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Dovern E, Aydin M, DeBaun MR, Alizade K, Biemond BJ, Nur E. Effect of allogeneic hematopoietic stem cell transplantation on sickle cell disease-related organ complications: A systematic review and meta-analysis. Am J Hematol 2024; 99:1129-1141. [PMID: 38517255 DOI: 10.1002/ajh.27297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/31/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024]
Abstract
Sickle cell disease (SCD)-related organ complications are a major cause of morbidity and mortality in patients with SCD. We sought to assess whether hematopoietic stem cell transplantation (HSCT) stabilizes, attenuates, or exacerbates organ decline. We performed a systematic review and meta-analysis of trials investigating organ function before and after HSCT in patients with SCD. We searched MEDLINE/PubMed and EMBASE up to September 21, 2023. Continuous data were expressed as standardized mean difference (SMD) and pooled in a weighted inverse-variance random-effects model; binomial data were expressed as risk ratio (RR) using the Mantel-Haenszel random-effects meta-analyses. Of 823 screened studies, 34 were included in this review. Of these, 17 (774 patients, 23.6% adults, 86.3% HLA-identical sibling donor, 56.7% myeloablative conditioning regimen) were included in the meta-analyses. Pulmonary function remained stable. Mean tricuspid regurgitant jet velocity decreased but did not reach statistical significance. In children, estimated glomerular filtration rate decreased (SMD -0.80, p = .01), and the presence of proteinuria increased (RR 2.00, p = <.01), while splenic uptake and phagocytic function improved (RR 0.31, p = <.01; RR 0.23, p = <.01). Cerebral blood flow improved (SMD -1.39, p = <.01), and a low incidence of stroke after transplantation in high-risk patients was found. Retinopathy and avascular osteonecrosis were investigated in only one study, showing no significant changes. While HSCT can improve some SCD-related organ dysfunctions, transplantation-related toxicity may have an adverse effect on others. Future research should focus on identifying individuals with SCD who might benefit most from HSCT and which forms of organ damage are more likely to exacerbate post-transplantation.
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Affiliation(s)
- Elisabeth Dovern
- Department of Hematology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Mesire Aydin
- Department of Hematology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, USA
| | - Komeil Alizade
- Department of Hematology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Erfan Nur
- Department of Hematology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
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Afzali-Hashemi L, Dovern E, Baas KPA, Schrantee A, Wood JC, Nederveen AJ, Nur E, Biemond BJ. Cerebral hemodynamics and oxygenation in adult patients with sickle cell disease after stem cell transplantation. Am J Hematol 2024; 99:163-171. [PMID: 37859469 DOI: 10.1002/ajh.27135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/30/2023] [Accepted: 10/03/2023] [Indexed: 10/21/2023]
Abstract
Sickle cell disease (SCD) is characterized by chronic hemolytic anemia associated with impaired cerebral hemodynamics and oxygen metabolism. Hematopoietic stem cell transplantation (HSCT) is currently the only curative treatment for patients with SCD. Whereas normalization of hemoglobin levels and hemolysis markers has been reported after HSCT, its effects on cerebral perfusion and oxygenation in adult SCD patients remain largely unexplored. This study investigated the effects of HSCT on cerebral blood flow (CBF), oxygen delivery, cerebrovascular reserve (CVR), oxygen extraction fraction (OEF), and cerebral metabolic rate of oxygen (CMRO2 ) in 17 adult SCD patients (mean age: 25.0 ± 8.0, 6 females) before and after HSCT and 10 healthy ethnicity-matched controls (mean age: 28.0 ± 8.8, 6 females) using MRI. For the CVR assessment, perfusion scans were performed before and after acetazolamide as a vasodilatory stimulus. Following HSCT, gray and white matter (GM and WM) CBF decreased (p < .01), while GM and WM CVR increased (p < .01) compared with the baseline measures. OEF and CMRO2 also increased towards levels in healthy controls (p < .01). The normalization of cerebral perfusion and oxygen metabolism corresponded with a significant increase in hemoglobin levels and decreases in reticulocytes, total bilirubin, and LDH as markers of hemolysis (p < .01). This study shows that HSCT results in the normalization of cerebral perfusion and oxygen metabolism, even in adult patients with SCD. Future follow-up MRI scans will determine whether the observed normalization of cerebral hemodynamics and oxygen metabolism prevents new silent cerebral infarcts.
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Affiliation(s)
- Liza Afzali-Hashemi
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Hematology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Elisabeth Dovern
- Department of Hematology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Koen P A Baas
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Anouk Schrantee
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - John C Wood
- Division of Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Aart J Nederveen
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Erfan Nur
- Department of Hematology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
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Inam Z, Tisdale JF, Leonard A. Outcomes and long-term effects of hematopoietic stem cell transplant in sickle cell disease. Expert Rev Hematol 2023; 16:879-903. [PMID: 37800996 DOI: 10.1080/17474086.2023.2268271] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplant (HSCT) is the only readily available curative option for sickle cell disease (SCD). Cure rates following human leukocyte antigen (HLA)-matched related donor HSCT with myeloablative or non-myeloablative conditioning are >90%. Alternative donor sources, including haploidentical donor and autologous with gene therapy, expand donor options but are limited by inferior outcomes, limited data, and/or shorter follow-up and therefore remain experimental. AREAS COVERED Outcomes are improving with time, with donor type and conditioning regimens having the greatest impact on long-term complications. Patients with stable donor engraftment do not experience SCD-related symptoms and have stabilization or improvement of end-organ pathology; however, the long-term effects of curative strategies remain to be fully established and have significant implications in a patient's decision to seek therapy. This review covers currently published literature on HSCT outcomes, including organ-specific outcomes implicated in SCD, as well as long-term effects. EXPERT OPINION HSCT, both allogeneic and autologous gene therapy, in the SCD population reverses the sickle phenotype, prevents further organ damage, can resolve prior organ dysfunction in both pediatric and adult patients. Data support greater success with HSCT at a younger age, thus, curative therapies should be discussed early in the patient's life.
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Affiliation(s)
- Zaina Inam
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- Center for Cancer and Blood Disorders, Children's National Hospital, Washington, DC, USA
| | - John F Tisdale
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alexis Leonard
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
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Hulbert ML, Fields ME, Guilliams KP, Bijlani P, Shenoy S, Fellah S, Towerman AS, Binkley MM, McKinstry RC, Shimony JS, Chen Y, Eldeniz C, Ragan DK, Vo K, An H, Lee JM, Ford AL. Normalization of cerebral hemodynamics after hematopoietic stem cell transplant in children with sickle cell disease. Blood 2023; 141:335-344. [PMID: 36040484 PMCID: PMC9936296 DOI: 10.1182/blood.2022016618] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 02/08/2023] Open
Abstract
Children with sickle cell disease (SCD) demonstrate cerebral hemodynamic stress and are at high risk of strokes. We hypothesized that curative hematopoietic stem cell transplant (HSCT) normalizes cerebral hemodynamics in children with SCD compared with pre-transplant baseline. Whole-brain cerebral blood flow (CBF) and oxygen extraction fraction (OEF) were measured by magnetic resonance imaging 1 to 3 months before and 12 to 24 months after HSCT in 10 children with SCD. Three children had prior overt strokes, 5 children had prior silent strokes, and 1 child had abnormal transcranial Doppler ultrasound velocities. CBF and OEF of HSCT recipients were compared with non-SCD control participants and with SCD participants receiving chronic red blood cell transfusion therapy (CRTT) before and after a scheduled transfusion. Seven participants received matched sibling donor HSCT, and 3 participants received 8 out of 8 matched unrelated donor HSCT. All received reduced-intensity preparation and maintained engraftment, free of hemolytic anemia and SCD symptoms. Pre-transplant, CBF (93.5 mL/100 g/min) and OEF (36.8%) were elevated compared with non-SCD control participants, declining significantly 1 to 2 years after HSCT (CBF, 72.7 mL/100 g per minute; P = .004; OEF, 27.0%; P = .002), with post-HSCT CBF and OEF similar to non-SCD control participants. Furthermore, HSCT recipients demonstrated greater reduction in CBF (-19.4 mL/100 g/min) and OEF (-8.1%) after HSCT than children with SCD receiving CRTT after a scheduled transfusion (CBF, -0.9 mL/100 g/min; P = .024; OEF, -3.3%; P = .001). Curative HSCT normalizes whole-brain hemodynamics in children with SCD. This restoration of cerebral oxygen reserve may explain stroke protection after HSCT in this high-risk patient population.
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Affiliation(s)
- Monica L. Hulbert
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Melanie E. Fields
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- Department of Neurology, Washington University in St. Louis, St. Louis, MO
| | - Kristin P. Guilliams
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- Department of Neurology, Washington University in St. Louis, St. Louis, MO
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Priyesha Bijlani
- Department of Internal Medicine, University of California San Diego, San Diego, CA
| | - Shalini Shenoy
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Slim Fellah
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Alison S. Towerman
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | | | - Robert C. McKinstry
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Joshua S. Shimony
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Yasheng Chen
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Cihat Eldeniz
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Dustin K. Ragan
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI
| | - Katie Vo
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Hongyu An
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Jin-Moo Lee
- Department of Neurology, Washington University in St. Louis, St. Louis, MO
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
| | - Andria L. Ford
- Department of Neurology, Washington University in St. Louis, St. Louis, MO
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO
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Hulbert ML, King AA, Shenoy S. Organ function indications and potential improvements following curative therapy for sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:277-282. [PMID: 36485131 PMCID: PMC9820741 DOI: 10.1182/hematology.2022000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Curative therapies for sickle cell disease include allogeneic hematopoietic stem cell transplantation (HSCT) and gene-modified autologous stem cell transplantation. HSCT has been used for 30 years with success measured by engraftment, symptom control, graft-vs-host disease (GVHD) risk, organ toxicity, and immune reconstitution. While human leukocyte antigen-matched sibling donor (MSD) transplants have excellent outcomes, alternate donor transplants (unrelated/haploidentical) are just beginning to overcome GVHD and engraftment hurdles to match MSD. Gene therapy, a newly developed treatment, is undergoing careful evaluation in many trials with varying approaches. The risk/benefit ratio to the patient in relation to outcomes, toxicities, and mortality risk drives eligibility for curative interventions. Consequently, eligibility criteria for MSD transplants can be less stringent, especially in the young. Posttransplant outcome analysis after the "cure" with respect to organ function recovery is essential. While established damage such as stroke is irreversible, transplant can help stabilize (pulmonary function), prevent further deterioration (stroke), improve (neurocognition), and protect unaffected organs. Tracking organ functions postintervention uniformly between clinical trials and for adequate duration is essential to answer safety and efficacy questions related to curative therapies. Age-appropriate application/outcome analyses of such therapies will be the ultimate goal in overcoming this disease.
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Merli P, Guzzo I, Locatelli F. Sequential Stem Cell-Kidney Transplantation in Schimke Immuno-osseous Dysplasia. N Engl J Med 2022; 387:860. [PMID: 36053525 DOI: 10.1056/nejmc2209527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Pietro Merli
- IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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Mayer SL, Fields ME, Hulbert ML. Neurologic and Cognitive Outcomes in Sickle Cell Disease from Infancy through Adolescence. Neoreviews 2021; 22:e531-e539. [PMID: 34341160 DOI: 10.1542/neo.22-8-e531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Children with sickle cell disease (SCD) are at risk for neurologic and cognitive complications beginning in early childhood. Current treatment for SCD focuses on primary prevention of complications, such as hydroxyurea for prevention of pain and acute chest syndrome, and chronic transfusion therapy for children who are at high risk for strokes. In this article, the prevalence, pathophysiology, and available interventions to prevent and treat neurologic and cognitive complications of SCD will be reviewed.
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Affiliation(s)
- Sarah L Mayer
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Melanie E Fields
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University in St Louis, St Louis, MO
| | - Monica L Hulbert
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University in St Louis, St Louis, MO
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Chaturvedi A. Pediatric skeletal diffusion-weighted magnetic resonance imaging, part 2: current and emerging applications. Pediatr Radiol 2021; 51:1575-1588. [PMID: 34018037 DOI: 10.1007/s00247-021-05028-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/07/2021] [Accepted: 02/17/2021] [Indexed: 01/07/2023]
Abstract
Diffusion-weighted imaging (DWI) complements the more established T1, fluid-sensitive and gadolinium-enhanced magnetic resonance pulse sequences used to assess several pediatric skeletal pathologies. There is optimism that the technique might not just be complementary but could serve as an alternative to gadolinium and radiopharmaceuticals for several indications. As a non-contrast, free-breathing and noninvasive technique, DWI is especially valuable in children and is readily incorporated into existing MRI protocols. The indications for skeletal DWI in children include distinguishing between benign and malignant skeletal processes, initial assessment and treatment response assessment for osseous sarcomas, and assessment of inflammatory arthropathies and femoral head ischemia, among others. A notable challenge of diffusion MRI is the dynamic nature of the growing pediatric skeleton. It is important to consider the child's age when placing DWI findings in context with potential marrow pathology. This review article summarizes the current and evolving applications of DWI for assessing the pediatric skeleton, rounding off the discussion with evolving directions for further research in this realm.
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Affiliation(s)
- Apeksha Chaturvedi
- Division of Pediatric Radiology, Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY, 14642, USA.
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Stotesbury H, Kawadler JM, Saunders DE, Kirkham FJ. MRI detection of brain abnormality in sickle cell disease. Expert Rev Hematol 2021; 14:473-491. [PMID: 33612034 PMCID: PMC8315209 DOI: 10.1080/17474086.2021.1893687] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/18/2021] [Indexed: 02/08/2023]
Abstract
Introduction: Over the past decades, neuroimaging studies have clarified that a significant proportion of patients with sickle cell disease (SCD) have functionally significant brain abnormalities. Clinically, structural magnetic resonance imaging (MRI) sequences (T2, FLAIR, diffusion-weighted imaging) have been used by radiologists to diagnose chronic and acute cerebral infarction (both overt and clinically silent), while magnetic resonance angiography and venography have been used to diagnose arteriopathy and venous thrombosis. In research settings, imaging scientists are increasingly applying quantitative techniques to shine further light on underlying mechanisms.Areas covered: From a June 2020 PubMed search of 'magnetic' or 'MRI' and 'sickle' over the previous 5 years, we selected manuscripts on T1-based morphometric analysis, diffusion tensor imaging, arterial spin labeling, T2-oximetry, quantitative susceptibility, and connectivity.Expert Opinion: Quantitative MRI techniques are identifying structural and hemodynamic biomarkers associated with risk of neurological and neurocognitive complications. A growing body of evidence suggests that these biomarkers are sensitive to change with treatments, such as blood transfusion and hydroxyurea, indicating that they may hold promise as endpoints in future randomized clinical trials of novel approaches including hemoglobin F upregulation, reduction of polymerization, and gene therapy. With further validation, such techniques may eventually also improve neurological and neurocognitive risk stratification in this vulnerable population.
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Affiliation(s)
- Hanne Stotesbury
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jamie Michelle Kawadler
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dawn Elizabeth Saunders
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Fenella Jane Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK
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Hirtz D, Kirkham FJ. Sickle Cell Disease and Stroke. Pediatr Neurol 2019; 95:34-41. [PMID: 30948147 DOI: 10.1016/j.pediatrneurol.2019.02.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 01/04/2023]
Abstract
Cerebral infarction is a common complication of sickle cell disease and may manifest as overt stroke or cognitive impairment associated with "silent" cerebral infarction on magnetic resonance imaging. Vasculopathy may be diagnosed on transcranial Doppler or magnetic resonance angiography. The risk factors in sickle cell disease for cognitive impairment, overt ischemic stroke, silent cerebral infarction, overt hemorrhagic stroke, and vasculopathy defined by transcranial Doppler or magnetic resonance angiography overlap, with severe acute and chronic anemia, acute chest crisis, reticulocytosis, and low oxygen saturation reported with the majority. However, there are differences reported in different cohorts, which may reflect age, geographic location, or neuroimaging techniques, for example, magnetic resonance imaging field strength. Regular blood transfusion reduces, but does not abolish, the risk of neurological complications in children with sickle cell disease and either previous overt stroke or silent cerebral infarction or abnormal transcranial Doppler. There are relatively few data on the use of hydroxyurea or other management strategies. Early assessment of the risk of neurocognitive complications is likely to become increasingly important in the management of sickle cell disease.
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Affiliation(s)
- Deborah Hirtz
- University of Vermont School of Medicine, Burlington, Vermont
| | - Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Unit, Clinical and Experimental Sciences, University of Southampton, UCL Great Ormond Street Institute of Child Health, London, UK.
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