1
|
Araújo CPLCD, Duarte MDCMB, Torres LC. Analyses of the soluble levels of sCD40L, sCD62P and sCD40 in pediatric sickle cell anemia patients with abnormal transcranial Doppler. Hematol Transfus Cell Ther 2024; 46:237-241. [PMID: 37202335 DOI: 10.1016/j.htct.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 05/20/2023] Open
Abstract
INTRODUCTION Serum levels of sCD40L, sCD40 and sCD62P were evaluated in sickle cell anemia (SCA) patients aged between 2 and 16 years with normal transcranial Doppler (TCD) and no stroke (G1, n = 24); in SCA patients with abnormal TCD (G2, n = 16); in SCA patients with a previous history of stroke (G3, n = 8), and; in healthy controls (aged 2 to 13 years; n = 26). RESULTS The levels of sCD40L were significantly higher in the G1, G2 and G3 groups, compared to controls (p = 0.0001, p < 0.0002 and p = 0.004, respectively). Among patients with SCA, higher levels of sCD40L were found in the G3 group, compared to the G2 group (p = 0.03). In the sCD62P analysis, high levels in G3, compared to G1 (p = 0.0001), G2 (p = 0.03) and G4 (p = 0.01), and G2 also had high levels, compared to G1 (p = 0.04). The G1 patients had a higher sCD40L/sCD62P ratio, compared to G2 (p = 0.003) and controls (p < 0.0001). The sCD40L/sCD40 ratios were higher in G1, G2 and G3, compared to controls (p < 0.0001, p = 0.008 and p = 0.002, respectively). CONCLUSION It was concluded that the combination of TCD abnormality, associated with levels of sCD40L and sCD62P, may contribute to a better assessment of the risk for stroke in pediatric SCA patients. Favor pedir para os autores corrigirem esta frase, pois NÃO é uma sentença completa em inglês: Our data suggest that decreased values of the s[LSM1] CD40L/sCD62P ratio involving two inflammatory mediators produced in platelet activation, being unprecedented in the literature.
Collapse
Affiliation(s)
- Cinthya Pereira Leite Costa de Araújo
- University of Health Sciences of the State of Alagoas (UNCISAL), Maceió, Brazil; Translational Research Laboratory Prof CA Hart, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Brazil
| | | | - Leuridan Cavalcante Torres
- Translational Research Laboratory Prof CA Hart, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Brazil
| |
Collapse
|
2
|
Vinci F, Tiseo M, Colosimo D, Calandrino A, Ramenghi LA, Biasucci DG. Point-of-care brain ultrasound and transcranial doppler or color-coded doppler in critically ill neonates and children. Eur J Pediatr 2024; 183:1059-1072. [PMID: 38112802 DOI: 10.1007/s00431-023-05388-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023]
Abstract
Point-of-care brain ultrasound and transcranial doppler or color-coded doppler is being increasingly used as an essential diagnostic and monitoring tool at the bedside of critically ill neonates and children. Brain ultrasound has already established as a cornerstone of daily practice in the management of the critically ill newborn for diagnosis and follow-up of the most common brain diseases, considering the easiness to insonate the brain through transfontanellar window. In critically ill children, doppler based techniques are used to assess cerebral hemodynamics in acute brain injury and recommended for screening patients suffering from sickle cell disease at risk for stroke. However, more evidence is needed regarding the accuracy of doppler based techniques for non-invasive estimation of cerebral perfusion pressure and intracranial pressure, as well as regarding the accuracy of brain ultrasound for diagnosis and monitoring of acute brain parenchyma alterations in children. This review is aimed at providing a comprehensive overview for clinicians of the technical, anatomical, and physiological basics for brain ultrasonography and transcranial doppler or color-coded doppler, and of the current status and future perspectives of their clinical applications in critically ill neonates and children. CONCLUSION In critically ill neonates, brain ultrasound for diagnosis and follow-up of the most common cerebral pathologies of the neonatal period may be considered the standard of care. Data are needed about the possible role of doppler techniques for the assessment of cerebral perfusion and vasoreactivity of the critically ill neonate with open fontanelles. In pediatric critical care, doppler based techniques should be routinely adopted to assess and monitor cerebral hemodynamics. New technologies and more evidence are needed to improve the accuracy of brain ultrasound for the assessment of brain parenchyma of critically ill children with fibrous fontanelles. WHAT IS KNOWN • In critically ill neonates, brain ultrasound for early diagnosis and follow-up of the most common cerebral and neurovascular pathologies of the neonatal period is a cornerstone of daily practice. In critically ill children, doppler-based techniques are more routinely used to assess cerebral hemodynamics and autoregulation after acute brain injury and to screen patients at risk for vasospasm or stroke (e.g., sickle cell diseases, right-to-left shunts). WHAT IS NEW • In critically ill neonates, research is currently focusing on the use of novel high frequency probes, even higher than 10 MHz, especially for extremely preterm babies. Furthermore, data are needed about the role of doppler based techniques for the assessment of cerebral perfusion and vasoreactivity of the critically ill neonate with open fontanelles, also integrated with a non-invasive assessment of brain oxygenation. In pediatric critical care, new technologies should be developed to improve the accuracy of brain ultrasound for the assessment of brain parenchyma of critically ill children with fibrous fontanelles. Furthermore, large multicenter studies are needed to clarify role and accuracy of doppler-based techniques to assess cerebral perfusion pressure and its changes after treatment interventions.
Collapse
Affiliation(s)
- Francesco Vinci
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Marco Tiseo
- Intensive Care Unit, 'Tor Vergata' University Hospital, Rome, Italy
| | - Denise Colosimo
- Pediatric Intensive Care Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Andrea Calandrino
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Luca Antonio Ramenghi
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Daniele Guerino Biasucci
- Department of Clinical Science and Translational Medicine, 'Tor Vergata' University of Rome, Rome, Italy.
| |
Collapse
|
3
|
O'Brien NF, Moons P, Johnson H, Tshimanga T, Musungufu DA, Ekandji RT, Mbaka JP, Babatila LK, Mayindombe L, Giresse B, Mwanza S, Lupumpaula C, Chilima JS, Nanyangwe A, Kabemba P, Kafula LN, Phiri T, June S, Gushu MB, Chagaluka G, Chunda‐Liyoka CM. Transcranial Doppler ultrasound velocities in a population of unstudied African children with sickle cell anemia. EJHAEM 2024; 5:3-10. [PMID: 38406536 PMCID: PMC10887331 DOI: 10.1002/jha2.818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 02/27/2024]
Abstract
The greatest burden of sickle cell anemia (SCA) globally occurs in sub-Saharan Africa, where significant morbidity and mortality occur secondary to SCA-induced vasculopathy and stroke. Transcranial Doppler ultrasound (TCD) can grade the severity of vasculopathy, with disease modifying therapy resulting in stroke reduction in high-risk children. However, TCD utilization for vasculopathy detection in African children with SCA remains understudied. The objective was to perform a prospective, observational study of TCD findings in a cohort of children with SCA from the Democratic Republic of the Congo, Zambia, and Malawi. A total of 770 children aged 2-17 years without prior stroke underwent screening TCD. A study was scored as low risk when the time-averaged maximum of the mean (TAMMX) in the middle cerebral artery or terminal internal carotid artery was <170 cm/s but >50 cm/s, conditional risk when 170-200 cm/s, and high risk when >200 cm/s. Low-risk studies were identified in 604 children (78%), conditional risk in 129 children (17%), and high risk in three children (0.4%). Additionally, 34 (4%) were scored as having an unknown risk study (TAMMX <50 cm/s). Over the course of 15 months of follow-up, 17 children (2.2%) developed new neurologic symptoms (six with low-risk studies, seven with conditional risk, and four with unknown risk). African children with SCA in this cohort had a low rate of high-risk TCD screening results, even in those who developed new neurologic symptoms. Stroke in this population may be multifactorial with vasculopathy representing only one determinant. The development of a sensitive stroke prediction bundle incorporating relevant elements may help to guide preventative therapies in high-risk children.
Collapse
Affiliation(s)
- Nicole F. O'Brien
- Department of PediatricsDivision of Critical Care MedicineNationwide Children's Hospital, The Ohio State UniversityColumbusOhioUSA
| | - Peter Moons
- Department of Pediatrics and Child HealthKamuzu University of Health SciencesBlantyreMalawi
| | - Hunter Johnson
- Department of PediatricsDivision of Critical Care MedicineNationwide Children's Hospital, The Ohio State UniversityColumbusOhioUSA
| | - Taty Tshimanga
- Departement de PediatrieCliniques Universitaires de Kinshasa, Hopital Pediatrique de Kalembe Lembe, Universite De KinshasaKimwenzaLembeRepublique Democratic du Congo
| | | | - Robert Tandjeka Ekandji
- Universite des Sciences et des Technologie de Lodja, L'Hopital General de Reference de Lodja, Sankuru DistrictLodjaRepublique Democratic du Congo
| | - Jean Pongo Mbaka
- Universite des Sciences et des Technologie de Lodja, L'Hopital General de Reference de Lodja, Sankuru DistrictLodjaRepublique Democratic du Congo
| | - Lydia Kuseyila Babatila
- Departement de PediatrieCliniques Universitaires de Kinshasa, Hopital Pediatrique de Kalembe Lembe, Universite De KinshasaKimwenzaLembeRepublique Democratic du Congo
| | - Ludovic Mayindombe
- Departement de PediatrieCliniques Universitaires de Kinshasa, Hopital Pediatrique de Kalembe Lembe, Universite De KinshasaKimwenzaLembeRepublique Democratic du Congo
| | - Buba Giresse
- Departement de PediatrieCliniques Universitaires de Kinshasa, Hopital Pediatrique de Kalembe Lembe, Universite De KinshasaKimwenzaLembeRepublique Democratic du Congo
| | - Suzanna Mwanza
- Department of PaediatricsChipata Central HospitalChipataZambia
| | | | | | - Alice Nanyangwe
- University Teaching Hospitals—Children's HospitalLusakaZambia
| | - Peter Kabemba
- University Teaching Hospitals—Children's HospitalLusakaZambia
| | | | - Tusekile Phiri
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, ChichiriBlantyreMalawi
| | - Sylvester June
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, ChichiriBlantyreMalawi
| | | | - George Chagaluka
- Department of Pediatrics and Child HealthKamuzu University of Health SciencesBlantyreMalawi
| | | |
Collapse
|
4
|
Effects of age, gender, and hemisphere on cerebrovascular hemodynamics in children and young adults: Developmental scores and machine learning classifiers. PLoS One 2022; 17:e0263106. [PMID: 35120173 PMCID: PMC8815867 DOI: 10.1371/journal.pone.0263106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 01/13/2022] [Indexed: 11/19/2022] Open
Abstract
A constant blood supply to the brain is required for mental function. Research with Doppler ultrasonography has important clinical value and burgeoning potential with machine learning applications in studies predicting gestational age and vascular aging. Critically, studies on ultrasound metrics in school-age children are sparse and no machine learning study to date has used color duplex ultrasonography to predict age and classify age-group. The purpose of our study is two-fold: first to document cerebrovascular hemodynamics considering age, gender, and hemisphere in three arteries; and second to construct machine learning models that can predict and classify the age and age-group of a participant using ultrasonography metrics. We record peak systolic, end-diastolic, and time-averaged maximum velocities bilaterally in internal carotid, vertebral, and middle cerebral arteries from 821 participants. Results confirm that ultrasonography values decrease with age and reveal that gender and hemispheres show more similarities than differences, which depend on age, artery, and metric. Machine learning algorithms predict age and classifier models distinguish cerebrovascular hemodynamics between children and adults. Blood velocities, rather than blood vessel diameters, are more important for classifier models, and common and distinct variables contribute to age classification models for males and females.
Collapse
|
5
|
Dlamini N, Pohl K, Eley B, Van Toorn R, Kilborn T, Padayachee S, Pontigon AM, Kirkham FJ, Wilmshurst J. Stroke transcranial Doppler in children with human immunodeficiency virus. Dev Med Child Neurol 2020; 62:735-741. [PMID: 31916251 DOI: 10.1111/dmcn.14439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 11/28/2022]
Abstract
AIMS To describe stroke syndromes and transcranial Doppler (TCD) findings in children with human immunodeficiency virus (HIV) and examine the associations between TCD and clinical and laboratory data. METHOD We enrolled 42 children (24 males, 18 females) with HIV (median age=7y 6mo; 2y 7mo-15y 6mo), with and without stroke who underwent a TCD examination of the anterior and posterior circulations to derive time-averaged maximum mean velocity (TAMMV) measurements for comparison with previous studies. Clinical and laboratory variables were extracted from the medical records. RESULTS Of the 42 children with HIV, five had right-sided hemiparesis, three had chronic lung disease, two occurred post-varicella infection, one after herpetic oral ulceration, and one had a poorly functioning left ventricle. Neuroimaging showed middle cerebral artery (MCA) TAMMV greater than 200cm/s, moyamoya-like arteriopathy, left basal ganglia infarction with ipsilateral stenosis, hygroma consistent with venous thrombosis, and a hyperdense left MCA. Eight neurologically asymptomatic children had atypical TCD. The CD4 cell count was non-significantly lower in 6 out of 30 children with atypical TCD (median=21.5; interquartile range=16.1-26.5) compared with the remainder (median=29; interquartile range=21.3-35.0; p=0.09). INTERPRETATION A variety of stroke syndromes occur in children with HIV. TCD suggests atypical intracranial vessels and/or haemodynamics in some children with HIV infection, consistent with vasculopathy, possibly related directly to immunodeficiency and/or infection. WHAT THIS PAPER ADDS A range of stroke syndromes are found in children with human immunodeficiency virus (HIV). Transcranial Doppler (TCD) velocities in HIV are commonly outside the range for typically developing children. TCD and neuroimaging data in children with HIV suggest intracranial vasculopathy as one mechanism for stroke. CD4 cell count is non-significantly lower in children with HIV and atypical TCD.
Collapse
Affiliation(s)
- Nomazulu Dlamini
- Evelina Children's Hospital, London, UK.,The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Brian Eley
- Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Tracy Kilborn
- Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
| | | | | | - Fenella J Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK.,Child Health, University Hospital Southampton, Southampton, UK.,Paediatric Neurosciences, King's College Hospital, London, UK
| | - Jo Wilmshurst
- Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
6
|
Terrell D, Savardekar AR, Whipple SG, Dossani RH, Spetzler RF, Sun H. Cerebral Revascularization for Moyamoya Syndrome Associated with Sickle Cell Disease: A Systematic Review of the Literature on the Role of Extracranial-Intracranial Bypass in Treating Neurologic Manifestations of Pediatric Patients with Sickle Cell Disease. World Neurosurg 2020; 137:62-70. [PMID: 32014541 DOI: 10.1016/j.wneu.2020.01.182] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 01/16/2023]
Abstract
Moyamoya syndrome (MMS) in patients with sickle cell disease (SCD) accentuates the risk of recurrent strokes. Chronic transfusion therapy (CTT) is an excellent option for preventing recurrent strokes in most patients with SCD. In SCD with MMS, CTT may fail as a long-term solution. Cerebral revascularization, in the form of extracranial-intracranial bypass, has been shown to prevent recurrent strokes in this cohort. We review the evolution of this paradigm shift in the management of SCD-associated MMS. A systematic review, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, was conducted. Our primary objectives were 1) to study the evolution of cerebral revascularization techniques in management of MMS in SCD and 2) to analyze the impact of neurosurgical intervention in this high-risk population. Four patients with SCD-associated MMS, who underwent indirect cerebral revascularization at our institute were retrospectively reviewed. A summary of 13 articles chronicling the advent and subsequent evolution of cerebral revascularization as a viable treatment strategy for stroke prevention in SCD-associated MMS is presented. The literature review suggests that early detection and surgical intervention (in addition to CTT) could significantly reduce stroke recurrence and improve neurocognitive outcome. Our short series of 4 patients also had a good outcome and no recurrence of strokes postoperatively. The literature emphasizes the use of a traditional standardized protocol for early identification (transcranial Dopplers, selective magnetic resonance angiography, and CTT). Early treatment and screening that involves early magnetic resonance angiography and referral to neurosurgery for revascularization may be considered for this high-risk population.
Collapse
Affiliation(s)
- Danielle Terrell
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Amey R Savardekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Stephen Garrett Whipple
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Rimal H Dossani
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Hai Sun
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
| |
Collapse
|
7
|
Kapustin D, Leung J, Odame I, Williams S, Shroff M, Kassner A. Hydroxycarbamide treatment in children with Sickle Cell Anaemia is associated with more intact white matter integrity: a quantitative MRI study. Br J Haematol 2019; 187:238-245. [PMID: 31215028 DOI: 10.1111/bjh.16063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/07/2019] [Indexed: 11/29/2022]
Abstract
Sickle cell anaemia (SCA) is a devastating genetic blood disorder leading to chronic anaemia, impaired cerebrovascular dilatory capacity and cerebral infarctions. Our aim was to assess the relationship between microstructural properties of the white matter (WM) and both cerebrovascular reactivity (CVR) and cerebral blood flow, as well as the effects of hydroxycarbamide on these relationships. Our results demonstrate that mean CVR was increased in hydroxycarbamide-treated patients compared to untreated patients. Moreover, untreated SCA patients had increased skew and kurtosis of mean diffusivity histograms in the WM compared to hydroxycarbamide-treated patients and healthy age-matched controls, indicating disruption of WM integrity. Regression analysis of CVR and WM mean diffusivity (MD) revealed a significant linear relationship between CVR and MD histogram skew and kurtosis in healthy controls, but not in either of the two SCA groups. These findings suggest that patients treated with hydroxycarbamide possess white matter MD histogram parameters which more closely resemble those of healthy controls.
Collapse
Affiliation(s)
- Daniel Kapustin
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jackie Leung
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Isaac Odame
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Suzan Williams
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Manohar Shroff
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrea Kassner
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
8
|
Detterich JA. Simple chronic transfusion therapy, a crucial therapeutic option for sickle cell disease, improves but does not normalize blood rheology: What should be our goals for transfusion therapy? Clin Hemorheol Microcirc 2018; 68:173-186. [PMID: 29614631 DOI: 10.3233/ch-189006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Sickle cell anemia is characterized by a mutation resulting in the formation of an abnormal beta-hemoglobin called hemoglobin S. Hemoglobin S polymerizes upon deoxygenation, causing impaired red blood cell deformability and increased blood viscosity at equivalent hematocrits. Thus, sickle cell disease is a hemorheologic disease that results in various pathologic processes involving multiple organ systems including the lungs, heart, kidneys and brain. Red blood cell mechanics and the perturbations on blood flow-endothelial interaction underlie much of the pathology found in sickle cell disease. Transfusion therapy is one of the few therapeutic options available to patients, acting as both primary and secondary prevention of stroke. Transfusion therapy, both simple and exchange, is also used for unremitting and frequent pain crises and pulmonary hypertension. Therefore, understanding basic rheologic changes following transfusion inform other therapeutic options that aim to mitigate this diffuse pathologic process. This review will aim to highlight transfusion effects on blood rheology.
Collapse
Affiliation(s)
- Jon A Detterich
- Division of Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.,Department of Biophysics and Physiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| |
Collapse
|
9
|
Moeen SM, Thabet AF, Hasan HA, Saleh MA. Lower Transcranial Doppler Flow Velocities in Sickle Cell Anemia Patients on Hydroxyurea: Myth or Fact. Indian J Hematol Blood Transfus 2018; 34:97-103. [PMID: 29398806 DOI: 10.1007/s12288-017-0814-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 04/04/2017] [Indexed: 12/21/2022] Open
Abstract
Transcranial Doppler (TCD) detects stroke risk in patients with sickle cell anemia (SCA). Hydroxyurea therapy has the ability to induce increased levels of fetal hemoglobin in sickle cells thus decreasing tendency for red cell sickling. This study aimed to evaluate TCD findings in SCA patients on hydroxyurea and correlate the time-averaged mean velocity (TAMV) with their hematological parameters. Forty SCA patients of both sexes, aged 16-22 years with no history of stroke were screened with TCD for an elevated TAMV, divided into: Group T (20 patients on blood transfusion); and Group H (20 patients on daily hydroxyurea). For all, full medical history, clinical examination, hemoglobin, hematocrit, leukocytes, platelets, fetal hemoglobin and sickling test, in addition TCD to describe the pattern of cerebral blood flow abnormalities were done. TAMV in all cerebral arteries were significantly higher in Group T than Group H, the highest TAMV (147.5 ± 57.09 cm/s) was found in the right middle cerebral artery and correlated negatively with hematocrit in Groups H (P < 0.001). There were 2 (10%) abnormal TAMV results and 5 (25%) conditional in Group T, while all results were normal in Group H. Hydroxyurea therapy may lower TCD velocities and prevent the risk of primary stroke in SCA patients.
Collapse
Affiliation(s)
- Sawsan M Moeen
- 1Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmad F Thabet
- 1Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hosam A Hasan
- 2Department of Radio-diagnosis, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Medhat A Saleh
- 3Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| |
Collapse
|
10
|
Chevret S, Verlhac S, Ducros-Miralles E, Dalle JH, de Latour RP, de Montalembert M, Benkerrou M, Pondarré C, Thuret I, Guitton C, Lesprit E, Etienne-Julan M, Elana G, Vannier JP, Lutz P, Neven B, Galambrun C, Paillard C, Runel C, Jubert C, Arnaud C, Kamdem A, Brousse V, Missud F, Petras M, Doumdo-Divialle L, Berger C, Fréard F, Taieb O, Drain E, Elmaleh M, Vasile M, Khelif Y, Bernaudin M, Chadebech P, Pirenne F, Socié G, Bernaudin F. Design of the DREPAGREFFE trial: A prospective controlled multicenter study evaluating the benefit of genoidentical hematopoietic stem cell transplantation over chronic transfusion in sickle cell anemia children detected to be at risk of stroke by transcranial Doppler (NCT 01340404). Contemp Clin Trials 2017; 62:91-104. [DOI: 10.1016/j.cct.2017.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 08/09/2017] [Accepted: 08/14/2017] [Indexed: 01/28/2023]
|
11
|
Adegoke SA, Macedo-Campos RDS, Braga JAP, Figueiredo MS, Silva GS. Changes in Transcranial Doppler Flow Velocities in Children with Sickle Cell Disease: The Impact of Hydroxyurea Therapy. J Stroke Cerebrovasc Dis 2017; 27:425-431. [PMID: 29056404 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/30/2017] [Accepted: 09/17/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hydroxyurea (HU) was recently described as a substitute for chronic transfusion for children with sickle cell disease (SCD) and abnormal transcranial Doppler (TCD) velocities who have received at least 1 year of transfusions. However, the role of HU in reverting elevated TCD velocities in patients not treated with transfusion is still debatable. The objective of the study was to examine whether HU influences the progression of TCD velocities in children with SCD. PATIENTS AND METHODS Children with SCD with at least 2 TCDs not less than 6 months apart were evaluated over 51 months. Time-averaged maximum mean (TAMM) velocities for the initial and the last transcranial Doppler examinations were noted and differences compared between HU and HU-naive groups. RESULTS Overall, 68.8% of the HU-group with elevated TCD velocities compared with 40.0% of the HU-naive experienced TCD reversal (P = .047). A higher proportion of the HU-naive group, 7 (14.3%) versus 9.8% of the HU group experienced TCD conversion. Those with initial conditional velocities in the HU-group experienced a significant reduction in TAMM velocities (from 176.8 ± 5.3 to 162.7 ± 13.9 cm/s, difference of 14.1 cm/s; P = .001) unlike those in the HU-naive group (176.3 ± 5.3 to 170.0 ± 18.6 cm/s, difference of 6.3 cm/s; P = .148). The change in the TAMM velocities was also significantly higher among the HU-group (14.1 ± 12.4 cm/s versus 6.3 ± 18.5 cm/s, P = .015). CONCLUSION Our data suggest a beneficial role of HU in TCD velocity reduction in patients not treated with chronic transfusions, particularly among those with initial conditional TCD velocities.
Collapse
Affiliation(s)
- Samuel Ademola Adegoke
- Haematology and Blood Transfusion Division, Universidade Federal de São Paulo, São Paulo, Brazil; Department of Pediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria.
| | | | | | - Maria Stella Figueiredo
- Haematology and Blood Transfusion Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, São Paulo, Brazil
| |
Collapse
|
12
|
Buckley EM, Platt MO, Lam WA. Novel in vivo and in vitro techniques to image and model the cerebral vasculature in sickle cell disease. Blood Cells Mol Dis 2017; 67:114-119. [PMID: 28822622 DOI: 10.1016/j.bcmd.2017.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 08/07/2017] [Indexed: 01/20/2023]
Affiliation(s)
- Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, United States; Department of Pediatrics, Emory University, United States.
| | - Manu O Platt
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, United States.
| | - Wilbur A Lam
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, United States; Department of Pediatrics, Emory University, United States; Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, United States.
| |
Collapse
|
13
|
Buch K, Arya R, Shah B, Nadgir RN, Saito N, Qureshi MM, Sakai O. Quantitative Analysis of Extracranial Arterial Tortuosity in Patients with Sickle Cell Disease. J Neuroimaging 2016; 27:421-427. [DOI: 10.1111/jon.12418] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/13/2016] [Accepted: 11/14/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- Karen Buch
- Departments of Radiology; Boston Medical Center, Boston University School of Medicine; Boston MA
| | - Rahul Arya
- Departments of Radiology; Boston Medical Center, Boston University School of Medicine; Boston MA
| | - Bhavya Shah
- Departments of Radiology; Boston Medical Center, Boston University School of Medicine; Boston MA
| | - Rohini N. Nadgir
- Departments of Radiology; Boston Medical Center, Boston University School of Medicine; Boston MA
| | - Naoko Saito
- Departments of Radiology; Boston Medical Center, Boston University School of Medicine; Boston MA
| | - Muhammad M. Qureshi
- Departments of Radiology; Boston Medical Center, Boston University School of Medicine; Boston MA
- Radiation Oncology; Boston Medical Center, Boston University School of Medicine; Boston MA
| | - Osamu Sakai
- Departments of Radiology; Boston Medical Center, Boston University School of Medicine; Boston MA
- Radiation Oncology; Boston Medical Center, Boston University School of Medicine; Boston MA
- Otolaryngology - Head and Neck Surgery; Boston Medical Center, Boston University School of Medicine; Boston MA
| |
Collapse
|
14
|
Rivera CP, Veneziani A, Ware RE, Platt MO. Original Research: Sickle cell anemia and pediatric strokes: Computational fluid dynamics analysis in the middle cerebral artery. Exp Biol Med (Maywood) 2016; 241:755-65. [PMID: 26946534 DOI: 10.1177/1535370216636722] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Children with sickle cell anemia (SCA) have a high incidence of strokes, and transcranial Doppler (TCD) identifies at-risk patients by measuring blood velocities in large intracerebral arteries; time-averaged mean velocities greater than 200 cm/s confer high stroke risk and warrant therapeutic intervention with blood transfusions. Our objective was to use computational fluid dynamics to alter fluid and artery wall properties, to simulate scenarios causative of significantly elevated arterial blood velocities. Two-dimensional simulations were created and increasing percent stenoses were created in silico, with their locations varied among middle cerebral artery (MCA), internal carotid artery (ICA), and anterior cerebral artery (ACA). Stenoses placed in the MCA, ICA, or ACA generated local increases in velocity, but not sufficient to reach magnitudes > 200 cm/s, even up to 75% stenosis. Three-dimensional reconstructions of the MCA, ICA, and ACA from children with SCA were generated from magnetic resonance angiograms. Using finite element method, blood flow was simulated with realistic velocity waveforms to the ICA inlet. Three-dimensional reconstructions revealed an uneven, internal arterial wall surface in children with SCA and higher mean velocities in the MCA up to 145 cm/s compared to non-SCA reconstructions. There were also greater areas of flow recirculation and larger regions of low wall shear stress. Taken together, these bumps on the internal wall of the cerebral arteries could create local flow disturbances that, in aggregate, could elevate blood velocities in SCA. Identifying cellular causes of these microstructures as adhered blood cells or luminal narrowing due to endothelial hyperplasia induced by disturbed flow would provide new targets to treat children with SCA. The preliminary qualitative results provided here point out the critical role of 3D reconstruction of patient-specific vascular geometries and provide qualitative insight to complex interplay between vascular geometry and rheological properties possibly altered by SCA.
Collapse
Affiliation(s)
- Christian P Rivera
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Alessandro Veneziani
- Department of Math and Computer Science at Emory University, Atlanta, GA 30322, USA
| | - Russell E Ware
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Manu O Platt
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| |
Collapse
|
15
|
Sommet J, Alberti C, Couque N, Verlhac S, Haouari Z, Mohamed D, François M, Missud F, Holvoet L, Elmaleh M, Ithier G, Denjean A, Elion J, Baruchel A, Benkerrou M. Clinical and haematological risk factors for cerebral macrovasculopathy in a sickle cell disease newborn cohort: a prospective study. Br J Haematol 2016; 172:966-77. [DOI: 10.1111/bjh.13916] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 11/13/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Julie Sommet
- U 1123; ECEVE; Hôpital Robert-Debré; INSERM; Paris France
- UMR-S 1123; ECEVE; Sorbonne Paris Cité; Univ Paris Diderot; Paris France
- Hôpital Robert-Debré; Unité d'Epidémiologie Clinique; AP-HP; Paris France
| | - Corinne Alberti
- U 1123; ECEVE; Hôpital Robert-Debré; INSERM; Paris France
- UMR-S 1123; ECEVE; Sorbonne Paris Cité; Univ Paris Diderot; Paris France
- Hôpital Robert-Debré; Unité d'Epidémiologie Clinique; AP-HP; Paris France
| | - Nathalie Couque
- Hôpital Robert-Debré; UF de Génétique Moléculaire; AP-HP; Paris France
| | - Suzanne Verlhac
- Hôpital Robert-Debré; Service de Radiologie; AP-HP; Paris France
| | - Zinedine Haouari
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
| | - Damir Mohamed
- Hôpital Robert-Debré; Unité d'Epidémiologie Clinique; AP-HP; Paris France
| | | | - Florence Missud
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
| | - Laurent Holvoet
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
| | - Monique Elmaleh
- Hôpital Robert-Debré; Service de Radiologie; AP-HP; Paris France
| | - Ghislaine Ithier
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
| | - André Denjean
- Hôpital Robert-Debré; Service de Physiologie; AP-HP; Paris France
- UMR 1141; Sorbonne Paris Cité; Univ Paris Diderot; Paris France
| | - Jacques Elion
- Hôpital Robert-Debré; UF de Génétique Moléculaire; AP-HP; Paris France
- UMR-S 1134; Laboratoire d'Excellence GR-Ex; INSERM; Paris France
| | - André Baruchel
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Institut Universitaire d'Hématologie EA3518; Hôpital Saint Louis; Univ Paris Diderot; Sorbonne Paris Cité; Paris France
| | - Malika Benkerrou
- U 1123; ECEVE; Hôpital Robert-Debré; INSERM; Paris France
- UMR-S 1123; ECEVE; Sorbonne Paris Cité; Univ Paris Diderot; Paris France
- Hôpital Robert-Debré; Service d'Hématologie; AP-HP; Paris France
- Hôpital Robert-Debré; Centre de Référence de la Drépanocytose; AP-HP; Paris France
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW A major advantage of transcranial Doppler (TCD) ultrasound is its ability to measure cerebral hemodynamics noninvasively at the patient's bedside. This article summarizes the basic physics and variables used during TCD, recent pediatric data published on the use of TCD in stroke and cerebrovascular disorders and how it may impact diagnosis and management, and some issues to be resolved so that TCD can be put into clinical practice. RECENT FINDINGS In sickle cell disease in children, TCD is the gold standard stroke prediction tool. Recent data suggest that TCD may provide important information in ischemic stroke because of other childhood arteriopathies such as moyamoya syndrome, transient or focal cerebral arteriopathy, and genetic/syndromic causes. TCD may also detect cerebral emboli and diagnose right-to-left atrial cardiac shunts in children with cryptogenic stroke and transient ischemic attack. SUMMARY There are many potential clinical applications for TCD in pediatric stroke and cerebrovascular disorders. Additional research in children is needed to determine whether TCD can identify markers of increased stroke risk, elucidate underlying stroke mechanisms, influence the choice of additional testing and treatment, and ultimately impact patient outcomes.
Collapse
|
17
|
LaRovere KL, O'Brien NF. Transcranial Doppler Sonography in Pediatric Neurocritical Care: A Review of Clinical Applications and Case Illustrations in the Pediatric Intensive Care Unit. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:2121-32. [PMID: 26573100 DOI: 10.7863/ultra.15.02016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/31/2015] [Indexed: 05/25/2023]
Abstract
Transcranial Doppler sonography is a noninvasive, real-time physiologic monitor that can detect altered cerebral hemodynamics during catastrophic brain injury. Recent data suggest that transcranial Doppler sonography may provide important information about cerebrovascular hemodynamics in children with traumatic brain injury, intracranial hypertension, vasospasm, stroke, cerebrovascular disorders, central nervous system infections, and brain death. Information derived from transcranial Doppler sonography in these disorders may elucidate underlying pathophysiologic characteristics, predict outcomes, monitor responses to treatment, and prompt a change in management. We review emerging applications for transcranial Doppler sonography in the pediatric intensive care unit with case illustrations from our own experience.
Collapse
Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts USA (K.L.L.); and Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio USA (N.F.O.).
| | - Nicole F O'Brien
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts USA (K.L.L.); and Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio USA (N.F.O.)
| |
Collapse
|
18
|
Dépistage de la vasculopathie cérébrale drépanocytaire par doppler transcrânien au Mali. Arch Pediatr 2015; 22:260-6. [DOI: 10.1016/j.arcped.2014.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 10/24/2014] [Accepted: 12/09/2014] [Indexed: 11/22/2022]
|
19
|
Arkuszewski M, Krejza J, Chen R, Ichord R, Kwiatkowski JL, Bilello M, Zimmerman R, Ohene-Frempong K, Melhem ER. Sickle cell anemia: intracranial stenosis and silent cerebral infarcts in children with low risk of stroke. Adv Med Sci 2014; 59:108-13. [PMID: 24797985 DOI: 10.1016/j.advms.2013.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 09/13/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Children with sickle cell anemia (SCA), who have mean blood flow velocities <170 cm/s in the terminal internal carotid (tICA) or middle cerebral (MCA) arteries on transcranial Doppler ultrasonography (TCD), are considered to be at low risk of stroke. The prevalence of intracranial stenosis, which raises the risk of stroke, is not known in these children. Here, we estimated the prevalence of stenosis and explored its association with silent cerebral infarcts determined based on Magnetic Resonance (MR) scans. PATIENTS/METHODS We studied prospectively a cohort of 67 children with SCA without prior clinically overt stroke or TIA (median age 8.8 years; range limits 2.3-13.1 years; 33 females) and with TCD mean velocity <170 cm/s. They underwent MR imaging of the brain and MR angiography of intracranial arteries. RESULTS In 7 children (10.5%, 95% CI: 4.9-20.3%) we found 10 stenoses, including 4 with isolated left tICA stenosis and 3 with multiple stenoses. We found silent infarcts in 26 children (37.7%, 95% CI: 27.2-49.5%). The median number of infarcts in an affected child was 2 (range limits: 1-9), median volume of infarcts was 171 mm(3) (range limits: 7-1060 mm(3)), and median infarct volume in relation to total brain volume was 0.020% (range limits: 0.001-0.101%). The number and volume of infarcts were significantly higher in children with arterial stenosis (both p=0.023). CONCLUSIONS The prevalence of intracranial arterial stenosis in children with SCA classified as at low risk of stroke by TCD mean velocity <170 cm/s is high. Children with stenosis are at higher risk of brain parenchymal injury as they have more silent cerebral infarcts.
Collapse
|
20
|
Cox SE, Makani J, Soka D, L'Esperence VS, Kija E, Dominguez-Salas P, Newton CRJ, Birch AA, Prentice AM, Kirkham FJ. Haptoglobin, alpha-thalassaemia and glucose-6-phosphate dehydrogenase polymorphisms and risk of abnormal transcranial Doppler among patients with sickle cell anaemia in Tanzania. Br J Haematol 2014; 165:699-706. [PMID: 24666344 PMCID: PMC4154124 DOI: 10.1111/bjh.12791] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 01/05/2014] [Indexed: 02/04/2023]
Abstract
Transcranial Doppler ultrasonography measures cerebral blood flow velocity (CBFv) of basal intracranial vessels and is used clinically to detect stroke risk in children with sickle cell anaemia (SCA). Co‐inheritance in SCA of alpha‐thalassaemia and glucose‐6‐phosphate dehydrogenase (G6PD) polymorphisms is reported to associate with high CBFv and/or risk of stroke. The effect of a common functional polymorphism of haptoglobin (HP) is unknown. We investigated the effect of co‐inheritance of these polymorphisms on CBFv in 601 stroke‐free Tanzanian SCA patients aged <24 years. Homozygosity for alpha‐thalassaemia 3·7 deletion was significantly associated with reduced mean CBFv compared to wild‐type (β‐coefficient −16·1 cm/s, P = 0·002) adjusted for age and survey year. Inheritance of 1 or 2 alpha‐thalassaemia deletions was associated with decreased risk of abnormally high CBFv, compared to published data from Kenyan healthy control children (Relative risk ratio [RRR] = 0·53 [95% confidence interval (CI):0·35–0·8] & RRR = 0·43 [95% CI:0·23–0·78]), and reduced risk of abnormally low CBFv for 1 deletion only (RRR = 0·38 [95% CI:0·17–0·83]). No effects were observed for G6PD or HP polymorphisms. This is the first report of the effects of co‐inheritance of common polymorphisms, including the HP polymorphism, on CBFv in SCA patients resident in Africa and confirms the importance of alpha‐thalassaemia in reducing risk of abnormal CBFv.
Collapse
Affiliation(s)
- Sharon E Cox
- MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, UK; Muhimbili Wellcome Programme, Muhimbili University of Health & Allied Sciences, Dar es Salaam, Tanzania
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
|
22
|
Majumdar S, Webb S, Norcross E, Mannam V, Ahmad N, Lirette S, Iyer R. Stroke with intracranial stenosis is associated with increased platelet activation in sickle cell anemia. Pediatr Blood Cancer 2013; 60:1192-7. [PMID: 23509099 DOI: 10.1002/pbc.24473] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 12/17/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Overt stroke in sickle cell anemia (SCA) is associated with intracranial stenosis and thrombus formation. Platelet activation is critical for thrombus formation. PROCEDURE Platelet activation studies were performed in 50 subjects: 18 SCA patients with history of stroke or abnormal transcranial Doppler (TCD) and intracranial stenosis seen by magnetic resonance angiogram (MRA), 7 SCA patients with history of stroke or abnormal TCD but no intracranial stenosis, 13 SCA patients with no history of stroke or abnormal TCD, and 12 healthy African-Americans. RESULTS Of the 18 patients with intracranial stenosis, 11 (61%) had evidence of the moyo-moya phenomenon on MRA. SCA children with intracranial stenosis had a significantly greater total white cell count compared to both healthy African-American controls and SCA patients in the steady-state (P < 0.001). In addition, SCA patients with history of stroke or abnormal TCD had a significantly higher platelet count compared to healthy African-American controls (P < 0.002). The percentage of platelet surface P-selectin expression was significantly greater in patients with intracranial stenosis compared to the other groups (P < 0.05), particularly in individuals that did not have the moya-moya phenomenon seen on MRA. CONCLUSION Stroke with intracranial stenosis is associated with increased platelet activation in sickle cell anemia, and further investigation is needed on the role of anti-platelet agents in this high-risk population.
Collapse
Affiliation(s)
- Suvankar Majumdar
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA.
| | | | | | | | | | | | | |
Collapse
|
23
|
Karimi M, Haghpanah S, Ashjazadeh N, Shariat A, Nazeri M, Emami S, Forough AA, Petramfar P, Yaghoubi E. Cerebral Artery Velocity Determined by Transcranial Doppler Ultrasonography in Patients With β-Thalassemia Intermedia Compared to β-Thalassemia Major. Clin Appl Thromb Hemost 2013; 19:367-73. [DOI: 10.1177/1076029612461068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We aimed to compare cerebral artery velocity and relevant clinical factors in patients with β-thalassemia intermedia (β-TI), β-thalassemia major (β-TM), and healthy individuals. For this study, 60 patients with β-TM and 64 with β-TI were randomly selected. Sixty healthy adults comprised the control group. Time average maximum mean velocity (TAMMV) was measured in large cerebral arteries with transcranial Doppler (TCD) ultrasonography. In all arteries, TAMMV was significantly higher in the β-TI group than that of β-TM or controls ( P < .001). Patients with β-TM had significantly higher TAMMV than controls in most arteries evaluated ( P < .001). Overall, the lack of regular blood transfusions, splenectomy, and lower age (to a lesser extent) was found to be independent influencing factors contributing to high cerebral artery velocities. Further detailed longitudinal studies are needed to confirm these results and to determine the risk of silent infarction and stroke in patients with thalassemia and abnormal TCD, with particular focus on patients with β-TI.
Collapse
Affiliation(s)
- Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sezaneh Haghpanah
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nahid Ashjazadeh
- Department of Neurology, Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdolhamid Shariat
- Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Masoume Nazeri
- Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sajad Emami
- Department of Neurology, Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Abolhasani Forough
- Medical Imaging research Center, Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Petramfar
- Department of Neurology, Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ehsan Yaghoubi
- Department of Neurology, Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
24
|
Doepp F, Kebelmann-Betzing C, Kivi A, Schreiber SJ. Stenosis or hyperperfusion in sickle cell disease--ultrasound assessment of cerebral blood flow volume. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:1333-1338. [PMID: 22698503 DOI: 10.1016/j.ultrasmedbio.2012.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 03/24/2012] [Accepted: 04/06/2012] [Indexed: 06/01/2023]
Abstract
Increased blood flow velocity (BFV) in basal cerebral arteries measured by transcranial color-coded sonography (TCCS) is a stroke risk factor in sickle cell disease (SCD). Raised BFV may be caused by vessel narrowing or by hyperperfusion. In 44 SCD patients and 14 controls, intracranial arterial BFVs and global cerebral blood flow (CBF) were analyzed by TCCS and extracranial duplex ultrasound, respectively. Magnetic resonance imaging and magnetic resonance angiography were performed in all patients with pathologic intracranial BFV rise. Intracranial BFVs and CBF in SCD were significantly higher than in controls. CBF in SCD correlated with BFV in all intracranial arteries and correlated inversely with age and hemoglobin values. Magnetic resonance angiography failed to demonstrate any stenosis in our SCD patients, thus raised intracranial BFVs must be interpreted as an anemia-dependent cerebral hyperperfusion. These findings suggest that the pathomechanism of stenosis-derived arterio-arterial embolism might be less relevant in SCD-related ischemic stroke, and other factors like small vessel disease or sickle cell-induced microvascular blood clotting have to be considered.
Collapse
Affiliation(s)
- Florian Doepp
- Department of Neurology, University Hospital Charité, Berlin, Germany.
| | | | | | | |
Collapse
|
25
|
Hokazono M, Silva GS, Silva EMK, Braga JAP. Results from transcranial Doppler examination on children and adolescents with sickle cell disease and correlation between the time-averaged maximum mean velocity and hematological characteristics: a cross-sectional analytical study. SAO PAULO MED J 2011; 129:134-8. [PMID: 21755247 PMCID: PMC10866317 DOI: 10.1590/s1516-31802011000300003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 06/17/2010] [Accepted: 02/04/2011] [Indexed: 11/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Transcranial Doppler (TCD) detects stroke risk among children with sickle cell anemia (SCA). Our aim was to evaluate TCD findings in patients with different sickle cell disease (SCD) genotypes and correlate the time-averaged maximum mean (TAMM) velocity with hematological characteristics. DESIGN AND SETTING Cross-sectional analytical study in the Pediatric Hematology sector, Universidade Federal de São Paulo. METHODS 85 SCD patients of both sexes, aged 2-18 years, were evaluated, divided into: group I (62 patients with SCA/Sß(0) thalassemia); and group II (23 patients with SC hemoglobinopathy/Sß(+) thalassemia). TCD was performed and reviewed by a single investigator using Doppler ultrasonography with a 2 MHz transducer, in accordance with the Stroke Prevention Trial in Sickle Cell Anemia (STOP) protocol. The hematological parameters evaluated were: hematocrit, hemoglobin, reticulocytes, leukocytes, platelets and fetal hemoglobin. Univariate analysis was performed and Pearson's coefficient was calculated for hematological parameters and TAMM velocities (P < 0.05). RESULTS TAMM velocities were 137 ± 28 and 103 ± 19 cm/s in groups I and II, respectively, and correlated negatively with hematocrit and hemoglobin in group I. There was one abnormal result (1.6%) and five conditional results (8.1%) in group I. All results were normal in group II. Middle cerebral arteries were the only vessels affected. CONCLUSION There was a low prevalence of abnormal Doppler results in patients with sickle-cell disease. Time-average maximum mean velocity was significantly different between the genotypes and correlated with hematological characteristics.
Collapse
Affiliation(s)
- Mary Hokazono
- Department of Pediatrics, Universidade Federal de São Paulo, Brazil.
| | | | | | | |
Collapse
|
26
|
Meairs S, Hennerici M, Mohr J. Ultrasonography. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
27
|
Silva CM, Giovani P, Viana MB. High reticulocyte count is an independent risk factor for cerebrovascular disease in children with sickle cell anemia. Pediatr Blood Cancer 2011; 56:116-21. [PMID: 20949593 DOI: 10.1002/pbc.22680] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2009] [Accepted: 05/06/2010] [Indexed: 11/08/2022]
Abstract
BACKGROUND Transcranial Doppler ultrasonography (TCD) is an important way of detecting risk of ischemic stroke in children with sickle cell anemia. PROCEDURE A random sample of 262 FS-hemoglobin children from a newborn screening inception cohort in Brazil (1998-2005) was followed up to May 2009. Pulsed TCD followed STOP protocol. Children with mean blood flow velocity < 170 cm/sec in cerebral arteries were classified as low risk; between 170 and 184, low conditional risk; between 185 and 199, high conditional risk; and ≥ 200, high risk. RESULTS Median age, 6.2 years (2-11.2 years); 147 female; 13 children (5%) had ischemic stroke prior to TCD; 186/249 (74.7%) were classified as low risk; 19 (7.6%) as low conditional; 7 (2.8%) as high conditional; and 8 (3.2%) as high risk; inadequate tests, 11.6%. The probability of ischemic stroke at 10 years was 8.3% (SEM 2.3%); of stroke or high-risk TCD 15.6% (3.5%). Children with stroke or altered TCD (conditional and high risk) were compared to children with normal examinations. They were younger (P = 0.03), with lower hemoglobin (P = 0.003), higher leukocytosis (P = 0.015), and higher reticulocytosis (P < 0.001). Episodes per year of acute chest syndrome were also higher in that group, but not significantly (P = 0.09). Reticulocytosis remained the only significant variable upon multivariate analysis (P = 0.004). Basilar and middle cerebral artery velocities were significantly correlated (R = 0.55; P < 0.001). CONCLUSIONS Probability of stroke was similar to international reports; of belonging to high-risk group, lower. High-reticulocyte count was the most important factor associated with cerebrovascular disease. Basilar artery velocity > 130 cm/sec seems to be an indirect sign of an underlying cerebrovascular disease.
Collapse
|
28
|
|
29
|
Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, Hobson R, Kidwell CS, Koroshetz WJ, Mathews V, Villablanca P, Warach S, Walters B. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke 2009; 40:3646-78. [PMID: 19797189 DOI: 10.1161/strokeaha.108.192616] [Citation(s) in RCA: 286] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
30
|
Parzy E, Miraux S, Franconi JM, Thiaudière E. In vivo quantification of blood velocity in mouse carotid and pulmonary arteries by ECG-triggered 3D time-resolved magnetic resonance angiography. NMR IN BIOMEDICINE 2009; 22:532-537. [PMID: 19156686 DOI: 10.1002/nbm.1365] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Blood flow velocity is a functional parameter of fundamental importance in diagnosis and follow-up of various vascular diseases. Vascular pathologies can be efficiently studied in animal models, especially in small rodents. ECG-gated magnetic resonance imaging (MRI) assessment of blood velocity in small animals is a challenge because of limited spatial resolution and high-frequency physiological parameters. Here it is shown that a bright-blood cine-3D-MRI method can be used to measure blood velocity at specific times of the cardiac cycle in mouse pulmonary and carotid arteries. The method used a series of time-of-flight (TOF) acquisitions in a volume of interest at different times after signal cancellation in the same volume. This scheme was repeated at different periods of the cardiac cycle by varying the delay between the ECG R-wave peak and signal cancellation. Velocity values in mouse pulmonary artery varied from 35 cm/s in systole to 0-10 cm/s in diastole. A similar pattern was displayed in carotid arteries (18 and 2.5 cm/s, in systole and diastole, respectively). Results are discussed in terms of efficiency, limitation, and comparison with other methods.
Collapse
Affiliation(s)
- Elodie Parzy
- Magnetic Resonance Center, UMR 5536, CNRS University Victor Segalen Bordeaux 2, Bordeaux, France.
| | | | | | | |
Collapse
|
31
|
Makani J, Kirkham FJ, Komba A, Ajala-Agbo T, Otieno G, Fegan G, Williams TN, Marsh K, Newton CR. Risk factors for high cerebral blood flow velocity and death in Kenyan children with Sickle Cell Anaemia: role of haemoglobin oxygen saturation and febrile illness. Br J Haematol 2009; 145:529-32. [PMID: 19344425 PMCID: PMC3001030 DOI: 10.1111/j.1365-2141.2009.07660.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
High cerebral blood flow velocity (CBFv) and low haemoglobin oxygen saturation (SpO2) predict neurological complications in sickle cell anaemia (SCA) but any association is unclear. In a cross-sectional study of 105 Kenyan children, mean CBFv was 120 ± 34·9 cm/s; 3 had conditional CBFv (170–199 cm/s) but none had abnormal CBFv (>200 cm/s). After adjustment for age and haematocrit, CBFv ≥150 cm/s was predicted by SpO2 ≤ 95% and history of fever. Four years later, 10 children were lost to follow-up, none had suffered neurological events and 11/95 (12%) had died, predicted by history of fever but not low SpO2. Natural history of SCA in Africa may be different from North America and Europe.
Collapse
Affiliation(s)
- Julie Makani
- Department of Haematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania.
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Zimmerman SA, Schultz WH, Burgett S, Mortier NA, Ware RE. Hydroxyurea therapy lowers transcranial Doppler flow velocities in children with sickle cell anemia. Blood 2007; 110:1043-7. [PMID: 17429008 DOI: 10.1182/blood-2006-11-057893] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Hydroxyurea has hematologic and clinical efficacy in sickle cell anemia (SCA), but its effects on transcranial Doppler (TCD) flow velocities remain undefined. Fifty-nine children initiating hydroxyurea therapy for clinical severity had pretreatment baseline TCD measurements; 37 with increased flow velocities (≥ 140 cm/s) were then enrolled in an institutional review board (IRB)–approved prospective phase 2 trial with TCD velocities measured at maximum tolerated dose (MTD) and one year later. At hydroxyurea MTD (mean ± 1 SD = 27.9 ± 2.7 mg/kg per day), significant decreases were observed in the right middle cerebral artery (MCA) (166 ± 27 cm/s to 135 ± 27 cm/s, P < .001) and left (MCA) (168 ± 26 cm/s to 142 ± 27 cm/s, P < .001) velocities. The magnitude of TCD velocity decline was significantly correlated with the maximal baseline TCD value. At hydroxyurea MTD, 14 of 15 children with conditional baseline TCD values improved, while 5 of 6 with abnormal TCD velocities whose families refused transfusions became less than 200 cm/s. TCD changes were sustained at follow-up. These prospective data indicate that hydroxyurea can significantly decrease elevated TCD flow velocities, often into the normal range. A multicenter trial is warranted to determine the efficacy of hydroxyurea for the management of increased TCD values, and ultimately for primary stroke prevention in children with SCA.
Collapse
Affiliation(s)
- Sherri A Zimmerman
- Duke Pediatric Sickle Cell Program, and Division of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, NC, USA
| | | | | | | | | |
Collapse
|
33
|
Abstract
PURPOSE OF REVIEW Stroke is one of the most devastating complications of sickle cell disease, but current research has led to improved understanding of its pathogenesis and to new approaches in the prevention of both primary and secondary stroke. This review focuses on advances reported in the past 2 years. RECENT FINDINGS New concepts in the pathophysiology of central nervous system events in sickle cell disease have centered around hemolytic anemia and nitric oxide metabolism. Genetic risk factors are now being explored. Major improvement in primary stroke prevention has occurred through transcranial Doppler ultrasonography screening, but utilization of this technique is far from optimal. Hydroxyurea is now being tested as an alternative approach to chronic transfusion for secondary stroke prevention through a multicenter trial. Other studies are addressing the management of silent infarcts and nocturnal hypoxemia. SUMMARY Increased understanding of the etiology and pathogenesis of stroke in sickle cell disease should eventually lead to improved management of all central nervous system complications. Alternative secondary stroke prevention with hydroxyurea may allow patients to avoid dependence on life-long chronic transfusion. Primary stroke prevention through transcranial Doppler ultrasonography screening may ultimately yield a dramatic reduction in the incidence of stroke in sickle cell disease.
Collapse
Affiliation(s)
- Winfred C Wang
- Department of Hematology, St Jude Children's Research Hospital, Memphis, TN 38105, USA.
| |
Collapse
|
34
|
Wang WC. Central Nervous System Complications of Sickle Cell Disease in Children: An Overview. Child Neuropsychol 2007; 13:103-19. [PMID: 17364568 DOI: 10.1080/09297040600788136] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Complications involving the central nervous system are among the most devastating manifestations of sickle cell disease. Although overt stroke occurs in 1 in 10 children with Hemoglobin SS, "silent cerebral infarcts" are even more frequent. Both are associated with significant neuropsychological deficits. The end result of these effects on the CNS often is diminished school performance. The use of transcranial Doppler ultrasonography screening allows the identification of patients at high risk for clinical stroke as well as stroke prevention by chronic transfusion. However, definitive prophylaxis and treatment for most CNS complications of sickle cell disease have yet to be determined.
Collapse
Affiliation(s)
- Winfred C Wang
- Department of Hematology/Oncology, St. Jude Children's Research Hospital. Memphis, TN38105, USA.
| |
Collapse
|
35
|
Bulas D. Screening children for sickle cell vasculopathy: guidelines for transcranial Doppler evaluation. Pediatr Radiol 2005; 35:235-41. [PMID: 15703903 DOI: 10.1007/s00247-005-1417-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Revised: 01/11/2005] [Accepted: 01/11/2005] [Indexed: 10/25/2022]
Abstract
Cerebral infarction is a major cause of morbidity and mortality in children with sickle cell disease. Prevention of primary stroke might be feasible with a way to identify children at greatest risk. Transcranial Doppler (TCD) has been shown to be a noninvasive, reliable, inexpensive method of identifying children at highest risk for cerebral infarction. The pros and cons of imaging and non-imaging TCD techniques are discussed. The protocol for the stroke prevention trial in sickle cell anemia (STOP), including data acquisition and interpretation, is reviewed. Providing TCD to sickle cell patients can be a valuable service that results in a significant decrease in first stroke rates.
Collapse
Affiliation(s)
- Dorothy Bulas
- Department of Diagnostic Imaging and Radiology, Children's National Medical Center, George Washington University School of Medicine, 111 Michigan Ave. NW, Washington, DC 20010, USA.
| |
Collapse
|
36
|
Comparison of Transcranial Doppler Sonography With and Without Imaging in the Evaluation of Children With Sickle Cell Anemia. AJR Am J Roentgenol 2004; 183:1117-22. [DOI: 10.2214/ajr.183.4.1831117] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
37
|
Haller JO, Slovis TL, Babcock DS, Teele RL. Early history of pediatric ultrasound (circa 1960-1985). JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2004; 23:323-329. [PMID: 15055778 DOI: 10.7863/jum.2004.23.3.323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- Jack O Haller
- Department of Radiology, Beth Israel Medical Center, New York, New York, USA
| | | | | | | |
Collapse
|
38
|
Meairs S, Hennerici M, Mohr J. Ultrasonography. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50026-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
39
|
Oguz KK, Golay X, Pizzini FB, Freer CA, Winrow N, Ichord R, Casella JF, van Zijl PCM, Melhem ER. Sickle cell disease: continuous arterial spin-labeling perfusion MR imaging in children. Radiology 2003; 227:567-74. [PMID: 12663827 DOI: 10.1148/radiol.2272020903] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cerebral blood flow (CBF) was measured with continuous arterial spin-labeling perfusion magnetic resonance (MR) imaging in 14 children with sickle cell disease and seven control subjects. Mean CBF values were higher in patients (P <.005) than in control subjects in all cerebral artery territories. Three patients had decreased CBF in right anterior and middle cerebral artery territories compared with CBF on the left, and one patient had a profound decrease in CBF in all three territories in the right hemisphere. Baseline CBF was significantly decreased in territories seen as unaffected on conventional MR images and MR angiograms in four children with sickle cell disease.
Collapse
Affiliation(s)
- Kader K Oguz
- Dept of Radiology, Johns Hopkins Med Insts, Baltimore, Md, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Neish AS, Blews DE, Simms CA, Merritt RK, Spinks AJ. Screening for stroke in sickle cell anemia: comparison of transcranial Doppler imaging and nonimaging US techniques. Radiology 2002; 222:709-14. [PMID: 11867789 DOI: 10.1148/radiol.2223010524] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine whether criteria for screening patients with sickle cell anemia for stroke established with a nonimaging transcranial Doppler ultrasonographic (US) technique are applicable to studies performed with a transcranial Doppler US imaging technique. MATERIALS AND METHODS One hundred sixty-eight examinations in 66 children were performed for sickle cell stroke screening. Children were examined with nonimaging and imaging transcranial Doppler US techniques on the same day, for a total of 84 paired examinations. The time-averaged maximum mean velocity (V(mean)) and resistive index (RI) were calculated in the middle cerebral arteries, bifurcations of the distal internal carotid arteries, distal internal carotid arteries, anterior cerebral arteries, posterior cerebral arteries, and basilar arteries. The maximum systolic velocity (V(max)) was evaluated in the distal internal carotid arteries and middle cerebral arteries. V(mean), V(max), and RI measurements were subjected to repeated-measures multivariate analysis of covariance, and the Pearson product moment correlation was used for middle cerebral artery velocity, age, and hemoglobin. RESULTS V(mean) measurements obtained with nonimaging and imaging techniques varied substantially for the bifurcation of the distal internal carotid artery, the posterior cerebral artery, and the basilar artery. Substantial differences were found in RIs for every vessel. Examination time was shorter with the nonimaging technique. CONCLUSION V(mean) measurements in the middle cerebral artery, distal internal carotid artery, and anterior cerebral artery did not vary substantially between nonimaging and imaging transcranial Doppler US. RI data did not yield comparable measurements.
Collapse
Affiliation(s)
- Ariane S Neish
- Department of Radiology, Children's Health Care of Atlanta at Scottish Rite, 1001 Johnson Ferry Rd NE, Atlanta, GA 30342, USA.
| | | | | | | | | |
Collapse
|
41
|
Abstract
Sickle cell disease (SCD), a class of genetic disorders characterized by abnormal, sickled red blood cells, is a chronic illness that results in progressive cerebrovascular disease. Neurocognitive sequelae of clinically apparent cerebrovascular accidents in children with SCD are characterized by pervasive impairments, including decrements in general intellectual functioning, language and verbal abilities, visual-motor and visual-spatial processing, memory, academic achievement, and processing of subtle prosodic information. In contrast, subtle neurocognitive deficits in the areas of attention and concentration, executive function, and visual-motor speed and coordination appear to be associated with silent infarcts that are not necessarily detected on physical examination. Investigation of the disease course and associated neurocognitive sequelae suggest a disease-specific model of neuropsychological impairment. Recommendations are made for clinical and research efforts in the field of pediatric neuropsychology.
Collapse
Affiliation(s)
- M C Kral
- Department of Pediatrics, Medical University of South Carolina, Charleston 29425, USA.
| | | | | |
Collapse
|
42
|
Miller ST, Macklin EA, Pegelow CH, Kinney TR, Sleeper LA, Bello JA, DeWitt LD, Gallagher DM, Guarini L, Moser FG, Ohene-Frempong K, Sanchez N, Vichinsky EP, Wang WC, Wethers DL, Younkin DP, Zimmerman RA, DeBaun MR. Silent infarction as a risk factor for overt stroke in children with sickle cell anemia: a report from the Cooperative Study of Sickle Cell Disease. J Pediatr 2001; 139:385-90. [PMID: 11562618 DOI: 10.1067/mpd.2001.117580] [Citation(s) in RCA: 195] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To determine whether children with homozygous sickle cell anemia (SCD) who have silent infarcts on magnetic resonance imaging (MRI) of the brain are at increased risk for overt stroke. METHODS We selected patients with homozygous SCD who (1) enrolled in the Cooperative Study of Sickle Cell Disease (CSSCD) before age 6 months, (2) had at least 1 study-mandated brain MRI at age 6 years or older, and (3) had no overt stroke before a first MRI. MRI results and clinical and laboratory parameters were tested as predictors of stroke. RESULTS Among 248 eligible patients, mean age at first MRI was 8.3 +/- 1.9 years, and mean follow-up after baseline MRI was 5.2 +/- 2.2 years. Five (8.1%) of 62 patients with silent infarct had strokes compared with 1 (0.5%) of 186 patients without prior silent infarct; incidence per 100 patient-years of follow-up was increased 14-fold (1.45 per 100 patient-years vs 0.11 per 100 patient-years, P =.006). Of several clinical and laboratory parameters examined, silent infarct was the strongest independent predictor of stroke (hazard ratio = 7.2, P =.027). CONCLUSIONS Silent infarct identified at age 6 years or older is associated with increased stroke risk.
Collapse
Affiliation(s)
- S T Miller
- State University of New York-Downstate Medical Center/Kings County Hospital, Brooklyn, New York 11203, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Malouf AJ, Hamrick-Turner JE, Doherty MC, Dhillon GS, Iyer RV, Smith MG. Implementation of the STOP protocol for Stroke Prevention in Sickle Cell Anemia by using duplex power Doppler imaging. Radiology 2001; 219:359-65. [PMID: 11323457 DOI: 10.1148/radiology.219.2.r01ap33359] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To compare the results of the nonduplex ultrasonography (US) Stroke Prevention Trial in Sickle Cell Anemia (STOP) with those of transcranial duplex power Doppler US by using the STOP protocol and to correlate abnormal transcranial Doppler findings with magnetic resonance (MR) imaging and MR angiographic findings. MATERIALS AND METHODS One hundred twenty-five asymptomatic patients aged 2-16 years with sickle cell anemia or sickle cell-beta thalassemia were examined by using transcranial duplex power Doppler US with a 2.5-MHz transducer and classified according to STOP criteria. The results were compared with those obtained in the nonduplex STOP study. Eight of 10 patients with abnormal results, as well as one who had normal results and a subsequent stroke, were examined with MR imaging and MR angiography. RESULTS Ten (8.0%) patients were judged to have abnormal findings by using the duplex Doppler US and STOP criteria compared with 9.4% of patients in the nonduplex US STOP study. Of the eight patients with abnormal transcranial Doppler US results who underwent MR imaging and MR angiography, six had abnormal MR imaging findings and all eight had abnormal MR angiographic findings. CONCLUSION The STOP protocol can be reproduced by using duplex power Doppler US. Abnormal results with the STOP criteria strongly suggest vascular abnormality.
Collapse
Affiliation(s)
- A J Malouf
- Department of Radiology, University of Mississippi Medical Center, Jackson, USA.
| | | | | | | | | | | |
Collapse
|
44
|
Steen RG, Langston JW, Ogg RJ, Xiong X, Ye Z, Wang WC. Diffuse T1 reduction in gray matter of sickle cell disease patients: evidence of selective vulnerability to damage? Magn Reson Imaging 1999; 17:503-15. [PMID: 10231177 DOI: 10.1016/s0730-725x(98)00204-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The objective of our study was to test the hypothesis that subtle brain abnormality can be present in pediatric sickle cell disease (SCD) patients normal by conventional MR imaging (cMRI). We examined 50 SCD patients to identify those patients who were normal by cMRI. Quantitative MR imaging (qMRI) was then used to map spin-lattice relaxation time (T1) in a single slice in brain tissue of all 50 patients and in 52 healthy age-similar controls. We also used a radiofrequency (RF) pulse to saturate blood spins flowing into the T1 map slice, to characterize the effect of blood flow on brain T1. Abnormalities were noted by cMRI in 42% (21/50) of patients, with lacunae in 32%, and encephalo malacia in 20%. Brain T1 in patients normal by cMRI was significantly lower than controls, in caudate, thalamus, and cortex (p < or =0.007), and regression showed that gray matter T1 abnormality was present in caudate and cortex by age 4 (p < or =0.002). In patients abnormal by cMRI, T1 reductions in gray matter were larger and more significant. White matter T1 was not significantly increased except in patients abnormal by cMRI. RF saturation in a slab below the T1 map produced no significant change in T1, compared to RF saturation in a slab above the T1 map, suggesting that inflow of untipped spins in blood does not cause an artifactual shortening of T1. Gray matter T1 abnormality was present in patients normal by cMRI, while white matter T1 abnormality was present only in patients also abnormal by cMRI. These findings suggest that gray matter is selectively vulnerable to damage in pediatric SCD patients and that white matter damage occurs later in the disease process. Our inability to find an effect from saturation of inflowing blood implies that rapid perfusion cannot account for T1 reduction in gray matter.
Collapse
Affiliation(s)
- R G Steen
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, University of Tennessee School of Medicine, Memphis 38105-2794, USA.
| | | | | | | | | | | |
Collapse
|
45
|
Steen RG, Langston JW, Ogg RJ, Manci E, Mulhern RK, Wang W. Ectasia of the basilar artery in children with sickle cell disease: Relationship to hematocrit and psychometric measures. J Stroke Cerebrovasc Dis 1998; 7:32-43. [PMID: 17895054 DOI: 10.1016/s1052-3057(98)80019-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/1997] [Accepted: 06/06/1997] [Indexed: 11/21/2022] Open
Abstract
GOAL To determine whether children with sickle cell disease (SCD), but without clinical evidence of cerebrovascular disease, have vasculopathy shown by quantitative magnetic resonance angiography (MRA). METHODS In a retrospective review of MRA films, we compared 47 SCD patients with 49 control patients. Time-of-flight three-dimensional T1-weighted gradient-echo images were reconstructed, by maximum-intensity projection, to show the basilar artery in coronal view, and basilar volume was calculated from measurements made on films. Basilar volume was correlated with hematocrit and with results of cognitive testing. FINDINGS Mean basilar artery volume was 74% larger in SCD patients than in controls (P<.001). If the upper limit of normal is defined as mean adult volume +2 SD (< or =427 mm(3)), 2% (1 of 43) of controls but 37% (17 of 46) of SCD patients exceed this value (chi(2)=19.0; P<.001). Basilar volume correlated inversely with hematocrit (r=-.60; P<.0001), with full-scale IQ (r=-.62; P<.005), and with freedom from distractability (r=-.61; P<.006) in SCD patients. Analysis of basilar artery tissue from a 5-year-old SCD patient showed that basilar dilatation can be associated with pathological changes typical of hypertension. CONCLUSIONS Approximately 37% of a heterogenous group of pediatric SCD patients had ectasia of the basilar artery. Quantitative MRA is sensitive to subtle vasculopathy that can go undetected in the qualitative analysis more commonly done. Data suggest that there is a substantial elevation of arteriolar blood volume in pediatric SCD patients, and that such patients may share disease features in common with adult hypertension.
Collapse
Affiliation(s)
- R G Steen
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | | | | |
Collapse
|
46
|
Thomas C, Lemerle S, Bernaudin F, Feingold J, Guillou-Bataille M, Reinert P. [Sickle cell anemia: study of the pediatric mortality in Ile de France from 1985 to 1992]. Arch Pediatr 1996; 3:445-51. [PMID: 8763714 DOI: 10.1016/0929-693x(96)86402-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Sickle cell anemia is now relatively frequent in France. Its clinical course is punctuated by acute episodes that threaten the life, specially during the first year of life. POPULATION AND METHODS The files of 26 children (14 boys, 12 girls) dead from sickle cell disease between 1985 and 1992 were retrospectively studied. These files concerned patients from the Ile-de-France area. RESULTS Their mean age at time of diagnosis was 13.7 months (0 to 3 years 4 months); mean age was 5.5 years at time of death. Infection was the cause of death in 15 patients (S pneumoniae in eight patients despite prophylactic penicillin and pneumococcal vaccine in the majority of them). Splenic sequestration crisis was the cause of death in three patients less than 5 years of age; vasocclusive crisis resulting in cerebral infarction was the cause in three patients aged 7.5 to 13 years. Mortality calculated from those patients followed since 1987 (total: 2,063 years) was 0.29% person/year. CONCLUSION Comfort of patients and risk of permanent disability become the main factors of choice for new treatments such as chemotherapy or bone marrow transplantation.
Collapse
Affiliation(s)
- C Thomas
- Service de pédiatrie, centre hospitalier intercommunal, Créteil, France
| | | | | | | | | | | |
Collapse
|
47
|
Venketasubramanian N, Prohovnik I, Hurlet A, Mohr JP, Piomelli S. Middle cerebral artery velocity changes during transfusion in sickle cell anemia. Stroke 1994; 25:2153-8. [PMID: 7974538 DOI: 10.1161/01.str.25.11.2153] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Sickle cell disease is associated with cerebral hyperemia, which is therapeutically reduced by transfusion; however, the process of transfusion-induced cerebral perfusion changes has heretofore not been observed. METHODS We document the acute changes of intracranial arterial velocity in 10 patients (7 with strokes, 3 without) undergoing transfusion therapy using transcranial Doppler ultrasonography. Middle cerebral artery velocities were bilaterally measured every 30 minutes for the duration of transfusion (4 to 5 hours). Regional cerebral blood flow was quantified in 5 of these patients before the transfusion and 24 hours later by the 133Xe technique. RESULTS Velocities in stroke-associated vessels (64.33 +/- 18.65 cm/s; n = 6) were significantly lower than in uninfarcted territories (99.54 +/- 27.39 cm/s; n = 13), and both types of vessels showed a robust reduction of blood flow velocities during transfusion. The rates of reduction were not significantly different as a function of prior stroke but did correlate with pretransfusion velocities and with the rise in hematocrit (multiple r = .887, P < .001). These reductions occurred rapidly within the first 3 hours of transfusion. Velocities attained at the end of transfusion were maintained in the hour after transfusion and the next day. CONCLUSIONS We conclude that transfusion induces rapid changes in cerebral hemodynamics that are related to pretransfusion velocities and a rise in hematocrit. Transcranial Doppler provides a safe, simple, and noninvasive technique of monitoring these changes and may provide a means of making therapeutic decisions regarding transfusion therapy in patients with sickle cell anemia.
Collapse
|
48
|
Adams RJ, Nichols FT, Figueroa R, McKie V, Lott T. Transcranial Doppler correlation with cerebral angiography in sickle cell disease. Stroke 1992; 23:1073-7. [PMID: 1636180 DOI: 10.1161/01.str.23.8.1073] [Citation(s) in RCA: 129] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral infarction in sickle cell disease is associated with arterial narrowing or occlusions of intracranial arteries. Primary stroke prevention would be feasible if a noninvasive screening test could be developed to detect intracranial disease in patients before symptoms develop. METHODS To determine the sensitivity and specificity of transcranial Doppler in detecting significant (greater than or equal to 50% lumen diameter reduction) intracranial arterial lesions, we compared transcranial Doppler and cerebral angiography in a primarily young, symptomatic group of 33 patients (18 males and 15 females) with sickle cell disease. RESULTS From a total of 34 examinations, transcranial Doppler detected significant abnormalities in 26 of 29 (sensitivity 90%, specificity 100%). Five were normal by both techniques. The transorbital examination detected abnormalities in two patients whose studies were otherwise unremarkable. CONCLUSIONS Transcranial Doppler is sensitive and specific for the detection of arterial vasculopathy of sickle cell disease. Screening should include a transorbital examination of the distal internal carotid artery as well as examination using the transtemporal approach.
Collapse
Affiliation(s)
- R J Adams
- Department of Neurology, Medical College of Georgia, Augusta 30912
| | | | | | | | | |
Collapse
|
49
|
Adams R, McKie V, Nichols F, Carl E, Zhang DL, McKie K, Figueroa R, Litaker M, Thompson W, Hess D. The use of transcranial ultrasonography to predict stroke in sickle cell disease. N Engl J Med 1992; 326:605-10. [PMID: 1734251 DOI: 10.1056/nejm199202273260905] [Citation(s) in RCA: 415] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Stroke, especially cerebral infarction, is a major cause of morbidity and mortality in children with sickle cell disease. Primary prevention of stroke by transfusion therapy may be feasible if there is a way to identify the patients at greatest risk. Transcranial Doppler ultrasonography can measure flow velocity in the large intracranial arteries. The narrowing of these arteries, which leads to cerebral infarction, is characterized by an increased velocity of flow. METHODS Using transcranial Doppler ultrasonography, we prospectively measured the velocity of cerebral blood flow in children and young adults being followed because of sickle cell disease. The results were classified as either normal or abnormal on the basis of the highest velocity of flow in the middle cerebral artery. Abnormal velocity was defined as a flow greater than or equal to 170 cm per second, a definition determined by post hoc analysis to maximize the predictive success of the test. The end point was a clinically apparent first cerebral infarction. RESULTS Two hundred eighty-three transcranial ultrasound examinations were performed in 190 patients with sickle cell disease (age at entry, 3 to 18 years). After an average follow-up of 29 months, cerebral infarction was diagnosed in seven patients. In 23 patients the results of the ultrasound examinations were abnormal, and in 167 patients they were normal. The clinical and hematologic characteristics of the two groups were similar, but six of the seven strokes occurred among the 23 patients with abnormal ultrasound results (P less than 0.00001 by Fisher's exact test). In this group, the relative risk of stroke was 44 (95 percent confidence interval, 5.5 to 346). CONCLUSIONS Transcranial ultrasonography can identify the children with sickle cell disease who are at highest risk for cerebral infarction. Periodic ultrasound examinations and the selective use of transfusion therapy could make the primary prevention of stroke an achievable goal.
Collapse
Affiliation(s)
- R Adams
- Department of Neurology, Medical College of Georgia, Augusta 30912
| | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Miller ST, Jensen D, Rao SP. Less intensive long-term transfusion therapy for sickle cell anemia and cerebrovascular accident. J Pediatr 1992; 120:54-7. [PMID: 1731025 DOI: 10.1016/s0022-3476(05)80597-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To determine the efficacy of a less intensive transfusion regimen in preventing recurrent cerebrovascular accidents and reducing transfusion requirements in patients with sickle cell anemia, we offered to 14 patients who had been undergoing aggressive transfusion therapy (sickle hemoglobin concentration kept less than 30% of total) for a mean of 9 years the option of either diminishing or stopping transfusion therapy. Thirteen patients chose to continue a modified transfusion regimen to maintain sickle hemoglobin concentration less than 60%; 10 of these patients have now been followed for 1 year or more (12 to 27 months, mean 15.5 months). There have been no recurrent neurologic events, although two patients have died of complications of hemochromatosis. All patients had a reduction in donor exposure, and there was a mean reduction in net transfusion requirement of 31.4% during the first year after modification. The greatest reduction was achieved in the single patient managed by small-volume (5 ml/kg) simple transfusion rather than partial packed cell exchange. We conclude that although long-term consequences of less aggressive transfusion therapy are unknown, the use of such a regimen may be reasonable, particularly in patients with significant transfusional hemochromatosis.
Collapse
Affiliation(s)
- S T Miller
- Department of Pediatrics, State University of New York Health Science Center, Brooklyn 11203
| | | | | |
Collapse
|