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Papers by monica saini

Neurology, Apr 5, 2016

Objective: To describe epidemiology, clinical features and outcomes of human immunodeficiency vir... more Objective: To describe epidemiology, clinical features and outcomes of human immunodeficiency virus (HIV) patients with acute cerebrovascular disease (CVD). Background: HIV infection is a risk factor for stroke, with several postulated etiological mechanisms. In Asia, there is paucity of data describing CVD in HIV patients. Methods: CVD (ischemic or hemorrhagic stroke, venous thrombosis) patients presenting to Tan Tock Seng Hospital between Apr 2004 and Dec 2014 were cross-matched with the hospital’s HIV database to identify those who developed CVD at or after diagnosis of HIV. Demographic, clinical, laboratory and neuroradiological information was obtained through retrospective chart review. Results: Of 26,998 CVD patients, 38 (mean age 52.7 ± 12.6 years; 36 male) had HIV infection. Sixteen (42.1[percnt]) presented within 2 years of HIV diagnosis; 2 (5.3[percnt]) diagnosed at index event. Fifteen (39.5[percnt]) were on anti-retroviral treatment. CVD included 34 (89.5[percnt]) ischemic strokes (IS), 4 (10.5[percnt]) hemorrhagic strokes (HS); none had venous thrombosis. Amongst IS patients, 24/34 (70.6[percnt]) had ≥ 2 and 10/34 (29.4[percnt]) had ≤ 1 out of 7 cerebrovascular risk factors. Trial of Org 10172 in Acute Stroke Treatment [TOAST] classification amongst IS patients was: large artery atherosclerosis 9 (26.5[percnt]), cardioembolic 9 (26.5[percnt]), small vessel disease 6 (17.6[percnt]), undetermined etiology 5 (14.7[percnt]). 4/34 IS patients were diagnosed with concurrent infections: 1 each for cryptococcal meningitis, tuberculous vasculitis, cryptococcosis/amoebiasis and cerebral toxoplasmosis. 3/4 had fever at presentation. 2/4 HS patients had thrombocytopenia. Mortality was: overall 7/38 (18.4[percnt]), infection-related IS 1/4 (25[percnt]), HS 3/4 (75[percnt]). 17/38 (44.7[percnt]) patients were discharged with no/mild functional impairment (modified Rankin Scale 0-2). 5/34 (14.7[percnt]) IS patients had recurrent IS within 12 months. Conclusions: Prevalence of CVS risk factors was significant in our population. Stroke in HIV patients may result from other disease mechanisms and carries significant mortality and morbidity. Fever at presentation suggests an infective etiology. Disclosure: Dr. Gan holds stock and/or stock options in a company which sponsored research in which Dr. Gan was involved as an investigator. Dr. Saini has nothing to disclose. Dr. Lee has nothing to disclose. Dr. Ng has nothing to disclose. Dr. Tan has nothing to disclose.

Expert Review of Neurotherapeutics, Feb 1, 2010

Hypertension is the most prevalent of the modifiable risk factors for stroke. The benefits of blo... more Hypertension is the most prevalent of the modifiable risk factors for stroke. The benefits of blood pressure (BP) lowering on primary and secondary prevention of stroke are undeniable. Despite this, BP control in hypertensive individuals and patients with prior cerebrovascular events is suboptimal. Noncompliance, inappropriate antihypertensive usage and under-utilization of medications contribute significantly to inadequate BP control. Recently, elegantly designed studies that assessed the preventive role of BP lowering in patients with cerebrovascular disease have helped clarify management issues in terms of BP targets and effective antihypertensive regimens. Current evidence suggests that BP targets for primary and secondary prevention are suboptimal and need reassessment. The effect of BP modulation in acute stroke is still not completely understood. Although the thresholds for BP treatment in acute stroke have been recommended, BP targets are as yet ill-defined. The available evidence supports early lowering of blood pressure following stroke. This review discusses the impact of blood pressure on stroke incidence and outcomes, outlines the recommendations for blood pressure lowering in stroke and delineates questions that still need to be addressed.

Journal of Clinical Neuromuscular Disease, Mar 1, 2022

Sexually Transmitted Diseases, Jan 28, 2021

This study was a case series of 3 patients with syphilitic spinal disease and a literature review... more This study was a case series of 3 patients with syphilitic spinal disease and a literature review on the diagnostic clinical, laboratory, and radiological features of this disease. Abstract Syphilitic spinal disease is a rare condition caused by the spirochete Treponema pallidum, either from direct spirochete involvement of the cord or as a consequence of indirect spirochete involvement of the meninges, blood vessels, or the vertebral column. After the introduction of penicillin therapy in the 1940s, it has become an increasingly rare condition. We report 3 challenging cases of syphilitic spinal disease presenting as myelopathy—1 with an extra-axial gumma of tertiary syphilis causing cord compression and 2 with tabes dorsalis complicated by tabetic spinal neuroarthropathy—each presenting a diagnostic dilemma to their treating physicians. We also review the literature for updates on modern investigative modalities and discuss pitfalls physicians need to avoid to arrive at the diagnosis.

Neurology India, 2009

In acute ischemic stroke, arterial occlusion results in a reduction in cerebral blood flow (CBF).... more In acute ischemic stroke, arterial occlusion results in a reduction in cerebral blood flow (CBF). The reduction in CBF varies regionally, within the distribution of the

Singapore Medical Journal, Apr 1, 2015

Annals of Indian Academy of Neurology, 2007

Stroke, Feb 1, 2019

Introduction: Increased visit-to-visit blood pressure variability (BPV) is linked to a higher ris... more Introduction: Increased visit-to-visit blood pressure variability (BPV) is linked to a higher risk of incident ischemic stroke in large epidemiologic studies. Hypothesis: Increased BPV in the acute phase after ischemic stroke will be correlated with death and poor outcome. Methods: This is a secondary analysis of patients in the placebo arms of the Virtual Stroke International Stroke Trial Archive (VISTA) with 4 or 5 blood pressure readings in the 24 hours after enrollment. Our primary outcome is death and the secondary is poor outcome, defined as a modified Rankin Scale of 3 to 6, both at 90 days from enrollment. We calculated BPV using 6 statistical methodologies (Table 1) and compared the highest to lowest tercile for each measure of BPV. Results: We included 1,947 patients, of whom 907 (46.6%) were female and the mean±SD age was 69.7±12.3 years. The mean±SD time from stroke onset to study enrollment was 4.8±2.4 hours and 534 (27.4%) received intravenous tPA. Of the 1,947 patients, 332 (19%) died within 90 days and 1,125 had a poor outcome (58%). We found that higher systolic BPV had a robust association with all-cause death, but not poor outcome (Tables 1 & 2). Diastolic BPV had a less consistent association with either outcome. Conclusion: Increased BPV in the first day after acute ischemic stroke is associated with a higher risk of death within 90 days, in the VISTA database. Prospective studies can establish if this is causal or an epiphenomenon.

Clinical Neurology and Neurosurgery, Mar 1, 2021

OBJECTIVE To determine prevalence and characteristics of mesiotemporal diffusion weighted imaging... more OBJECTIVE To determine prevalence and characteristics of mesiotemporal diffusion weighted imaging (DWI) lesions in transient global amnesia (TGA), and to determine prevalence of "missed" DWI lesions on routine radiological reporting. METHODS This is a retrospective study of patients with TGA admitted to a tertiary care hospital over ten years. Patients with TGA, who underwent magnetic resonance imaging (MRI) of the brain within one week of index event, were included in this study. MRI's were reviewed by two independent raters. Clinical data and other investigations were collated. RESULTS Of the 55 patients of TGA, 19 (35 %) had hyperintense DWI lesions with concordant apparent diffusion coefficient (ADC) hypointensity in the mesiotemporal region. Fifteen out of 19 (79 %) had unilateral lesions (6 left, 9 right). Twelve out of 19 DWI lesions were reported at the time of index scan. The false negative reporting rate was 36.8 %. DWI slice thickness (5 mm versus 3 mm), MRI machine strength (1.5 versus 3 T) and time interval from symptom onset to MRI brain (>24 h versus ≤ 24 h) were not significantly different between patients with or without DWI lesions and as well between patients with DWI lesions missed and initially reported at the time of index scan. CONCLUSION Punctuate DWI mesiotemporal lesions in TGA are prone to under-reporting. These lesions need to be categorically searched for at the time of reporting MRI Brain.

International Journal of Stroke, Sep 10, 2019

Stroke, Dec 1, 2010

Background and Purpose-Diffusion-weighted MRI (DWI) demonstrates ischemic tissue with high sensit... more Background and Purpose-Diffusion-weighted MRI (DWI) demonstrates ischemic tissue with high sensitivity. Although low cerebral blood volume (CBV) is also used as a marker for infarction, the quantitative relationship between diffusion abnormalities and CBV is unknown. We tested the hypothesis that CBV would decrease proportionally to the apparent diffusion coefficient in patients with acute stroke and thus could be used as a surrogate parameter for diffusion restriction. Methods-Perfusion-weighted imaging and DWI was performed in 54 patients within 28 hours of symptom onset. Mean apparent diffusion coefficient, cerebral blood flow, and CBV were measured within DWI lesions and contralateral regions. Results-Within DWI lesions, CBV (3.3Ϯ1.9 mL/100 g) was significantly decreased relative to contralateral regions (4.1Ϯ2.1 mL/100 g, PϽ0.001). Relative CBV was not decreased in patients with evidence of early reperfusion (1.2Ϯ0.5) or mild stroke (National Institutes of Health Stroke Scale Ͻ4, 1.1Ϯ0.6). Linear regression indicated that relative CBV was predictive of relative apparent diffusion coefficient only in patients imaged within 9 hours of symptom onset (Rϭ0.50, Pϭ0.02). Ischemic tissue volumes generated using a CBV threshold of the 50th percentile of normal tissue were correlated with DWI lesion volumes (Rϭ0.73, PϽ0.001). The mean difference between the CBV threshold of the 50th percentile of normal tissue and DWI lesion volumes was 6.3 mL (95% limits of agreement, 0.1 to 12.6 mL). Conclusions-Decreases in relative CBV are predictive of diffusion abnormalities in ischemic stroke. The pattern of CBV changes varies with clinical severity and symptom duration. Ischemic tissue volumes comparable to DWI lesions can be generated using CBV thresholds, but the use of this method is limited in patients with minor stroke. (Stroke. 2010; 41:2795-2800.

Journal of the Neurological Sciences, Nov 1, 2020

Purpose To describe the spectrum of COVID-19 neurology in Singapore. Method We prospectively stud... more Purpose To describe the spectrum of COVID-19 neurology in Singapore. Method We prospectively studied all microbiologically-confirmed COVID-19 patients in Singapore, who were referred for any neurological complaint within three months of COVID-19 onset. Neurological diagnoses and relationship to COVID-19 was made by consensus guided by contemporaneous literature, refined using recent case definitions. Results 47,572 patients (median age 34 years, 98% males) were diagnosed with COVID-19 in Singapore between 19 March to 19 July 2020. We identified 90 patients (median age 38, 98.9% males) with neurological disorders; 39 with varying certainty of relationship to COVID-19 categorised as: i) Central nervous system syndromes-4 acute disseminated encephalomyelitis (ADEM) and encephalitis, ii) Cerebrovascular disorders-19 acute ischaemic stroke and transient ischaemic attack (AIS/TIA), 4 cerebral venous thrombosis (CVT), 2 intracerebral haemorrhage, iii) Peripheral nervous system-7 mono/polyneuropathies, and a novel group, iv) Autonomic nervous system-4 limited dysautonomic syndromes. Fifty-one other patients had pre/co-existent neurological conditions unrelated to COVID-19. Encephalitis/ADEM is delayed, occurring in critical COVID-19, while CVT and dysautonomia occurred early in relatively mild infection. AIS/TIA was variable in onset, occurring in patients with differing COVID-19 severity; remarkably 63.2% were asymptomatic. CVT was more frequent than expected and occurred in mild/asymptomatic patients. There were no neurological complications in all 81 paediatric COVID-19 cases. Conclusion COVID-19 neurology has a wide spectrum of dysimmune-thrombotic disorders. We encountered relatively few neurological complications, probably because our outbreak involved largely young men with mild/ asymptomatic COVID-19. It is also widely perceived that the pandemic did not unduly affect Singapore healthcare system.

Stroke, Aug 1, 2011

Background and Purpose-Transient ischemic attack and minor stroke are associated with high ischem... more Background and Purpose-Transient ischemic attack and minor stroke are associated with high ischemic recurrence in the first week. We prospectively studied the correlation between baseline diffusion/perfusion deficits and development of new ischemic lesions. Methods-Patients with transient ischemic attack and those with minor stroke (nϭ50) underwent MRI at admission. Acute perfusion-weighted imaging deficit (Tmaxϩ2-second delay) and diffusion-weighted imaging (DWI) lesion volumes were measured planimetrically. Follow-up scans were examined for new DWI/fluid-attenuated inversion recovery lesions at Days 7 and 30. Results-Twenty-eight patients (56%) had acute DWI lesions. New DWI lesions developed in 9 of 50 patients (18%) at 1 week and 11 of 50 (cumulative 22%) at 4 weeks. Patients with new infarcts were more likely to have baseline DWI lesions (2 ϭ8.264, Pϭ0.003). Baseline DWI lesion volume was significantly larger in those who developed new lesions at Day 7 (median, 13.2 mL; interquartile range, 12 versus median 0.1 mL; interquartile range, 2 mL; PϽ0.001) and Day 30 (11.1 mL; interquartile range, 13 mL versus 0.1 mL; interquartile range, 13 mL; PϽ0.001). Thirty-eight patients had baseline perfusion-weighted imaging. Patients with recurrent lesions were more likely to have baseline perfusion deficits (2 ϭ19.5, PϽ0.0001). All new lesions developed within the baseline hypoperfused regions. Baseline DWI lesion volume predicted new lesion development at day 7 (OR, 1.17 per mL; CI, 1.05 to 1.30; Pϭ0.005) and Day 30 (OR, 1.39 per mL; CI, 1.03 to 1.26; Pϭ0.009) by regression analysis. Conclusions-Early recurrence of stroke is much more likely in patients with larger baseline DWI and perfusion-weighted imaging lesions. MRI lesion "recurrence" appears to be related to completion of the natural history of the original cerebrovascular syndrome rather than de novo events in most patients.

Alzheimers & Dementia, Jul 1, 2013

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Journal of the Neurological Sciences, May 1, 2021

10.1016/j.jns.2021.117406JOURNAL OF THE NEUROLOGICAL SCIENCES42

Annals Academy of Medicine Singapore, Aug 15, 2018

Dear Editor, Oculopharyngeal muscular dystrophy (OPMD) is a late onset, inherited muscle disease,... more Dear Editor, Oculopharyngeal muscular dystrophy (OPMD) is a late onset, inherited muscle disease, characterised by ptosis, dysphagia, variable proximal limb weakness and slow progression. 1-3 The highest reported prevalence is amongst Bukhara Jews (Israel; 1:600) and French Canadians (1:1000). Amongst East Asians, OPMD is thought to be rare. 4,5 The risk of misdiagnosis remains high, particularly when family history is not available, or symptoms are mild or isolated. Typically, diagnosis may be delayed for 3 to 20 years, with most patients undergoing extensive investigations and treatment for other suspected neurological conditions. 6,7 There have been a few reports from China, Taiwan, Hong Kong and Japan, with a small number of genetically confirmed OPMD cases from Southeast Asia (Thailand, Malaysia). 8-14 A previous case report from Singapore (1993) described a single patient, in whom OPMD was diagnosed clinically, with no genetic confirmation. 15 Underrecognition of OPMD may be one of the causes of the assumed rarity of OPMD in East Asia. Here, we describe 4 unrelated patients from Singapore diagnosed with OPMD over the past 4 years. Case 1: A 67-year-old Chinese gentleman presented with progressive ptosis since his 30s (Fig. 1), as well as progressive dysphagia and dysphonia for 5 years. Investigations are summarised in Table 1. Family history, which was not apparent prior to diagnosis, was notable for similar symptoms in approximately 20 family members living overseas, including his father and paternal grandfather. Mitochondrial cytopathy was initially considered, and muscle biopsy was performed (left biceps brachii muscle); needle electromyography of the contralateral biceps brachii muscle showed subpopulations of myopathic motor units. Subtle mitochondrial abnormalities were evident, with no rimmed vacuoles observed (Fig. 2). Genetic screening for OPMD showed heterozygous expansion of (GCN) in PABPN1 (13 repeats). Case 2: A 52-year-old Chinese gentleman presented with progressive, bilateral, asymmetrical ptosis for at least 10 years, and progressive dysphagia and dysphonia for 5 years. Ocular movements were slightly impaired bilaterally. The initial diagnosis was myasthenia gravis (MG), based on positive single fibre electromyography (SFEMG) study. He

QJM: An International Journal of Medicine, Aug 10, 2014

A 55-year-old gentleman underwent a percutaneous cardiac intervention (PCI) for an acute myocardi... more A 55-year-old gentleman underwent a percutaneous cardiac intervention (PCI) for an acute myocardial infarction. Towards the end of procedure, he developed acute vertigo. Neurological examination showed an isolated right internuclear ophthalmoplegia (INO). An urgent computed tomographic angiography of the brain was performed, which showed normal vertebrobasilar vessels. Magnetic resonance imaging done 24 h later (in view of recent cardiac stenting), showed an acute lacunar infarct involving the right medial longitudinal fasciculus (Figure 1). The reported rate of stroke in PCI is 0.4%, with mortality rates of 19%. 1 Scraping of aortic plaques, and microembolization is thought to be the etiologic mechanism. An isolated INO is a rare stroke syndrome, where embolism accounts only for a minority of cases. 2 Prognosis is excellent, and our patient also showed early complete recovery.

Journal of stroke and cerebrovascular diseases, Aug 1, 2014

Background: The aim of this study was to evaluate whether parameters noted on a single, acute com... more Background: The aim of this study was to evaluate whether parameters noted on a single, acute computed tomographic (CT) scan, are associated with significant cognitive impairment (SCogI), and can help in the prediction of SCogI 3-6 months after stroke or transient ischemic attack (TIA). Methods: Patients with a recent