Preventive Care

Patients undergo a Health Screening to identify any risk factors they may possess, such as cholesterol, hypertension and diabetes.

 

Diagnostic Procedures

• Computerized Tomography (CT) Scan
• Magnetic Resonance Imaging (MRI)
• Electroencephalogram (EEG)
• Electromyogram (EMG)
• Positron Emission Tomography (PET) Scan
• Digital Subtraction Angiography (DSA)

 

Neurological Surgery available

• Brain and Spinal Surgery
• Neurovascular Surgery
• Robotic Surgery

 

Stereotactic Radiosurgery

• X-Knife Stereotactic Radiosurgery System (Mount Elizabeth Hospital)
• Tomotherapy - first machine in South East Asia (Mount Elizabeth Hospital)
• BrainLab Stereotactic Radiosurgery System (Gleneagles Hospital)
• Gamma Knife Radiosurgery – only machine in Singapore
  (Parkway Day Surgery & Medical Centre)

In Stereotactic Radiosurgery, our hospitals use modern Linear Accelerators (Linac)-based systems for treating Intra-Cranial Tumours.

This highly accurate treatment allows us to deliver a good dose of radiation to the tumour without affecting the surrounding normal brain cells. This translates into a shortened recovery time, while also eliminating the need for patients to be hospitalised.

Treatment using our new Tomotherapy machine for cancer treatment has been available to patients since March 2006. With Tomotherapy, Radiation Oncologists can check the location of the patient’s tumour before each treatment, and subsequently, deliver painless and precise radiation therapy based on a carefully customised plan.

The Gamma Knife is recognised internationally as one of the most advanced radiosurgical treatment modalities for deep-seated brain tumours and other lesions that cannot be removed safely using conventional brain surgery. In Gamma Knife Radiosurgery, computer-planned finely collimated gamma-rays are precisely focused onto an intracranial target to ablate, without the need for open surgery. It can be an alternative or adjunct to conventional open surgery.

Rehabilitation may be needed for various types of neurological disorders. Comprehensive assessment and management is provided by our team of Occupational Therapists, Physiotherapists and Speech Therapists.

The aim of our programme is to rehabilitate patients, in order to ensure that they can confidently return to mainstream life as quickly as possible.

Recognizing the difficulties involved, our approach is to work closely with patients and their families to provide individualised rehabilitation.

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Rehabilitation may be needed for various types of neurological disorders. Comprehensive assessment and management is provided by our team of occupational Therapists, Physiotherapists and Speech Therapists.

The aim of our programme is to rehabilitate patients, in order to ensure that they can confidently return to mainstream life as quickly as possible.

Recognizing the difficulties involved, our approach is to work closely with patients and their families to provide individualised rehabilitation.

 

Physiotherapist’s Aim

• Help patients to exercise their limbs and trunk in order to regain normal muscle movement and function
• Teach safe methods of transfer from one place to another
• Teach ambulation
• Correct abnormal walking patterns
• Teach stair climbing with or without handrails

 

Occupational Therapist’s Aim

• Retrain patients on activities of daily living (e.g. showering and dressing)
• Evaluate and prescribe aids/appliances
• Correct cognitive/perceptual problems

 

Speech Therapist’s Aim

• Identify different types of communication disorders and plan appropriate treatment
• Address cognitive deficits affecting the patient’s memory, orientation, reasoning, problem-solving abilities and planning therapy accordingly
• Identify swallowing disorders and planning treatment

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A stroke occurs when blood supply to a part of the brain is disrupted. As a result, the brain cells are starved of oxygen, causing some to die, and damaging others.

 

What are the type of stroke and how do they occur?

There are two types of strokes:

• Ischemic Strokes are caused by the blockage of arteries supplying blood to the brain
  (e.g. due to High Cholesterol)
• Hemorrhagic Strokes are caused by the rupturing of blood vessels in the brain
  (e.g. due to High Blood Pressure)

 

What are the Risk Factors ?

• Old Age
• High Blood Pressure
• Smoking
• Diabetes Mellitus
• High Cholesterol

 

How do we diagnose Stroke?

The following tests may be performed:

• CT/MRI Scan of the brain to check the location of the blockage or bleeding in the brain, so as to determine the type of stroke the patient has suffered
• Blood Test to check for the presence risk factors (e.g. High Cholesterol and Diabetes Mellitus)
• Chest X-Ray/EEG to check for heart diseases
• Ultrasound studies, such as a Carotid Ultrasound, may be done to check for the narrowing of blood vessels in the neck area
• Angiogram, where an X –Ray of the blood supply in the brain is performed, so as to get information on the location and severity of the blockage or bleeding

 

What are the treatments available for Stroke?

Patients warded with stroke will be closely monitored, with special attention paid to their blood pressure, blood sugar and cholesterol levels.

Blood thinners like Aspirin may be used for Ischemic Stroke patients to allow for easier blood flow, while surgery may be needed for Hemorrhagic stroke patients.

The next phase of treatment is rehabilitation, which involves the help of a Physiotherapist/Speech Therapist. They will help train stroke patients to be independent in their daily activities.

 

What is the Prognosis? (Chance of Recovery)

Recovery varies depending on several factors, such as, the age of the patient and the severity of the stroke. Generally,

• 1/3 of patients fully recover
• 1/3 of patients partially recover
• 1/3 of patients do not recover at all

For more information, please call Parkway Neuroscience Programme

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A brain tumour is a mass of abnormal cells in the brain.

They may be primary (originating from the brain) or metastatic (spread to the brain from other parts of the body).

All brain tumours are either benign (slow-growing and non-cancerous) or malignant (fast-growing and cancerous).

 

What are the symptoms of Brain Tumour?

Common symptoms of brain tumour include:

• Recurring headaches that may worsen in the morning
• Vision problem
• Weakness in one part of the body
• Loss of balance
• Nausea and vomiting
• Seizures or loss of consciousness

 

What are the causes of Brain Tumour?

Research has shown genetic abnormality to be linked to some brain tumours, but in most cases of brain tumours, the cause is scientifically unknown.

 

How do we diagnose Brain Tumours?

Generally, tests prior to diagnosis involve the following:

• Scan/MRI scan of the brain
• Comprehensive neurological examination by the doctor

 

What are the Treatment Options

• Surgery is usually used to remove as much of the tumour as possible.
• Radiosurgery – the application of accurately focused beams of radiation directly to the tumour – aims to arrest the growth of the tumour, with treatment usually taking a few hours and done using the Gamma Knife machine or Linear accelerator machine
• Fractionated Radiotherapy is used for cancerous brain tumours that cannot be removed completely by surgery alone, with the treatment aiming to kill the remnant tumour cells and is given in daily small doses over a period of between two to six weeks
• Chemotherapy involves the use of drugs – taken either orally or given intravenously – to kill the cancer cells

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A seizure is an abnormal electrical discharge from a group of brain cells. A person is diagnosed as having epilepsy when he has more than one seizure recurrently.

 

What Causes Epilepsy?

People with the following conditions can have epilepsy

• Brain injury
• Stroke
• Brain Tumour
• Brain Infection

In over 50% of cases, the actual cause cannot be found.

 

What are the types of Epileptic Seizures and Symptoms?

There are two types of Epileptic Seizures:

• Focal Seizures affect only one part of the body – patients may have sensory, motor or visual disturbances but usually remain conscious
• Generalized Seizures usually start as a focal seizure but spread through the whole brain, causing rhythmic muscular contraction and relaxation lasting between one to two minutes; patients may experience tongue biting and breathing difficulties

 

How do we diagnose Epilepsy?

Epilepsy is diagnosed based on information obtained from observers or patients themselves regarding the events that happened during the seizures.

Doctors may request for patients to undergo further tests, such as:

• CT/MRI Scan of the brain, which is done to review the structural causes of the epilepsy
• Electroencephalogram (EEG), where electrodes are placed on the head of patients, who are then asked to perform certain tasks to see if epilepsy is triggered

 

What are the treatments available?

Medical Treatment

Anti–epileptic medications are usually the first line of treatment and patients may require more than one type of medication depending on the type of seizure they experience.

Surgical Treatment

Brain surgery may be considered for patients who do not respond to anti-epileptic medication.

 

What should i do when someone is having a Seizure?

Do

• Remain calm
• Protect the person from injury
• Observe the duration of seizure

Do not

• Restrain the person unless he is in danger of hurting himself
• Put anything into his mouth
• Crowd around the person

 

What are the prevention and precautions?

Prevent a seizure from recurring by following these precautions:

• Remember to medicate
• Relax
• Have enough sleep

 

Avoid the followings:

• Swimming alone in the pool/sea
• Bathing in a bathtub
• Cooking alone with an open fire
• Climbing to high places

For more information, please call the Parkway Neuroscience Programme

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Degenerative diseases of the Spine(Spondylosis)

Our spine is subjected to wear and tear, and the degeneration of the disc may cause it to bulge, thereby compressing the spinal cord. This will produce pain in the neck, back, or leg, and even numbness and weakness.

These degenerative disorders are diagnosed by imaging studies taken using a Magnetic Resonance Imaging (MRI) machine.

Treatment

Treatment varies based on the severity of the condition.

Conservative treatment, like medication, rest, and physiotherapy, will be the first line of treatment used.

Surgical intervention is only used for people with severe and painful symptoms so as to provide relief from pain. Options include:

• Microscopic Discectomy (removal of the damaged disc)
• Spinal fusions
• Artificial disc surgery, where the damaged disc is replaced with an implanted metallic disc
• Percutaneous pedicle screw (minimally invasive spine technique)
• Endoscopic discectomy (minimally invasive spine technique)

 

Spinal Tumor

Tumours growing in the spinal cord usually produce symptoms like back / leg pain, weakness, numbness of the leg and unsteady gait.

Treatment

Possible treatment usually includes surgery to relieve spinal cord pressure and to stabilize the spine.

Radiotherapy and Chemotherapy may be needed after surgery.

 

Spinal Traumas

Spinal injuries sustained from road traffic accidents are very common.

Spine fractures may cause pain or other neurological deficits, and surgery is needed in cases where the spine is rendered unstable or if there is a prolapsed disc causing cord compression.

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A brain aneurysm is a balloon-like bulge in the wall of a brain artery. If this balloon bursts and bleeds, the surrounding brain cells may be damaged.

 

What are the causes of Brain Aneurysm?

A brain aneurysm usually occurs in an artery wall that has a defect or is weak.

It is often associated with the hardening of the arteries.

High blood pressure, heredity factors, or head injury are possible causes that might have led to a brain aneurysm.

 

What are the symptoms?

Most people will not have any symptoms until the aneurysm bleeds.

When the aneurysm bleeds, symptoms experienced include:

• Severe headache, nausea and vomiting
• Brief blackout
• Neck stiffness
• Vision or speech problems
• Jerking movements
• Paralysis or weakness on one side of the body

 

How do we diagnose Brain Aneurysm?

Brain aneurysms need to be treated as soon as possible – otherwise, they can be fatal.

A fast and accurate diagnosis is essential for recovery. The following tests may be performed:

Cerebral Angiogram

A special dye that is visible on X-ray is injected into an artery that supplies blood to the brain. The dye will show any obstruction and bleeding in the X-ray images taken.

MRA

A Magnetic Resonance Angiogram (MRA) is done with the use of an MRI scanner to show the 3-dimensional structure of the blood supply in the brain.

CT Scan

A CT Scan will be able to detect any bleeding in the brain after a burst aneurysm.

 

What are the treatments available?

If the aneurysm has already ruptured, the goal of treatment is to prevent bleeding/another rupture while preserving the artery from which the aneurysm originated.

If the aneurysm has not burst, the goal will be to prevent it from bursting.

Surgery(Microsurgical Clipping of Aneurysm)

The neurosurgeon puts a clip on the aneurysm where it bulges from the artery. This prevents the blood from entering the aneurysm. As a result, further bleeding is avoided and the surrounding brain tissue is protected from additional damage.

Occlusion and Bypass

It may be best to stop blood flow through the artery leading to the aneurysm. This is called occlusion and is usually done as open surgery.

Sometimes occlusion is done together with a bypass. A bypass re-routes blood around the occlusion. It brings blood to the part of the brain that has been fed by the damaged artery. A small blood vessel is used for the bypass.

Endovascular Procedure

An endovascular procedure may be the best option for some aneurysms.

This is done in the X-ray Lab by the interventional Neuroradiologist. During this procedure, a catheter is guided from the groin to the brain arteries. Platinum coils are released into the aneurysm causing a blood clot to form within and sealing it off.

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Sweaty palms is a condition where there is excessive, uncontrollable hand sweating. This condition can lead to severe psychological and social problems, forcing many to seek treatment.

 

What causes it?

The condition is caused by over-activity of the sympathetic nervous system, a system of nerves within our body over which we have no control.

 

What are the treatments available?

A surgery called the Endoscopic Sympathectomy can be used for severe cases of sweaty palms. It involves cutting a section of the sympathetic nerves through small openings (from one to three) in the armpit.

 

What are the side effects of Surgery?

After the operation, there may be slightly more sweat in the legs and trunk but this is usually quite tolerable.

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Arteries normally carry oxygenated blood from the heart to the brain while the veins carry de-oxygenated blood away from the brain and back to the heart. An arteriovenous malformation (AVM) is a tangle of blood vessels in the brain which divert blood directly from the arteries to the veins, bypassing the normal brain tissue.

 

How common are brain AVMs?

Brain AVMs occur in less than one percent of the general population. It occurs in about one in 200–500 people, and is more common in males than females.

 

Why do brain AVMs occur?

We do not really know why brain AVMs occur. They are usually congenital, meaning someone is born with the condition. However, they are usually not hereditary. People probably do not inherit an AVM from their parents, and they probably will not pass an AVM on to their children.

 

Where do brain AVMs occur?

They can occur anywhere within the brain or on the covering of the brain. This includes the four major lobes of the front part of the brain (frontal, parietal, temporal, occipital), the back part of the brain (cerebellum), the brainstem, or the ventricles (deep spaces in the brain that produce the cerebrospinal fluid).

 

Do brain AVMs change or grow?

Most AVMs do not grow or change significantly, although the vessels involved may dilate. There are also reported cases of AVMs shrinking or enlarging. This can be explained by the clots in certain parts of an AVM, causing it to shrink, or the redistribution of blood flow into adjacent vessels, resulting in enlargement.

 

What are the symptoms of a brain AVM?

The symptoms of an AVM depend on where it occurs within the brain.

Over 50% of patients with an AVM present with intracranial haemorrhage.

20% - 25% of patients with an AVM have either focal or generalized seizures. Patients may experience localized pain in the head because of increased blood flow around an AVM.

15% of patients may have difficulty with movement, vision, or speech.

 

What causes brain AVMs to bleed?

A brain AVM contains abnormal and weakened blood vessels that direct blood away from the normal brain tissue. These weakened blood vessels dilate over time and may eventually burst due to the high pressure of blood flow from the arteries, causing bleeding into the brain.

 

What are the chances of a brain AVM bleeding?

Each AVM patient has a 1-3% chance of AVM bleeding per year.

Over a 15-year period, there is a 25% total chance of an AVM bleeding resulting in brain damage and stroke.

 

Does one bleed increase the chance of a second bleed?

The risk of a second bleeding is slightly elevated for a short period of time after the first bleed. In the first of two studies that were conducted, the risk during the first year after initial bleeding was 6% and then dropped to the baseline rate. In the second study, the risk of re-bleeding during the first year was 17.9%. The risk of recurrent bleeding may be even higher in the first year after the second bleed, and has been reported to be 25% during that year.

AVM patients between the ages of 11 and 35 are known to have a slightly higher risk of re-bleeding.

 

What can happen if a brain AVM bleeds?

There is a 10–15% risk of death related to each bleed and a 20–30% chance of permanent brain damage. Each time blood leaks into the brain, normal brain tissue is damaged. This results in the loss of normal function, which may be temporary or permanent. Some possible symptoms include arm or leg weakness/paralysis, or difficulty with speech, memory or vision. The extent of brain damage depends on the amount of blood leaking from the AVM.

 

How many different types of brain AVMs are there?

Although all blood vessel malformations involving the brain and its surrounding structures are commonly known as AVMs, there are actually 5 different classifications:

True arteriovenous malformation (AVM)

This is the most common brain vascular malformation and consists of a tangle of abnormal vessels connecting arteries and veins with no normal intervening brain tissue.

Venous malformation

This is an abnormality only of the veins. The veins are usually enlarged or appear in abnormal locations within the brain.

Occult AVM or cavernous malformations

This is a vascular malformation in the brain that does not actively divert large amounts of blood. It may bleed and often produces seizures.

Haemangiomas

Haemangiomas are abnormal blood vessels usually found at the surface of the brain and on the skin or facial structures. They are large and abnormal pockets of blood within normal tissue planes of the body.

Dural fistula

The covering of the brain is known as the "dura mater." When there is an abnormal connection between blood vessels in the dura, we call them dural fistula. There are three different types of dural fistulas:

• Dural carotid cavernous sinus fistula
  
  These occur behind the eye, and usually cause symptoms as a result of having diverted too much blood towards the eye. Patients may experience eye swelling, decreased vision, redness and congestion of the eye. They often can hear a "swishing" noise.
  
  
• Sagittal sinus and scalp dural fistula
  
  These occur near the top of the head. Patients usually complain of noise, headaches, and pain near the top of the head and they may present with prominent blood vessels on the scalp and above the ear.
  
  
• Transverse-Sigmoid sinus dural fistula
  
  These occur behind the ear and patients may complain of hearing a continuous noise that occurs with each heartbeat, local pain behind the ear, headaches, and neck pain.
  
  

What is the best available treatment for Dural Fistula?

The best treatment is usually endovascular surgical blocking of the abnormal connections that produce the fistula. This is done by guiding small tubes (catheters) inside the blood vessel and blocking off the abnormal connections under X-ray guidance. Depending upon the location and size, many of these can be successfully treated and cured using this technique.

 

How are AVMs diagnosed?

Most AVMs are detected either on a Computed Tomography (CT) brain scan or with a Magnetic Resonance Imaging (MRI) brain scan. These tests are very good at detecting brain AVMs. They also tell us about the location and size of the AVM and information on bleeding. A radiologist may also perform a cerebral angiogram, which involves the insertion of a catheter through an artery in the leg and guiding it into each of the vessels in the neck going to the brain, injecting contrast material (dye) and taking an X-ray of all the blood vessels in the brain. For treatments involving an AVM, an angiogram is usually done so that the doctor can identify the type of AVM present and plan the appropriate treatment.

 

What factors influence whether an AVM should be treated?

In general, an AVM may be considered for treatment if it has bled, if it is in an area of the brain that can be easily treated, and if it is not too large.

 

What is the best treatment for an AVM?

Treatment usually depends on the type of AVM (location and size) and the symptoms that it may be causing.

 

What are the different types of treatment available?

Medical Therapy

If the patient has no symptoms, or if the AVM occurs in a region of the brain that cannot be easily treated, conservative medical management may be necessary. The AVM patient will be advised to avoid blood thinners (Warfarin), and any activities that may excessively raise blood pressure (e.g. carrying heavy things or strenuous exercise).

They are encouraged to have regular checkups with a neurologist.

Surgery

If an AVM has bled and/or is in an area that can be easily operated upon, then surgical removal may be recommended. The patient is put to sleep with anaesthesia, a portion of the skull is removed, and the AVM is surgically removed. With the AVM completely removed, there will be no possibility of further bleeding.

Stereotactic Radiosurgery (Gamma Knife)

An AVM that is not too large, but is in an area that is difficult to reach by regular surgery, may be treated by performing Gamma Knife Radiosurgery.

A stereotactic frame is fixed onto the patient’s head by the neurosurgeon on the morning of the treatment.

Wearing this frame, the patient will have to undergo an MRI scan followed by a Cerebral Angiogram (X-ray to show blood vessels in the brain).The images of both studies are collected and fed into a special planning computer which allows the neurosurgeon to localize the AVM target, and create a good treatment plan.

A good treatment plan is one that enables us to deliver a high enough dose of radiation to the AVM for obliteration, while at the same time, sparing the surrounding normal brain tissue from radiation damage.

Once the plan is done and a dosage is prescribed by the radiation oncologist, a team of radiotherapists will carry out the treatment, which involves positioning the patient within the Gamma Knife machine so that focused beams of radiation are concentrated onto the AVM. This produces direct damage to the blood vessels and causes scarring of the vessel walls, allowing the AVM to ‘clot off’.

Interventional neuroradiology/endovascular neurosurgery

It may be possible to treat part – or all – of the AVM by placing a catheter (small tube) inside the blood vessels that supply the AVM, and blocking off the abnormal blood vessels with a variety of different materials. These include liquid tissue adhesives (glues), micro-coils, particles and other materials used to stop blood flowing to the AVM. The best course of treatment usually depends upon the type of symptoms, type of AVM present and the AVM’s size and location.

 

Who are the Specialists involved in treating brain AVMs?

Vascular neurosurgeons

Specialise in surgical removal of brain AVMs.

Radiation therapists/neurosurgeons

Specialise in the stereotactic radiosurgery treatment of brain AVMs.

Interventional neuroradiologists/endovascular neurosurgeons

Specialise in the endovascular therapy of brain AVMs.

Stroke neurologists

Specialise in the medical management of brain AVMs.

Neuroradiologists

Specialise in the diagnosis and imaging of the head, neck, brain, and spinal cord. They perform and interpret the CT, MRI, and cerebral angiograms necessary for evaluation, management, and treatment. Each of these specialists has gone through extensive training and is highly skilled at treating complex brain AVMs.

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