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Aim: This article aims to inform and share the experience of a Singaporean tertiary level neurosurgical unit in an academic medical centre during the COVID-19 outbreak. Method: This is a descriptive study of our segregation team model which is designed with the aim of optimizing manpower and ensuring the safety and welfare of the neurosurgical unit, while maintaining and prioritizing excellent patient care. Result: We describe our method of team segregation, rostering, and outline some principles that we adhere to in its design. We also summarise the restructuring of our inpatient and outpatient service, including the operating theatre and protocols for specific procedures, intensive care and general wards, as well as clinic services and multidisciplinary meetings. Conclusion:We end with a commentary on residency training and anticipated challenges. Given the likely protracted course of the pandemic, it is key to account for sustainability of such measures and the conservation of resource via the reduction of pateint volume, upkeep of staff emotional and physical health and harnessing technologies such as telemedicine.

Background The current standard-of-care treatment for brain metastases (BM)≥20 is Whole Brain Radiotherapy (WBRT), which can cause neurocognitive decline detrimental to patients’ quality of life, especially if their functional status is good on presentation. The benefits of Gamma Knife Surgery (GKS) have been shown for BM≤10, but there is no consensus on the upper limit where GKS is no longer beneficial. We hypothesize that selected patients with ≥20 BM may benefit by replacing WBRT with GKS to preserve neurocognition without compromising intracerebral tumor control and overall survival, with additional treatments as needed. Methodology This is retrospective analysis of 31 patients with ≥20 BM who underwent single-session GKS between 2016–2021. Twenty-two patients had ECOG of 0 at the time of GKS. Median number of BM at GKS was 30 (20–79) with median total tumour volume 4cm3 (2–28 cm3). Median marginal dose was 20Gy (10-25Gy). Results Median overall survival following GKS was 14-months (95%CI 4-24months), justifying GKS in this population. 11/12 patients that died succumbed due to extracranial disease, while 1 patient, who was treated with WBRT before GKS, succumbed to intracranial tumor progression. Local tumor control achieved was achieved for 63% of patients at 2-years and distal tumor control in 24% of patients at 1.5-years without additional radiation treatment. Salvage GKS was given in seven patients and salvage WBRT in three. One local recurrence was surgically resected. Systemic treatment given to most patients probably contributed to intracranial tumor control. No patients developed significant neurocognitive deficits attributable to GKS during the follow-up period of median 7-months (Q1-Q3: 3-12months). Conclusion Most patients treated with GKS for ≥20 BM have sufficient survival time to benefit from the treatment. Local and distal recurrences can be managed with systemic treatment, salvage GKS, or WBRT, resulting in intracerebral tumor control in vast majority of cases.

Introduction Gamma Knife Surgery (GKS) is widely used for treatment of brainstem metastases (BSMs) with or without whole bran radiation therapy (WBRT). We hypothesized that BSMs treated with GKS using lower doses and omitting WBRT result in acceptable tumor control rates and low complication rates. Methods A retrospective single center study was performed to investigate the outcome following GKS of BSMs. All 33 patients with follow-up information treated with GKS for 39 metastases located in the cerebral peduncle, midbrain, pons or medulla oblongata were included in the study. The median treatment dose, defined as the lowest dose to 95% of the tumor volume, was 18 Gy. The tumor control rate as well as the survival time were related to a number of patients, tumor and treatment parameters. Results The local tumor control rate was 100% at one year and 89% at five years, and the overall median survival was 17 months. A good performance status and a treatable extracranial disease were favorably related to survival time. Two complications were observed, one lethal hemorrhage at the day of the treatment and one transient complication three months following GKS, resulting in a 6% complication rate at five years. Four of the 10 patient with symptomatic BSM improved clinically after GKS, while six remained unchanged. Conclusions High local control and a low complication rates can be achieved using GKS for BSMs using lower doses as compared to brain metastases in other locations.