communication problems Symptoms of brain tumors in the brainstem (base of brain) may include: Seizures Endocrine problems (diabetes and/or hormone regulation) Visual changes or double vision Headaches Paralysis of nerves/muscles of the face, or half of the body Respiratory changes Increased intracranial pressure (ICP) Clumsy, uncoordinated walk Hearing loss Personality changes Symptoms of brain tumors in the cerebellum (back of brain) may include: Increased intracranial pressure (ICP) Vomiting (usually occurs in the morning without nausea) Headache Uncoordinated muscle movements Problems walking (ataxia) The symptoms of a brain tumor may resemble other conditions or medical problems. Some pituitary tumors may cause diabetes insipidus, with symptoms of abnormal electrolytes and changes in mental status. Some people with deep thalamic tumors have abnormal eating patterns. These tumors may be particularly difficult to diagnose in adolescents because of the symptoms. Always consult your child’s doctor for a diagnosis. How is a brain tumor diagnosed? In addition to a complete medical history and physical examination of your child, examination procedures for a brain tumor may include: Neurological exam. Your child’s doctor tests reflexes, muscle strength, eye and mouth movement, coordination, and alertness. Computed tomography scan (also called a CT or CAT scan). A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs, such as the brain. CT scans are more detailed than general X-rays. Magnetic resonance imaging (MRI) A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. MRI is very helpful for looking at the brain and spinal cord. X-ray A diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. Angiogram. A dye is used to visualize all the blood vessels in the brain with X-rays in order to detect certain types of tumors. (This test is used less often than in the past because special CT or MRI angiogram techniques can now be used to look at blood vessels in the brain.) Myelogram An X-ray of the spine, similar to an angiogram. Lumbar puncture/spinal tap.   A special needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. A small amount of cerebral spinal fluid (CSF) can be removed and sent for testing. CSF is the fluid which bathes the brain and spinal cord. Positron emission tomography (PET).  In nuclear medicine, a procedure that measures the metabolic activity of cells. A PET scan may show areas of cancer that may not be seen on a CT scan or an MRI scan. Liquid Biopsy This is done using fluid from a CSF tap (Cerebrospinal Fluid) or from a blood test. NGS(Next Gen Sequencing) can be used on cell fragments containing DNA or RNA from the tumor. Cell based cytology may also be possible. Brain Biopsy Needle biopsies can be done to obtain tissue for detailed study including microscopy and special staining for cell types. Computer Image-guided Neuro Navigation, Robotics and Endoscopy may be used depending on the circumstances of the tumor and patient. Examination of a brain tumor depends mostly on the types of cells in which the tumor begins and the tumor location. What are the different types of brain tumors? The most common type of brain tumor is a glioma. Gliomas begin from glial cells, which are the supportive tissue of the brain. There are several types of gliomas, categorized by where they are found, and the type of cells that originated the tumor. The following are the different types of gliomas: Tumor Type Description Astrocytomas Astrocytomas are glial cell tumors that are derived from connective tissue cells called astrocytes. These cells can be found anywhere in the brain or spinal cord. Astrocytomas are the most common type of childhood brain tumor. Astrocytomas are generally subdivided into high-grade, medium-grade or low-grade tumors. High-grade astrocytomas are the most malignant of all brain tumors. Astrocytomas are further classified for presenting signs, symptoms, treatment, and prognosis, based on the location of the tumor. The most common location of these tumors is in the cerebellum where they are called cerebellar astrocytomas. These tumors usually cause symptoms of increased intracranial pressure, headache, and vomiting. There can also be problems with walking and coordination, as well as double vision. Brain stem gliomas / DIPG Brain stem gliomas / DIPG are tumors found in the brain stem; 80% in the pons and the remaining 20% in the medulla, mid-brain and cervico-medullary junction. Most brain stem tumors cannot be surgically removed because of the remote location and delicate and complex function this area controls. Brain stem gliomas occur almost exclusively in children; the group most often affected is the school-age child. The child usually does not have increased intracranial pressure, but may have problems with double vision, movement of the face or one side of the body, or difficulty with walking and coordination. Stereotactic Biopsy can be done to diagnose these tumors and obtain tissue for Molecular genetic markers that could aid treatment and diagnosis. This includes the lysine 27 to methionine (K27M) mutation on Histone 3 (H3K27M). Ependymomas Ependymomas are also glial cell tumors. They usually develop in the lining of the ventricles or in the spinal cord. The most common place they are found in children is near the cerebellum. The tumor often blocks the flow of the CSF (cerebral spinal fluid, which bathes the brain and spinal cord), causing increased intracranial pressure. Ependymomas can be slow growing, compared to other brain tumors, but may recur after treatment is completed. Recurrence of ependymomas results in a more invasive tumor with more resistance to treatment. About 5 to 10 percent of childhood brain tumors are ependymomas. Optic nerve gliomas Optic nerve gliomas are found in or around the nerves that send messages from the eyes to the brain. They are frequently found in persons who have neurofibromatosis, a condition a child is born with that makes him or her more likely to develop tumors in the brain. Persons usually experience loss of vision, as well as hormone problems, since these tumors are usually located at the base of the brain where hormonal control is located and arise (begin) from the optic nerve. These are typically difficult to treat due to the surrounding sensitive brain structures. Primitive neuroectodermal tumors (PNET) PNET can occur anywhere in the brain of a child, although the most common place is in the back of the brain near the cerebellum. When they occur here, they are called medulloblastomas. The symptoms depend on their location in the brain, but typically the child experiences increased intracranial pressure. These tumors are fast growing and often malignant, with occasional spreading throughout the brain or spinal cord. Medulloblastomas Medulloblastomas are one type of PNET that are found near the midline of the cerebellum. This tumor is rapidly growing and often blocks drainage of the CSF (cerebral spinal fluid, which bathes the brain and spinal cord), causing symptoms associated with increased ICP. Medulloblastoma cells can spread (metastasize) to other areas of the central nervous system, especially around the spinal cord. A combination of surgery, radiation, and chemotherapy is usually needed to control these tumors. Craniopharyngiomas Craniopharyngiomas are benign tumors that occur at the base of the brain near the nerves from the eyes to the brain, and the hormone centers. Most occur in children and young adults, but can develop at any age. Symptoms include headaches, as well as problems with vision. Hormonal imbalances are common, including poor growth and short stature. Symptoms of increased intracranial pressure may also be seen. Although these tumors are benign, they are hard to remove due to the sensitive brain structures that surround them. They may need a combination of surgery using microsurgery followed by focussed radiation such as Radiosurgery including Gamma knife and Micro(MLC) Radiosurgery in order to achieve good tumor control and results. Pineal region tumors Many different tumors can arise near the pineal gland, a gland which helps control sleep and wake cycles. Gliomas are common in this region, as are PPID Pineal Parenchymal Tumors of Intermediate Diffrentiation, pinealcytomas and pineoblastomas (a type of PNET). In addition, germ cell tumors including Germinomas, another form of malignant tumor, can be found in this area. Benign pineal gland cysts are also seen in this location, which makes the diagnosis difficult between what is malignant and what is benign. Biopsy or removal of the tumor is frequently necessary to tell the different types of tumors apart. Persons with tumors in this region frequently experience headaches or symptoms of increased intracranial pressure. Treatment depends on the tumor type and size. Treatment for Pediatric Brain Tumours If your child has been diagnosed with a brain tumor, you may want to consider getting a second opinion before beginning treatment.  According to the American Cancer Society, it is very rare that the time it will take to get a second opinion will have a negative impact on your treatment. The peace of mind a second opinion provides may be well worth the effort. Specific treatment for brain tumors will be determined by your child’s doctor based on: Your child’s age, overall health, and medical history Type, location, and size of the tumor Extent of the disease Your child’s tolerance for specific medications, procedures or therapies Expectations for the course of the disease Your opinion or preference Treatment may include (alone or in combination): Surgery Surgery is usually the first step in the treatment of brain tumors. The goal is to remove as much of the tumor as possible while maintaining neurological function. Surgery for a biopsy may also be done to examine the types of cells the tumor is made of for a diagnosis. This is frequently done if the tumor is in an area with sensitive structures around it that may be injured during removal. Modern forms of surgery including Computer Aided Image Guided Microsurgery with Neuro Monitoring where needed explains Dr Prem Pillay a Singapore Neurosurgeon who specializes in Pediatric or Childrens Brain Tumors (He trained at the Cleveland Clinic-USA, MD Anderson Cancer Center and the Hospital for Sick Children-Toronto). Chemotherapy and Immunotherapy Radiation therapy including more advanced forms such as Stereotactic Radiotherapy and Radiosurgery; and Proton Beam Therapy explains Dr Prem Pillay who is an expert in the treatment of Childrens Brain and Spinal cord tumors. Steroids to treat and prevent swelling especially in the brain Antiseizure medication to treat and prevent seizures associated with intracranial pressure Ventriculoperitoneal shunt (also called a VP shunt) A VP shunt may be placed in the head to drain excess fluid from inside the brain to the abdomen. A VP shunt helps control the pressure inside the brain. Endoscopic Third Ventriculostomy is another option where a small opening is made in the floor of the third Ventricle. Others Bone marrow transplantation Supportive care (for the side effects of the tumor or treatment) Rehabilitation (to regain lost motor skills and muscle strength; speech, physical, and occupational therapists may be involved in the health care team) Antibiotics (to treat and prevent infections) Continuous follow-up care (to manage disease, detect recurrence of the tumor and to manage late effects of treatment) Long-term outlook for a child with a brain tumor Prognosis greatly depends on: The type of tumour The extent of the disease Size and location of the tumour Presence or absence of metastasis The tumour’s response to therapy The age and overall health of your child Your child’s tolerance of specific medications, procedures, or therapies New developments in treatment As with any cancer, prognosis and long-term survival can vary greatly from individual to individual. Prompt medical attention and aggressive therapy are important for the best prognosis. Continuous follow-up care is essential for a child diagnosed with a brain tumor. Side effects of radiation and chemotherapy, as well as second malignancies, can occur in survivors of brain tumors. Rehabilitation for lost motor skill and muscle strength may be required for an extended amount of time. Speech therapists and physical and occupational therapists may be involved in some form of rehabilitation. More research is needed to improve treatment, decrease side effects of the treatment for this disease, and develop a cure. New methods are continually being discovered to improve treatment and to decrease side effects. Conclusion Paediatric brain tumours are complex but treatable with early diagnosis and a multidisciplinary approach. At Singapore Brain Spine Nerves Center, we provide comprehensive care tailored to each child’s unique needs, prioritising both effective treatment and long-term quality of life. If you notice persistent symptoms in your child, seek medical attention promptly. Visit us for expert consultation and compassionate care for your child’s neurological health. References and Acknowledgements Columbia University Dept of Neurology Information and Protocols Singapore Brain Spine Nerves Center Protocols

Dr. Prem Pillay, Singapore Senior Consultant Neurosurgeon with super specialty training in Neurosurgical Oncology (Fellow at MD Anderson Cancer Center and Hospital, U of Texas, USA) The goal of anti-aging therapy is to prolong a healthy human existence, and a primary goal would be brain rejuvenation in aging bodies. Replacement and repair therapies are likely to be more successful with organ systems like the kidney, the heart and the lungs which are quite mechanistic in character and lend themselves to piecemeal or whole organ replacement with either biological (cells/tissue) or synthetic parts (mechanical heart pumps). I anticipate that brain repair or even replacement will be a major stumbling block in attempts to significantly extend good quality human life. It is currently possible to replace some central sensory input to the brain as with artificial vision and hearing systems which are computer chip based with electrodes implanted into specific brain areas. However repair and rejuvenation of these specific areas is still problematic. Dr Robert White , a neurosurgeon, from Cleveland was able to transplant entire brains between dogs and keep them alive. As this was a head transplant, sensations such as vision, hearing and taste were preserved. However control of the body and feedback from the peripheral senses was lost. Another unsolved issue with significant transfer of replacement brain cells/tissue will be related to the nature of the association between the mind and the brain. Our experience with stoke and head injury has shown that this can be associated with significant changes in an individuals behavior and character. Thus we may be able to repair significant chunks of the human brain with stem cells, but the final product may produce a mind quite unlike the one that was repaired or rejuvenated! Despite this however I continue to believe that advances in cell and computer based technologies will help repair and replace the ravages of stokes, brain injury and dementia. Microsurgical techniques, endoscopic technology, robotics and stereotaxis are available currently for us to safely carry out repair and implantations into the human brain and spine. The central nervous system also includes the spinal cord and peripheral nerves and future strategies will allow us to repair, replace and rejuvenate this entire system so that we will be able to avoid the fate of Dr White’s dogs. Solving the Mind-Brain interface issues may also allow us to download our personae into sophisticated computer systems either as a temporary storage while a entire new body/brain is being grown or as a back-up in case of sudden destruction of our bodies/brain/minds. It is clearly the beauty of our minds that has to be preserved at all costs as the body can be altered according to the tastes and fads of each new generation. Presented at the Anti-Aging Conference, (Association of Anti-Aging Medicine) KL , 2006. Invited Speaker.

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) Pituitary tumors that occur from the pituitary gland which can be described as the “Master” hormone gland of the body which is located below the base of the brain and in front of the brainstem . It sits in a bony fossa (depression) called the sellar turcica. It is divided into an anterior lobe and a posterior lobe (with a small intermediate lobe). Pituitary tumors account for about 15% of all intracranial tumors. Mean age: 20 to 50 years Sex: More females and males for prolactin and ACTH secreting tumors and a male predominance for GH-producing tumors. Microadenomas  are tumors less than 10 mm in size, and Macroadenomas  are more than 10 mm in size. Local invasion can occur with macroadenomas, particularly into the skull base regions such as the cavernous sinus. Superior growth of macroadenomas can compress the optic chiasm/optic nerves and cause visual disturbances. Malignancy is rare (<1% of all pituitary tumors). Prolactin producing tumors  are the most frequent type of pituitary tumor (30%). Failure of menstruation (amenorrhea) and milk production from the breasts in non-pregnant females (galactorrhea) are the common symptoms. In men, decreased libido and impotence and visual loss are commoner symptoms, as the tumors tend to be larger when discovered. GH secreting tumors  are the second commonest hormone-producing pituitary tumors (15%).It can cause children to grow into “giants” (gigantism) and break height records in their communities. In adults, it can cause acromegaly  with an enlarged head, hands, and feet. ACTH producing tumors  (10%) can cause Cushing’s disease . Such patients have central obesity, a moonface, and abdominal marks called striae. TSH secreting tumors  are rare (1%) and cause symptoms of hyperthyroidism . Null cell tumors  are the second most common tumor and do not produce hormones (25%). They can grow to a large size and cause visual loss before detection. They can be invasive. Diagnosis of Pituitary Tumours This is based on the clinical symptoms and signs mentioned above. An emergency situation can be created by sudden bleeding in a tumor, called pituitary apoplexy . This can cause sudden loss of vision and even collapse and coma. Blood tests of all the common pituitary hormones are carried out. Vision tests such as Visual Fields  and retinal photographs  can reveal visual loss and its extent. MRI with contrast (gadolinium)  is superior to CT scanning in diagnosis, particularly for the smaller microadenomas. Some patients with ACTH producing microadenomas are difficult to find, and selective venous sampling  of the hormone may be required by angiography. Differential Diagnosis Nelson’s syndrome  is an enlargement of the pituitary gland caused by a surgical adrenalectomy. Lymphocytic hypophysitis  can cause a tumor-like appearance but it is an autoimmune disease. Giant cell pituitary granulomas  and Tuberculous granulomas  can be mistaken for pituitary tumors on MRI or CT. Treatment Pituitary Tumors Hormone-secreting tumors which are microadenomas can be treated by oral agents. For tumors that do not respond to medical treatment or if patients have side effects from medical treatment, then alternatives are surgery  or radiosurgery . Surgery In the past, this was carried out using an open craniotomy , and then later with open approaches  through the nose or above the teeth through the mouth. Modern approaches include Endoscopic approaches  through the nasal passages with microsurgical methods . Computer guidance (StealthStation)  can be used to guide such minimally invasive microsurgery. Radiosurgery Gamma Knife  and stereotactic radiotherapy (SRT)  are more focused treatments than traditional radiotherapy. There is a more precise treatment of tumors with fewer side effects. The latest technologies include: Tomotherapy (NeuroTomotherapy) MicroRadiosurgery  (using a robotic couch and the latest fine MMLC) Proton Therapy systems Combined Endoscopy/Microsurgery and Radiosurgery In patients with large invasive tumors, combination treatment  may be safer and more effective than single modality treatments. Ultimately, the best treatment methods and choices are determined by an experienced Neurosurgeon  based on all the available information and presented to the patient for his or her final decision. Post-Treatment Testing and Follow-Up Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests  or check-ups . The most common follow-up tests are: A hormonal screen Visual fields A fundal eye exam and photo MRI of the brain  with a focus on the pituitary gland and its surroundings Conclusion Pituitary tumours, while often benign, can significantly impact health due to their effects on hormones and nearby structures. Early detection and treatment are essential to prevent complications and improve quality of life. If you or your loved one are experiencing symptoms related to pituitary tumours, consult a healthcare professional promptly. For expert care and personalised treatment, visit the Singapore Brain Spine Nerves Center today. References and Acknowledgements National Institutes of Health\ National Cancer Institute – USA Singapore Brain Spine Nerves Center Treatment 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) Craniosynostosis occurs when a baby’s skull bones fuse too early before 2 years of age and causes problems with the shape of the baby’s skull. This restricts the growth of the brain. With early treatment, most children don’t experience any other craniosynostosis symptoms. Babies may undergo helmet therapy or surgery to correct the skull shape. What is craniosynostosis? A newborn baby’s skull consists of several bones that fit together. Usually, newborns have spaces called sutures between their skull bones. The sutures let the skull size grow to accommodate the baby’s growing brain. When the bones of the skull are fused together either at birth or fuse too soon, the condition is called craniosynostosis. The sutures of the skull fuse around the brain at around age 2 years. When a baby has craniosynostosis, one or more of these sutures hardens too early and closes before the baby reaches age 2. How does craniosynostosis affect the body? In places where sutures have fused too early, a baby’s head may stop growing. In other areas, where sutures haven’t fused, the baby’s head will continue to grow. As a result, babies with craniosynostosis often have heads that are asymmetrical (misshapen). If a baby has multiple sutures that close too early, the brain might not have enough room to grow. As a result, these babies might experience a buildup of pressure in the skull (intracranial pressure). What are the types of craniosynostosis? Craniosynostosis types are based on where the sutures close: • Sagittal craniosynostosis affects the suture on the top of the head. Babies with sagittal craniosynostosis often have a long, narrow head (scaphocephaly). • Coronal craniosynostosis affects one of the coronal sutures, which run from both ears to the top of the head. Babies with this type may have a flat forehead and a broad head. • Lambdoid craniosynostosis affects the suture along the back of the head. Babies with this type often have a flat back of the head (Plagiocephaly) • Metopic craniosynostosis affects the suture that runs from the top of the nose to the top of the forehead. Babies with this type may have a triangular head, with the narrow ridge at the midline of the forehead. How common is craniosynostosis? Craniosynostosis is uncommon. It affects about 1 in every 2,500 babies in the United States. Sagittal craniosynostosis is the most common type of congenital craniosynostosis. Symptoms and Causes What causes craniosynostosis? In most babies, experts can’t identify one known cause of craniosynostosis. Sometimes, craniosynostosis occurs because of a sporadic (random) gene mutation (change), or it may run in families. Prematurity is a risk factor for craniosynostosis. In other cases, some factors during pregnancy increase a baby’s risk for developing craniosynostosis. These include: Fertility medications such as clomiphene citrate (Clomid®). Maternal thyroid disease (developing thyroid disease while pregnant). What are the symptoms and signs of craniosynostosis? The primary symptom of craniosynostosis is a misshapen skull. If babies receive early surgical treatment such as Endoscopic release or MicroSurgery with release of the fuse sutures they may not experience any other craniosynostosis symptoms. Other signs of craniosynostosis include: • No fontanelle (soft spot) on a baby’s head where the skull hasn’t closed. • Small, hard ridge of bone that can be felt on the baby’s head. • Face that looks uneven or asymmetrical. What are the complications of craniosynostosis? If left untreated, craniosynostosis or the resulting intracranial pressure can lead to: • Developmental Delays and Seizures. • Vision or eye movement disorders, such as strabismus (crossed eyes)or other disorders. • Breathing difficulties, especially if associated with other bony abnormalities of the face. • Persistent head or facial deformities. Some children may struggle with self-esteem and body image if they have facial asymmetry or deformities. Support groups, counseling and psychotherapy can help your child a positive self image. Diagnosis and Tests How is craniosynostosis diagnosed? Neurosurgeons and Pediatricians usually can diagnose craniosynostosis by feeling for soft spots on your baby’s head, feeling for ridges that signify fused skull sutures and measuring the head circumference. If the size of your baby’s head is not growing as expected, the healthcare provider will check for craniosynostosis. It’s important to remember that a small-sized head can be due to several other reasons as well. Your baby may need an X-ray , CT scan , MRI of the head and brain to confirm this diagnosis. Management and Treatment How is craniosynostosis treated? Craniosynostosis treatment varies depending on the severity and the baby’s symptoms. Treatment may include: Helmet therapy Babies with mild craniosynostosis may wear a special medical helmet. This helmet gently reshapes the skull over time Surgery Many babies need head surgery by a Neurosurgeon to release the fused sutures and reshape the skull thus relieveing increased intracranial pressure and allowing the baby’s brain room to grow and develop properly. The Neurosurgeon determines the timing of the surgerydepending on the severity of the condition and the symptoms associated. Babies might need surgery within the first year of life. Endoscopic surgery could be used before 6 months of age in selected patients to release the craniosynostosis without open surgery says Dr Prem Pillay a Neurosurgeon who was trained at the Hospital for Sick Children, Toronto and the Cleveland Clinic; and now practises at Mt Elizabeth Hospital in Singapore. Your child may need other supportive therapies such a physical, occupational and speech therapies to support return to normal functioning and activities. Prevention How can I prevent craniosynostosis? There is no guaranteed way to prevent craniosynostosis. Prenatal genetic testing may show gene mutations that could lead to craniosynostosis. A genetic counselor can help you understand genetic risks and possible treatment options if your baby is born with craniosynostosis. You can increase your chances of having a healthy baby by: • Scheduling regular prenatal visits. • Speaking with your doctor about potential risk factors, including risks associated with fertility medications or thyroid disease. • Taking prenatal supplements or other supplements as directed. Outlook / Prognosis What is the outlook for babies with craniosynostosis? Most babies who receive timely craniosynostosis treatment live a healthy life. Earlier treatment can minimize developmental problems due to pressure on the brain. What conditions are related to craniosynostosis? Some babies with craniosynostosis also have a genetic syndrome. Some genetic syndromes that can cause a misshapen skull and other associated abnormalities include: • Apert syndrome. • Carpenter syndrome. • Crouzon syndrome. • Pfeiffer syndrome. • Saethre-Chotzen syndrome. Conclusion Craniosynostosis is a manageable condition when diagnosed and treated early. At Singapore Brain Spine Nerves Center, our multidisciplinary team is dedicated to providing personalised care for children with craniosynostosis, ensuring the best possible outcomes. If you have concerns about your child’s head shape or development, seek medical advice promptly. Early intervention can significantly improve your child’s quality of life. For expert guidance and care, visit the Singapore Brain Spine Nerves Center today. References 1. The Cleveland Clinic Foundation, Dept of Neurosurgery and Children’s hospital. 2. Protocols of the Singapore Brain Spine Nerves Center, Mt Elizabeth Medical Center, Singapore (Contact: brainspinesg@gmail.com)

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 Brain Metastases? Brain metastases are tumor cells that have spread to the brain from primary tumors in other organs in the body . Metastatic tumours are among the most common mass lesions in the brain. Signs and symptoms Approximately 60% of patients with brain metastases have subacute symptoms. Symptoms are usually related to the location of the tumor and may include the following: Headache Seizure Nausea Vomiting Nuchal rigidity Photophobia Cognitive dysfunction Motor dysfunction Diagnosis Lab Studies Laboratory investigations include blood work, such as CBC, electrolyte panel, coagulation screen, and liver function panel. Imaging studies Images provide information on tumour burden in the brain and associated structures, in addition to the rest of the body, and are integral part in formulating the optimal treatment plan. Imaging studies include the following: Chest radiography Computerized tomography (CT) Positron emission tomography (PET) Magnetic Resonance Imaging (MRI) Management Medical care Medical treatments consist of symptomatic and systematic treatments. Medical management of metastatic diseases has mainly focused on the treatment of cerebral edema, headache, and seizure. Other options are radiation therapy (whole brain radiation, focal beam, and stereotactic radiation therapy), medical therapy, combined therapies and integration therapy. Most tumors that metastasize to the brain are not chemosensitive, though small-cell lung tumor, breast tumor, and lymphoma respond to medical therapy. In most cases, 2-3 chemotherapeutic agents are used in combination and in conjunction with whole-brain radiation therapy (WBRT). Radiation therapy has become a mainstream therapy for brain metastasis. Radiation therapy includes WBRT and stereotactic radiosurgery. Stereotactic radiosurgery is a more preferred treatment modality for radio-resistant lesions such as nonsmall cell lung tumor, renal cell carcinoma, and melanoma. It is also more frequently used to treat the resection cavity of brain metastasis, particularly in patients with breast metastatic disease. Surgical care Surgical resection is considered standard care for solitary metastases larger than 3 cm and in noneloquent areas of the brain. Other indications for surgical resection include the following: Limited and/or controlled systemic disease Karnofsky score greater than 70 One symptomatic lesion with multiple asymptomatic lesions Contraindications to surgery include a radiosensitive tumor (e.g., small-cell lung tumor), patient life expectancy < 3 months (WBRT indicated), and multiple lesions. Background Metastatic tumors are among the most common mass lesions in the brain. In the United States, an estimated 98,000-170,000 cases occur each year. This is about 24-45% of all cancer patients. [1] The prevalence of brain metastasis is thought to be 120,000-140,000 per year. This disease accounts for 20% of cancer deaths annually, a rate that can be traced to an increase in the median survival of patients with cancer because of modern therapies, increased availability of advanced imaging techniques for early detection, and vigilant surveillance protocols for monitoring recurrence. In addition, most systemic treatments (eg, the use of chemotherapeutic agents, which may penetrate the brain poorly) can transiently weaken the blood-brain barrier (BBB) and allow systemic disease to be seeded in the CNS, leaving the brain a safe haven for tumour growth. Metastases from systemic cancer can affect the brain parenchyma, its covering, and the skull. This discussion is restricted to the incidence, pathophysiology, and management of metastases to the brain parenchyma. Multiple brain metastasis in a patient with known non-small cell lung adenocarcinoma. There was also systemic disease in the liver. Pathophysiology To metastasize, tumor cells have to gain access to the circulation, survive while circulating, pass through the microvasculature of the adopted organs, xtravasate into the organ parenchyma, and reestablish themselves at the secondary site. This process requires the tumor cells to penetrate the basement membrane and cross the subendothelial membrane. Tumor cells achieve this by producing proteolytic enzymes, particularly metalloproteinases and cathepsins to help them to break down the basal matrix and enhance their invasiveness. Tumor cells modulate the expression of fibronectin, collagen, or laminin, and change the type of integrin receptor on their surface and on the surface of the surrounding stromal cells, resulting in desegregation of the stromal cells and creating a permissive environment for them to expand and invade. Invading cells detach from the tumor mass, disperse, and traverse the epithelial/endothelial boundary; they will use the vascular conduit to colonize distant organs. Furthermore, they have to survive intravascular circulation and avoid immune surveillance during this journey. They accomplish that by coating themselves with a shield made out of the coagulating elements such as fibrin and platelets in the blood. These metastatic emboli also produce adherens to slow themselves down to a halt in the blood stream. These adheren molecules allow the circulating cancer cells to reattach onto the vascular wall and gain entry to the host tissue by disruption of the endothelial barrier. This leads to re-establishment of distant micrometastasis. Tumor cells can survive in environments of low oxygen tension. When a tumor increases in volume by more than 2-3 times, the tumor expresses angiogenic factors such as angiopoietin-2 and vascular endothelial growth factors. These angiogenic modulators promote sprouting of surrounding blood vessels, which results in tumor angiogenesis. Additionally, these paracrine factors influence the readiness of target organs to accept tumor growth to prepare a favorable microenvironment for the tumor to undergo exponential growth and become a macrometastasis. [2] Different tumors metastasize preferentially to different organs. Cells with similar embryologic origins are generally believed to have similar growth constraints and express similar sets of adhesion molecules, such as addressins. An example is melanoma; the cells are closely related to CNS cells (they are derived from the neural crest cells), and melanoma commonly metastasizes to the brain. Certain cell-surface markers in cancer are indicators and/or predictors of distant metastasis, eg, nm23 and CD44 in breast cancer. [3] Similarly, breast cancer cells that are HER positive are more likely to metastasis to the brain. [4] Renal, gastrointestinal, and pelvic cancer tend to metastasize to the cerebellum, whereas breast cancer is more commonly found in the posterior pituitary. Thus, the trafficking of cancer cells to their final destination is not entirely random and may be guided by factors produced by stromal cells of their host organ. Recently, it has been shown that metastases may have originated from cancer initiating cells, which are more resistant to therapy by virtue of their stemlike properties. [5] Additionally, cancer cells recruit bone marrow–derived cells to modify the microenvironment of distant recipient sites, forming a premetastatic niche by alternating the level of fibronectin and making the site more favorable for the colonization of metastatic tumor. [6] Cancer cells have been shown to recruit bone marrow—derived cells to modify the microenvironment of distant recipient site; the formation of a premetastatic niche by alternating the level of fibronectin and making the site more favorable for the colonization of metastatic tumor. [7] Frequency United States The incidence of metastatic brain tumors exceeds that of primary brain tumors, accounting for 50% of total brain tumors and for as many as 30% of tumors seen on imaging studies alone. An estimated 100,000 new cases are diagnosed per year in the United States; about 60% of patients are aged 50-70 years. More than 20% of patients with systemic disease have brain metastasis on autopsy. About 15% of patients with cancer present with neurologic symptoms before their systemic cancer is diagnosed. Among them, 43-60% have an abnormal chest radiograph suggestive of bronchogenic primary or other metastases to the lung. In 9%, the CNS is the only site of spread. About 10% of patients with proven metastatic disease have no identifiable primary source. Mortality/Morbidity The most common origins of brain metastasis are systemic cancer of the lung, breast, skin, or GI tract. In 2700 cases from the Memorial Sloan-Kettering Cancer Center in New York, the distribution of primary cancers was as follows: 48% lung, 15% breast, 9% melanoma, 1% lymphoma (mainly non-Hodgkin), 3% GI (3% colon and 2% pancreatic), 11% genitourinary (21% kidney, 46% testes, 5% cervix, 5% ovary), 10% osteosarcoma, 5% neuroblastoma, and 6% head and neck tumor. Of note, renal, GI, and pelvic cancers tend to metastasize to the cerebellum, whereas breast cancer most commonly affects the posterior pituitary. Cancer-cell trafficking may not be entirely random, and factors produced by stromal cells may guide their final destination in the brain. Primary lung tumors account for 50% of all metastatic brain tumors. Lung cancer is the most common origin of metastatic disease. Of lung cancer patients who survive for more than 2 years, 80% will have brain metastases. The average time interval between the diagnosis of primary lung cancer and brain metastases is 4 months. Interestingly, small cell carcinomas, which are only 20% of all lung cancers, account for 50% of brain metastases from lung cancer. In a retrospective study, 6.8% of the first cancer recurrence was in the brain. Breast tumor is the main source of metastatic disease in women, followed by melanoma, renal, and colorectal tumors. Breast cancer is a heterogeneous disease demonstrating genotypic and phenotypic diversity. The interval between the diagnosis of primary breast cancer and brain metastasis can be up to 3 years. The first site of distant failure is the brain, alone or as a component of metastatic disease, and a proportionately high number are ER- or HER2 negative. Yet HER positive cancer is twice as common to metastasize to the brain. Additionally, it has been shown that nm23 and CD44 in breast cancer are indicators for distant metastasis. Melanoma commonly metastasizes to the brain. Melanoma has an increased incidence among other systemic cancers in terms of metastasizing to the brain. About 40-60% of patients with melanoma will have brain metastasis. Melanoma cells are closely related to CNS cells due to their embryonic origin and neural crest cells, and they share common antigens such as MAG-1 and MAG-2. After melanoma is detected in the brain, median survival is 3 months. These metastases are poorly responsive to all treatments. Approximately 14% of cases have no identifiable primary tumor. Melanomagenic tumors also involve the pial/arachnoid. In CT imaging, they are marginally enhanced with contrast compared with bronchogenic cancer. They are distinctive in MRI because of the melanin or due to hemorrhage. Others metastatic tumors that commonly bleed are thyroid and renal cell carcinoma. Metastatic disease from the breast, thyroid, renal cells, and colon are more commonly found as a single metastatic lesion, whereas metastatic disease from lung tumor and melanoma are more commonly found to be multiple lesions. Testicular tumor is uncommon and yet it more frequently metastasizes to the brain as compared with lung cancer. Patients with brain metastasis at the same time of having systemic cancer (synchronous metastasis) tend to do worse as compared with patients with metachronous metastatic disease. Sex Although melanoma spreads to the brain more commonly in males than in females, gender does not affect the overall incidence of brain metastases. Age About 60% of patients are aged 50-70 years.CNS metastasis is not common in children; it accounts for only 6% of CNS tumors in children.Leukemia accounts for most metastatic CNS lesions in young patients, followed by lymphoma, osteogenic sarcoma, and rhabdomyosarcoma.Germ-cell tumors are common in adolescents and young adults aged 15-21 years. History Approximately 60% of patients with brain metastases have subacute symptoms. Symptoms are usually related to the location of the tumor. About 85% of the lesions are in the cerebrum, 15% are in the cerebellum, and 5% are in the brainstem. Morning headache with nausea and vomiting together with papilledema are suggestive of intracranial hypertension. Features such as headache, nuchal rigidity and photophobia indicate meninges involvement. The timing of the onset of these symptoms is subacute rather than acute. Acute onset of symptoms suggests vascular or electrical etiology such as bleeding or seizure. Dementia and cognitive deficits of a gradual onset most likely indicate a demyelination problem, radiation necrosis. Paraneoplastic syndromes include limbic encephalopathy and cerebellar degeneration. The latter is commonly associated with ovarian cancer. Progressive weight loss and general fatigue can be ominous and highly suggestive of recurrent systemic cancer. Similarly, neurologic problems such as polyneuropathy or myopathy can be sinister. Headache (42%) and seizure (21%) are the 2 most common presenting symptoms. New onset of seizures in a patient older than 35 years is highly suggestive of primary or metastatic disease. In addition, 35% of patients have cognitive dysfunction, and 30% have motor dysfunction. About 10% of patients present with hemorrhage. Metastases commonly derive from choriocarcinoma, melanoma, bronchogenic carcinoma, thyroid carcinoma, and renal carcinoma bleeding; most of these hemorrhages are intramural. Physical Findings on the neurologic examination depend on the location of the metastatic lesions. Focal findings are common. Findings consistent with generalized CNS dysfunction also can occur secondary to the cumulative effects of multiple CNS lesions, edema associated with large single or multiple CNS lesions, and/or adverse effects of medications. Diagnostic Considerations Any Subacute Neurological Disease About 11% of mass lesions in patients with cancer are not metastases. Mass lesions that can masquerade as brain metastasis include: Abscess (20%) Granuloma (less common and mostly associated with mycobacterial or fungal infection) Other Mimics and Considerations Acute demyelinating diseases (mostly secondary to acute postinfective demyelination) Progressive multifocal leukoencephalopathy (PML) Radiation necrosis, if patient had prophylactic radiotherapy for previous metastases to the brain Vascular and Coagulation Disorders Nonbacterial thrombotic endocarditis (NBTE)  and intravascular thrombosis: Frequently encountered in patients with disseminated disease of the lung, breast, GI or genitourinary tract, or with tumours of haematopoietic origin NBTE is uncommon in patients whose disease is in remission Resolving haematoma due to coagulopathy secondary to NBTE or intravascular thrombosis from associated coagulation disorder Coagulopathy: Associated with breast cancer and leukaemia In some cases, cardiolipin antibodies are present In other cases, abnormalities in viper-venom coagulation results have been documented Differential Diagnoses Blood Dyscrasias and Stroke Brainstem Gliomas Cardioembolic Stroke Cerebral Venous Thrombosis Glioblastoma Multiforme Imaging in Oligodendroglioma Low-Grade Astrocytoma Multiple Sclerosis Neurological Sequelae of Infectious Endocarditis00 Laboratory Studies Laboratory investigations include blood work, such as CBC, electrolyte panel, coagulation screen, and liver function panel. Specific markers, such as anti-Hu antibody in limbic encephalopathy, anti-Yo antibody in cerebellar degeneration, and anti-Ri antibody in opsoclonus and ataxia are of some value, especially in patients with small-cell lung cancer, ovarian cancer, and breast or lung cancers. Chronic anemia is common in systemic disease. Electrolyte imbalance, such as in hyponatremia (hypothyroidism or syndrome of inappropriate secretion of antidiuretic hormone [SIADH]), can be found in patients with metastasis to the pituitary gland and meninges. Abnormal coagulopathy can be observed in patients with breast cancer or leukemia. Abnormal liver function is common in patients with advanced systemic diseases or in those receiving chemotherapy. Specific markers, such as anti-Hu antibody in limbic encephalopathy, anti-Yo antibody in cerebellar degeneration, and anti-Ri antibody in opsoclonus and ataxia, are of some diagnostic value, especially in patients with small-cell lung cancer, ovarian cancer, breast cancer, or lung cancers. The recent advancement in genomic and proteomic medicine allows the use of a molecular signature to gauge the risk of developing brain metastasis. For example, in young breast cancer patients, an ER-positive, PR-positive, and HER2 -negative profile incurs a higher brain metastasis risk compared with a triple-negative or HER2 -positive profile. [8] It is especially true if the patient has a short interval between initial diagnosis and systemic metastasis; this risk is noted to be even higher if there are multiple sites of systemic metastasis. In current practice, this is beginning to be used as a method to guide personalized therapy. Imaging Studies Imaging study for metastatic disease to the brain can be divided into systemic imaging and imaging of the neuraxis. Images provide information on tumor burden in the brain and associated structures, in addition to the rest of the body, and are integral part in formulating the optimal treatment plan. Systemic imaging studies Chest radiography should be included in the workup of any mass lesion in the brain, specifically in patients without a history of systemic cancer. Chest radiographs may reveal the primary cancer and suggest an alternative site for obtaining tissue for histologic diagnosis. Additional imaging modalities such as CT, positron emission tomography (PET), and bone scanning are used to stage the systemic disease. Imaging of the neuraxis (brain and spinal cord) Head CT imaging of the brain is not as reliable as MRI in determining the extent of brain metastases. Head CT can cause underestimation of the number of brain lesions. In 20% of cases and even when contrast medium is used, head CT shows asolitary lesion but subsequent MRI shows multiple lesions. High-resolution MRI can be used to detect additional brain metastases in patients undergoing Gamma Knife surgery. [9] Contrast medium enhances visualization of mass lesions in the brain and should be used in both CT and MRI. Newer imaging modalities, such as magnetization transfer imaging and perfusion imaging, are not particularly useful. Diffusion-perfusion MRI Diffusion-perfusion MRI has been used to differentiate poorly enhancing lesions. Tien et al reported that peritumoral edema and nonenhancing tumor have distinguishable features. [10] The utility of this imaging technique in metastatic diseases is not established, though peritumoral edema is prominent in most cases. Magnetic resonance (MR) spectrometry and PET scan (positron emission tomography). MR spectroscopy uses the chemical signature of rapid membrane turnover of proliferative cells to reveal the presence of cancer cells. Multiple voxel analysis is more commonly used because it has an advantage over signal voxel study to yield more information about the region of interest and to differentiate edema and possible necrosis. CT-PET and bone scans are used to stage the extent of the systemic disease. This helps to formulate the extensiveness of future treatments (see Treatment) and their justification. Patients with multiple systemic metastasis do not do well in intensive therapy. Other experimental imaging studies such as receptor-targeted and ligands-based molecular imaging are on the horizon. These imaging modalities are cancer specific. Both MRI spectrometry and PET studies are useful to differentiate radiation necrosis from tumor. Thallium-201 chloride PET seems to have high specificity (91%) in this regard. Neither of these methods is useful for differentiating metastasis from primary brain tumors, but they are helpful whenever the possibility of an abscess is being considered. Procedures Tissue diagnosis Eleven percent of cancer patients with a solitary mass in the brain have lesions other than metastatic disease. Hence, tissue diagnosis is sometimes necessary to resolve this diagnostic uncertainty, especially when there is ambiguity in the imaging study. Brain biopsy Tissue diagnosis should be performed in cases of uncertain etiology. Of note, most surgeons advocate excision biopsy for a solitary lesion in an accessible area of the brain. For stereotactic brain biopsy, the morbidity rate is 3% with a 1% rate of hemorrhage and a 1% rate of deficit without hemorrhage. In the past, the morbidity rate associated with tumor resection was 20%, and mortality rate was 2%. With recent advances in intraoperative navigation, the morbidity and mortality rates of excisional biopsy have been reduced to 10% and 0.5-2%, respectively, which are still higher than the rates with biopsy alone. Medical Care Medical treatments consist of symptomatic and systematic treatments. Other options are surgical treatments, radiation therapy (whole brain radiation, focal beam and stereotactic radiation therapy, eg, radiosurgery), chemotherapy, combined therapies, and integration therapy. Integration therapy is a multidisciplinary approach with combination therapy of behavioral modification/coping, nutritional counseling, alternative medicine (herbal), physical therapy, and occupational therapy. Integration therapy has become more accessible to most healthcare providers in the past few years. Medical management of metastatic diseases has mainly focused on the treatment of cerebral edema, headache, and seizure. Headache and cerebral edema are interrelated and are discussed as such. Management of headache and edema Causes of headache are cerebral edema with increased intracranial pressure and meningeal irritation secondary to infiltration of cancer cells. Other causes, such as hydrocephalus and hemorrhage, require surgical intervention. The diagnosis is normally confirmed with radiographic studies. Hydrocephalus is uncommon in metastatic disease. In most cases, carcinomatosis meningitis is the cause. In rare cases, obstruction of the aqueduct of Sylvan or the fourth ventricle is the cause. Shunting of the ventricle is the treatment of choice. The most common concern with this maneuver is the possibility of systemic seeding oftumor cells into the peritoneal cavity. Cerebral edema of metastatic disease is mainly vasogenic. Brain swelling causes a secondary insult to the surrounding healthy brain, which may worsen cognitive function and/or motor and sensory deficits. If severe, it compromises cerebral perfusion and results in cerebralinfarction. Management of seizures The frequency of seizures in patients with metastatic brain tumor is 30-40%. One half of patients who have seizures present with them. The type of seizure guides treatment. Prophylactic treatment for seizure is not necessary in patients with no history of seizure. Status epilepticus occurs infrequently in patients with metastasis, but it is associated with a high mortality rate (6-35%). Status epilepticus should be considered the cause in patients with a prolong postictal state or in stuporous or comatose patients whose imaging study does not show significant mass effect of edema. Chemotherapy Medical treatment directed at cancer cells that have seeded into the brain is ineffective. The failure of chemical therapy has always been attributed to an intact BBB and the acquisition of drug resistance by the cancer cells. Most tumors that metastasize to the brain are not chemosensitive, though small-cell lung cancer, breast cancer, and lymphoma respond to chemotherapy. Hence, management and treatment depend on the systemic disease, the tumor type, and the stage of the disease. Radiation therapy Radiation therapy has become a mainstream therapy for brain metastasis. Radiation therapy includes WBRT and stereotactic radiosurgery. For decades, WBRT has been advocated for patients with multiple lesions. WBRT is also advocated for patients with a low Karnofsky score or a life expectancy of < 3 months. Effectiveness of this treatment depends on the histological type of the tumor. Small-cell lung tumor and germ-cell tumors are highly susceptible to radiation, other types of lung cancer and breast cancers are less sensitive, and melanoma and renal-cell carcinoma are not sensitive at all. Regarding the effectiveness of radiation therapy, the Radiation Therapy Oncology Group (RTOG) has recommended a treatment schedule of 30 Gy delivered in 10 fractions over 2 weeks. With this treatment, median survival is 3-6 months depending on number of lesions, their radiosensitivity, and the status of systemic disease. Disadvantages are short- and long-term adverse effects. Besides hair loss, headache, nausea, otitis media, and cerebral edema, patients may have increased somnolence. After 6 months, patients may have evidence of radiation necrosis, leukoencephalopathy, and/or dementia. Hippocampal avoidance (HA), a modification of WBRT, may preserve short-term memory in cancer patients with brain metastases. In a study involving 113 adult cancer patients with a measurable brain metastasis outside a 5-mm margin around the hippocampus, the HA-WBRT group showed a 7% performance decline on a standardized memory test at 4 months, whereas the control group showed a 30% decline. [17] At 6 months, the decline averaged 2%. Stereotactic radiosurgery This modality makes use of multiple, well-collimated beams converging on a small lesion with a steep dose gradient at the edge of the beam. This conformity allows a high dose of radiation to be delivered to the target in a single fraction without causing excessive radiation damage to surrounding healthy brain. Several lesions can theoretically be treated on a single clinic visit. As the number of lesions increase, the overlapping of fields exceeds tolerance of healthy brain to radiation injury. For lesions 1-3 cm, the median dose is 15-24 Gy. Stereotactic radiosurgery is a more preferred treatment modality for radio-resistant lesions such as nonsmall cell lung tumor, renal cell carcinoma, and melanoma. It is also more frequently used to treat the resection cavity of brain metastasis, particularly in patients with breast metastatic disease. The latter population of patients has a higher survival potential, thus whole brain radiation or EBRT, with their long-term cognitive adverse effects, make these modalities a less favorable choice. Median survival after radiosurgery is 14.1 months. Twenty-four percent of patients with brain metastasis from breast cancer have 24-month overall survival. The overall control rate in breast metastasis in the brain is 82-90%. Unfortunately, 47% of the patients have new brain metastasis 11-15 months after initial radiosurgery. This is especially true in melanoma. The median tumor control for most brain metastasis is about 10 months. The size of metastatic tumors may not change until months after radiation. The lesion may appear to grow slightly immediately after treatment. Acute reactions due to edema occur within 2 weeks in 7-10% of patients. These reactions include headache, nausea, vomiting, worsening of preexisting neurological deficits, and seizure. Radiation necrosis happens later, 6 months after treatment in 4% of patients. It can manifest as a transient increase in tumor size, edema, or mass effect with or without frank necrosis. It can be difficult to distinguish from the tumor itself. Collectively, these merging data confirm that radiosurgery is equally effective in treating brain metastasis. Radiosurgery is particularly useful in treating patients with limited systemic disease and higher Karnofsky scores and in patients with life expectancies of more than 6 months. However, radiosurgery is now commonly offered to patients with higher systemic tumor burden when a shorter treatment regimen is more desirable. Radiosurgery is also increasingly used as the adjuvant therapy in patients who have undergone metastatic brain-tumor resection. The effectiveness of this treatment depends on the histology of the tumor Surgical Care Indications for surgical resection include the following: Solitary lesions larger than 3 cm Lesions in noneloquent areas of the brain Limited and/or controlled systemic disease Karnofsky score greather than 70 One symptomatic lesion with multiple asymptomatic lesions (The symptomatic lesion should be resected, and remaining lesions should be treated with radiotherapy.) The surgical morbidity rate is about 10%, and the mortality rate is less than 5%. The outcome of resection can be improved by applying intraoperative navigation and monitoring with cortical mapping; this allows for aggressive resection, even in eloquent regions. Contraindications to surgery include a radiosensitive tumor (eg, small-cell lung tumor), patient life expectancy < 3 months (WBRT indicated), and multiple lesions. However, Bindal et al recently indicated that patients who underwent resection of multiple lesions fared better than patients with multiple lesions who did not undergo surgery. [19] Morbidity and mortality rates are essentially the same as those in patients with a solitary lesion. Surgical resection versus radiosurgery Surgical resection is considered standard care for solitary metastases larger than 3 cm and in noneloquent areas of the brain. Surgical resection is superior to radiosurgery, with a median survival nearly twice that of radiosurgery. About 13% of surgically treated patients have local recurrence, whereas 39% of patients treated with radiosurgery have local progression of disease. Cho and Auchter reported that combined therapies (eg, resection plus radiosurgery or radiosurgery plus WBRT) yield outcomes better than those of WBRT alone. [20, 21] Read more in Stereotactic Radiosurgery in the Management of Brain Metastasis Multimodality therapy In 2 prospective randomized trials, surgical resection plus WBRT was more effective than WBRT alone in controlling disease. The combination had a median survival of 8-16 months and 7-15% local recurrence rates. The role of adjunctive WBRT after surgery for a solitary lesion is controversial. Postoperative WBRT reduces the recurrence rate but does not affect overall survival. In 1 comparison of radiosurgery plus WBRT versus WBRT alone in patients with multiple metastases (2-4 tumors, < 25-mm total diameter), combined therapy was most effective in controlling disease and that it had a survival advantage (median time to local failure of 36 vs 6 mo). WBRT after surgery or radiosurgery is controversial. Local control is best with a combined approach, but functional scores and overall survival were not clearly different. The growing trend is to postpone WBRT until recurrence and to use fractionated stereotactic radiotherapy with radiosensitizers (eg, gadolinium texaphyrin, RSR13). Management of recurrent metastasis The local recurrence rate of brain metastasis is relatively high. It can be as high as 85% in patients undergoing craniotomy without WBRT.For patients given radiation therapy and stereotactic radiosurgery, the relapse rate can be as much as 67%. The recurrence rate of brain metastasis is related to the duration of survival, which in turn mostly depends on the nature and the course of the systemic disease. Treatment outcomes for patients with brain metastases who live 24 months or longer after initial treatment include primary tumor control, single-organ metastasis, and a long latency period between primary treatment and recurrence. Management of single/solitary brain metastasis in patients without prior WBRT The algorithm for the management of a solitary brain tumor (patient with no or stable systemic disease) is easier than that of a single metastatic tumor. If the solitary lesion is symptomatic and/or in a noneloquent area, then surgical resection is the best option; this provides tissue confirmation and reduces mass effect. Even then, the use of WBRT or radiosurgery as adjuvant therapy remains controversial. It is a general belief that adjuvant radiotherapy is indicated since the hazard ratios for local recurrence and distance recurrence in patients without WBRT are 3.14 and 2.16 (as compared to 0.58 and 0.42), respectively. However, the use of stereotactic radiosurgery as an adjuvant therapy is gaining momentum. A body of clinical evidence suggests that radiosurgery to the rim of the tumor resection cavity is equally effective in achieving local control. An upcoming NCCTG-N107C study is designed to categorically address this issue. Radiosurgery has been used effectively in treating multiple lesions as an upfront therapy; therefore, there is no reason to doubt it will not be able to control local diseases around the resection cavity if an adequate marginal dose is achievable; thus, reserve WBRT to be used in distance relapse with multiple lesions, local progression, or in cases in which leptomeningeal spread is suspected. It is also possible to perform re-resection in cases in which local progression is evidenced, as well as in cases in which the differentiation of local recurrence and radiation necrosis is not possible. Management of brain metastasis with unknown primary diseases Metastatic cancer of an unknown primary lesion accounts for 3-5% of all cancers, and makes it the seventh most common malignancy. About 15% of brain metastasis is included in this category. Metastasis without a primary lesion is considered present when a complete history, physical examination (including breast and pelvic examination in female patients and prostate and testicular examination in male patients), standard laboratory investigations, and histologic examination fail to confirm systemic disease before any form of treatment is given. In this situation, the likelihood of identifying the primary disease is about 30-82%. The general belief is that the primary lesion has become involuted or that the phenotype and/or genotype of the tumor suggest metastatic potency instead of a slow local expansion of the tumor. This designation creates uncertainty regarding treatment and an assumption of a poor prognosis. In fact, this condition represents a subgroup of cancers with widely divergent prognoses. Serum markers, such as cancer antigen (CA)15.3 for breast tumor, CA19.9 for pancreatic tumors, and CA125 for ovarian cancers have helped to focus the search of the primary disease and have empirically guided treatment. Brain metastases of unknown primary origin are often adenocarcinomas or squamous cell carcinomas (31% and 9%, respectively). A search for occult head and neck cancer frequently reveals the origin of the systemic disease. Nevertheless, in 42% of cases, the origin remains unclear after extensive investigation. The median survival of patients with brain metastasis without a primary cancer is about 6 months; those with solitary lesions have a better prognosis. Surgery in combination of WBRT is the most common mode of therapy. Chemotherapy is infrequently used when serum markers and histological clues indicate the most likely source of the disease.

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 Astrocytomas? Astrocytomas are tumours that arise from astrocyte cells, which are part of the supportive (neuroepithelial) tissue of the brain. These cells are named for their star-like shape. These are the most common primary CNS tumours, representing about half of brain and spinal cord tumours. The most frequent types of astrocytoma, in increasing degrees of grade, are the pilocytic astrocytoma (grade I), astrocytoma (grade II), anaplastic astrocytoma (grade III), and glioblastoma multiforme (grade IV). If the tumour also contains oligodendroglioma and/or ependymoma cells, it is called a mixed glioma. Low-Grade Astrocytoma Pilocytic astrocytomas and subependymal giant cell astrocytomas are grade I tumours. These non-infiltrating tumours occasionally form cysts or are enclosed in a cyst. Metastasis or a secondary malignant tumour is rare. Although they are slow-growing, these tumours can become very large. Grade I tumours are often effectively treated by surgery alone. Radiation therapy may be given for incompletely removed tumours. If the tumour recurs, reoperation and some form of radiation are options. Pilocytic astrocytomas occur mainly in children. They are the most benign of the astrocytomas. Cerebellar astrocytomas and optic tract gliomas are often pilocytic tumours. Grade II tumours include low-grade astrocytoma, fibrillary or protoplasmic astrocytoma, and some pleomorphic xanthoastrocytomas. They are usually infiltrating tumours but grow relatively slowly. A tumour’s location often determines its treatment. Complete surgical removal is sometimes possible for accessible tumours, although they can be locally invasive. If total surgical removal is thought to have been achieved, periodic follow-up with MRI or CT scans may be the only additional care required. External beam whole brain radiation therapy is often used in addition to surgery (partial resection) or for inoperable low-grade astrocytomas. If necessary, Gamma Knife may be utilized as a boost to surgery and radiation where total removal of the tumour was not accomplished. European studies and our own experience have shown good results using implanted seeds of irradiation with permanent implants. Again, stereotactic radiosurgery may be assessed as an alternative. Anaplastic Astrocytoma Anaplastic astrocytoma, sometimes called grade III malignant tumours, are tumours that grow more rapidly than low-grade tumours and tend to invade nearby healthy tissue. They recur more frequently and more quickly than some lower-grade tumours because their tendency to spread into surrounding tissue makes it difficult to completely remove them during surgery. An anaplastic astrocytoma can be a recurrence from a lower grade of an already treated astrocytoma tumour. Treatment recommendations for these types of tumours are based on the tumour’s location, if the tumour has spread, how far it has spread, and the patient’s general health and age. Surgery followed by conventional external beam radiation therapy is the primary treatment for accessible mid-grade astrocytomas. Boost radiation using interstitial or radiation seeds implanted directly into the tumour site has shown promising results in our experience. Glioblastoma Multiforme By definition, a glioblastoma Multiforme (GBM) tumour is considered a grade IV tumour. 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 tumour cells (necrosis) is called a glioblastoma multiforme.GBM represents about 30 percent of all primary brain tumours 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 tumours are glioblastomas. 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, and behavioral changes are the most common presenting symptoms. The first procedure for most GBMs is either surgery to remove the tumour or a biopsy for diagnosis. Surgery alone rarely controls the GBM because of its aggressive nature whereby its cells quickly infiltrate throughout the brain. Thus, radiation therapy almost always follows surgery or biopsy to attempt to control the spread of the cells. Conclusion Astrocytomas, though complex, are manageable with the right diagnosis and treatment plan. If you or your loved one are experiencing symptoms that could indicate a brain tumour, consult a healthcare professional promptly for evaluation. Early intervention is crucial in improving outcomes and quality of life. For more information or to schedule a consultation, visit the Singapore Brain Spine Nerves Center today.