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Aldana PR, Hanel RA, Piatt J, Han SH, Bansal MM, Schultz C, Gauger C, Pederson JM, Iii JCW, Hulbert ML, Jordan LC, Qureshi A, Garrity K, Robert AP, Hatem A, Stein J, Beydler E, Adelson PD, Greene S, Grabb P, Johnston J, Lang SS, Leonard J, Magge SN, Scott A, Shah S, Smith ER, Smith J, Strahle J, Vadivelu S, Webb J, Wrubel D. Cerebral revascularization surgery reduces cerebrovascular events in children with sickle cell disease and moyamoya syndrome: Results of the stroke in sickle cell revascularization surgery retrospective study. Pediatr Blood Cancer 2023; 70:e30336. [PMID: 37057741 DOI: 10.1002/pbc.30336] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 03/01/2023] [Accepted: 03/04/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Recent studies suggest that cerebral revascularization surgery may be a safe and effective therapy to reduce stroke risk in patients with sickle cell disease and moyamoya syndrome (SCD-MMS). METHODS We performed a multicenter, retrospective study of children with SCD-MMS treated with conservative management alone (conservative group)-chronic blood transfusion and/or hydroxyurea-versus conservative management plus surgical revascularization (surgery group). We monitored cerebrovascular event (CVE) rates-a composite of strokes and transient ischemic attacks. Multivariable logistic regression was used to compare CVE occurrence and multivariable Poisson regression was used to compare incidence rates between groups. Covariates in multivariable models included age at treatment start, age at moyamoya diagnosis, antiplatelet use, CVE history, and the risk period length. RESULTS We identified 141 patients with SCD-MMS, 78 (55.3%) in the surgery group and 63 (44.7%) in the conservative group. Compared with the conservative group, preoperatively the surgery group had a younger age at moyamoya diagnosis, worse baseline modified Rankin scale scores, and increased prevalence of CVEs. Despite more severe pretreatment disease, the surgery group had reduced odds of new CVEs after surgery (odds ratio = 0.27, 95% confidence interval [CI] = 0.08-0.94, p = .040). Furthermore, comparing surgery group patients during presurgical versus postsurgical periods, CVEs odds were significantly reduced after surgery (odds ratio = 0.22, 95% CI = 0.08-0.58, p = .002). CONCLUSIONS When added to conservative management, cerebral revascularization surgery appears to reduce the risk of CVEs in patients with SCD-MMS. A prospective study will be needed to validate these findings.
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Affiliation(s)
- Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Joseph Piatt
- Division of Neurosurgery, Nemours Neuroscience Center, A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Sabrina H Han
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Manisha M Bansal
- Department of Pediatric Hematology/Oncology, Nemours Children's Health System and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Corinna Schultz
- Department of Pediatrics, Nemours Center for Cancer and Blood Disorders, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Cynthia Gauger
- Department of Pediatric Hematology/Oncology, Nemours Children's Health System and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - John M Pederson
- Superior Medical Experts, St. Paul, Minnesota, USA
- Nested Knowledge, St. Paul, Minnesota, USA
| | - John C Wellons Iii
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Monica L Hulbert
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adnan Qureshi
- Department of Neurology, Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri, USA
| | - Kelsey Garrity
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Adam P Robert
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Asmaa Hatem
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Jennifer Stein
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Emily Beydler
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Stephanie Greene
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Paul Grabb
- Department of Neurosurgery, Children's Mercy Hospital, Kansas, Missouri, USA
| | - James Johnston
- Department of Neurosurgery, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Shih-Shan Lang
- Department of Neurosurgery and Pediatric Neurosurgery, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey Leonard
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Suresh N Magge
- Department of Neurosurgery, CHOC Neuroscience Institute, Children's Health of Orange County, Orange, California, USA
| | - Alex Scott
- Department of Neurosurgery, Washington University School of Medicine, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Sanjay Shah
- Department of Pediatric Hematology/Oncology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Edward R Smith
- Department of Neurosurgery, Children's Hospital Boston, and Harvard Medical School, Boston, Massachusetts, USA
| | - Jodi Smith
- Department of Pediatric Neurosurgery, Goodman Campbell Brain and Spine, Peyton Manning Children's Hospital, Indianapolis, Indiana, USA
| | - Jennifer Strahle
- Department of Neurosurgery, Washington University School of Medicine, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer Webb
- Department of Hematology/Oncology, Children's National Hospital, Washington, District of Columbia, USA
| | - David Wrubel
- Department of Neurosurgery, Children's Healthcare of Atlanta, Egleston Hospital, Atlanta, Georgia, USA
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2
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Peer S, Singh P. Intraluminal arterial transit artifact as a predictor of intracranial large artery stenosis on 3D time of flight MR angiography: Expanding the application of arterial spin labeling MRI in ischemic stroke. J Clin Imaging Sci 2023; 13:17. [PMID: 37405363 PMCID: PMC10316254 DOI: 10.25259/jcis_27_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/24/2023] [Indexed: 07/06/2023] Open
Abstract
Objectives The objective of this study was to evaluate the diagnostic value of "intraluminal arterial transit artifact" in the prediction of intracranial large artery stenosis and to determine if this finding is predictive of ischemic stroke in the territory of the involved artery. Material and Methods The presence of arterial transit artifact (ATA) within the lumen of an intracranial large vessel was noted on three-dimensional time of flight (3D-TOF) magnetic resonance angiography (MRA) (ATA group). The patients with stenosis but with no ATA (no-ATA group), patients with total occlusion (total occlusion group), and patients with no stenosis/occlusion (normal group) were included in the analysis. Results There were four groups of patients included in the final analysis, the ATA group (n = 22), the no-ATA group (n = 23), the normal group (n = 25), and the total occlusion group (n = 9). Among patients with any demonstrable stenosis (n = 45), the presence of ATA within the stenotic segment was predictive of stenosis of ≥56% (Sensitivity of 100% [85.2-100, 95% CI], specificity of 100% [86.4-100, 95% CI]), with area under curve of 1.0 (0.92-.0, 95% CI). The presence of intra-arterial ATA signal was significantly associated with ischemic stroke as compared with the no-ATA group (86.36% vs. 26.08%, P = 0.0003). Intraluminal ATA was found to be an independent predictor of infarction in the territory of the involved artery. Conclusion Intraluminal ATA is predictive of stenosis of at least 56% in the involved artery on 3D-TOF MRA. Intraluminal ATA sign may be an independent predictor of infarction in the territory of the involved artery.
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Affiliation(s)
- Sameer Peer
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bathinda, Punjab, India
| | - Paramdeep Singh
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bathinda, Punjab, India
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3
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Alakbarzade V, Maduakor C, Khan U, Khandanpour N, Rhodes E, Pereira AC. Cerebrovascular disease in sickle cell disease. Pract Neurol 2023; 23:131-138. [PMID: 36123118 DOI: 10.1136/pn-2022-003440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 11/04/2022]
Abstract
Sickle cell disease (SCD) is the most common type of hereditary anaemia and genetic disorder worldwide. Cerebrovascular disease is one of its most devastating complications, with consequent increased morbidity and mortality. Current guidelines suggest that children and adults with SCD who develop acute ischaemic stroke should be transfused without delay. Those with acute ischaemic stroke aged over 18 years who present within 4.5 hours of symptom onset should be considered for intravenous thrombolysis; older patients with conventional vascular risk factors are the most likely to benefit. Endovascular thrombectomy should be considered carefully in adults with SCD as there are few data to guide how the prevalence of cerebral vasculopathy may confound the expected benefits or risks of intervention. We present a practical approach to cerebrovascular disease in sickle cell patients based on the available evidence and our experience.
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Affiliation(s)
- Vafa Alakbarzade
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Chinedu Maduakor
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Usman Khan
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Nader Khandanpour
- Department of Neuroradiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Elizabeth Rhodes
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Anthony C Pereira
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
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4
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Strumph K, Morrone K, Dhillon P, Hsu K, Gomes W, Silver E, Lax D, Peng Q, Lee SK, Manwani D, Mitchell W. Impact of magnetic resonance angiography parameters on stroke prevention therapy in pediatric patients with sickle cell anemia. Pediatr Blood Cancer 2023; 70:e30109. [PMID: 36441603 DOI: 10.1002/pbc.30109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 10/10/2022] [Accepted: 10/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Degree of cerebrovascular stenosis in pediatric patients with sickle cell anemia (SCA) informs need for chronic transfusion therapy, which has significant risks. Flow artifact, intrinsic to magnetic resonance angiography (MRA), is dependent on technical parameters and can lead to overinterpretation of stenosis. The primary objective of this study was to document any change in stroke prevention therapy that could be attributed to the implementation of a standardized MRA scanning protocol for patients with SCA. METHODS A standardized MRA scanning protocol with an echo time of less than 5 ms was implemented at Montefiore Medical Center (MMC), NY in May 2016. Retrospective chart review identified 21 pediatric patients with SCA, with an MRA head both pre- and post-May 2016. Arterial stenosis on MRA, machine parameters, and treatment plans were compared pre- and post-implementation. RESULTS Ten of the 21 patients met inclusion criteria. Previously seen stenosis was re-classified to a lower degree in six of the 10 patients, leading to discontinuation of transfusions in five patients. No patients required escalation of therapy to chronic transfusions. CONCLUSION Optimizing flow artifact by decreasing echo time to less than 5 ms can improve accurate interpretation of cerebrovascular disease, and ensure appropriate treatment plans are in place for stroke prevention. This is especially important for implementing "TCD With Transfusions Changing to Hydroxyurea (TWiTCH)" clinical trial results in the real-world setting.
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Affiliation(s)
- Kaitlin Strumph
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, New York, New York, USA
| | - Kerry Morrone
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, New York, New York, USA
| | - Parmpreet Dhillon
- Division of Child Neurology, Department of Neurology, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Kevin Hsu
- Division of Neuroradiology, Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - William Gomes
- Division of Neuroradiology, Department of Radiology, Westchester Medical Center and New York Medical College, New York, New York, USA
| | - Ellen Silver
- Division of Academic General Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, New York, New York, USA
| | - Daniel Lax
- Division of Child Neurology, Department of Neurology, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Qi Peng
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Seon Kyu Lee
- Division of Neuroradiology, Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Deepa Manwani
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, New York, New York, USA
| | - William Mitchell
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, New York, New York, USA
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5
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Jacob M, Kawadler JM, Murdoch R, Ahmed M, Tutuba H, Masamu U, Shmueli K, Saunders DE, Clark CA, Kim J, Hamdule S, Makani J, Stotesbury H, Kirkham FJ. Brain volume in Tanzanian children with sickle cell anaemia: A neuroimaging study. Br J Haematol 2022; 201:114-124. [PMID: 36329651 DOI: 10.1111/bjh.18503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/10/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Brain injury is a common complication of sickle cell anaemia (SCA). White matter (WM) and cortical and subcortical grey matter (GM), structures may have reduced volume in patients with SCA. This study focuses on whether silent cerebral infarction (SCI), vasculopathy or anaemia affects WM and regional GM volumes in children living in Africa. Children with SCA (n = 144; aged 5-20 years; 74 male) and sibling controls (n = 53; aged 5-17 years; 29 male) underwent magnetic resonance imaging. Effects of SCI (n = 37), vasculopathy (n = 15), and haemoglobin were assessed. Compared with controls, after adjusting for age, sex and intracranial volume, patients with SCA had smaller volumes for WM and cortical, subcortical and total GM, as well as bilateral cerebellar cortex, globus pallidus, amygdala and right thalamus. Left globus pallidus volume was further reduced in patients with vasculopathy. Putamen and hippocampus volumes were larger in patients with SCA without SCI or vasculopathy than in controls. Significant positive effects of haemoglobin on regional GM volumes were confined to the controls. Patients with SCA generally have reduced GM volumes compared with controls, although some subcortical regions may be spared. SCI and vasculopathy may affect the trajectory of change in subcortical GM and WM volume. Brain volume in non-SCA children may be vulnerable to contemporaneous anaemia.
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Affiliation(s)
- Mboka Jacob
- Department of Radiology and Imaging Muhimbili University of Health and Allied Sciences Dar Es Salaam Tanzania
| | - Jamie M. Kawadler
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
| | - Russell Murdoch
- Department of Medical Physics and Biomedical Engineering UCL London UK
| | - Magda Ahmed
- Department of Radiology Muhimbili Orthopaedic Institute Dar Es Salaam Tanzania
| | - Hilda Tutuba
- Muhimbili Sickle cell Program Muhimbili University of Health and Allied Sciences Dar Es Salaam Tanzania
| | - Upendo Masamu
- Muhimbili Sickle cell Program Muhimbili University of Health and Allied Sciences Dar Es Salaam Tanzania
| | - Karin Shmueli
- Department of Medical Physics and Biomedical Engineering UCL London UK
| | - Dawn E. Saunders
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
| | - Chris A. Clark
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
- Biomedical Research Centre Great Ormond Street hospital for Children London UK
| | - Jinna Kim
- Department of Radiology Yonsei University Seoul South Korea
| | - Shifa Hamdule
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
| | - Julie Makani
- Department of Haematology and Blood Transfusion Muhimbili University of Health and Allied Sciences Dar Es Salaam Tanzania
| | - Hanne Stotesbury
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
| | - Fenella J. Kirkham
- Developmental Neurosciences Section UCL Great Ormond Street Institute of Child Health London UK
- Biomedical Research Centre Great Ormond Street hospital for Children London UK
- Clinical Experimental Sciences University of Southampton Southampton UK
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6
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Bernaudin F, Arnaud C, Kamdem A, Hau I, Madhi F, Jung C, Epaud R, Verlhac S. Incidence, kinetics, and risk factors for intra- and extracranial cerebral arteriopathies in a newborn sickle cell disease cohort early assessed by transcranial and cervical color Doppler ultrasound. Front Neurol 2022; 13:846596. [PMID: 36188389 PMCID: PMC9515365 DOI: 10.3389/fneur.2022.846596] [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: 12/31/2021] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
The risk of stroke in children with sickle cell disease (SCD) is detected by abnormal intracranial arterial time-averaged mean of maximum velocities (TAMVs ≥200 cm/s). Recently, extracranial internal carotid artery (eICA) arteriopathy has been reported, and a cross-sectional study showed that eICA-TAMVs ≥160 cm/s are significantly associated with eICA kinkings and stenosis. The cumulative incidence of and predictive risk factors for intracranial arteriopathy are well described in sickle cell anemia (SCA=SS/Sβ0) but are lacking for SC/Sβ+ children, as is the cumulative incidence of eICA arteriopathy. We report a prospective longitudinal cohort study including 493 children with SCD (398 SCA, 95 SC/Sβ+), all assessed by transcranial and cervical color Doppler ultrasound. Cerebral MRI/MRA data were available in 375 children with SCD and neck MRA in 365 children. eICA kinkings were defined as eICA tortuosities on neck MRA, with an internal acute angle between the two adjacent segments <90°. The median follow-up was 10.6 years. The cumulative incidence of kinkings was significantly lower in SC/Sβ+ children than in children with SCA, and no SC/Sβ+ child developed intra- or extracranial stenotic arteriopathy. The 10-year KM estimate of cumulative incidence (95% CI) for eICA-TAMVs ≥160 cm/s revealed its development in the 2nd year of life in children with SCA, reaching a plateau of 17.4% (13.2–21.6%) by about 10 years of age, while the plateau for eICA stenosis was 12.3% (8.3–16.3%). eICA assessment identified 13.5% (9.3–17.7%) patients at risk of stroke who were not detected by transcranial color Doppler ultrasound. We also show, for the first time, that in addition to a congenital origin, eICA kinkings sin patients with SCD can develop progressively with aging as a function of eICA-TAMVs, themselves related to anemia severity. Ongoing hydroxyurea treatment was significantly associated with a lower risk of abnormal intracranial arteriopathy and eICA kinkings. After adjustment with hydroxyurea, baseline low hemoglobin, high reticulocyte, and WBC counts remained independent risk factors for intracranial arteriopathy, while low hemoglobin and SEN β-haplotype number were independent risk factors for extracranial arteriopathy. The association between extracranial arteriopathy and SEN β-haplotype number suggested a genetic link between the ethnic origin and incidence of eICA kinkings. This prospective cohort study shows the importance of systematically assessing the eICA and of recording biological parameters during the 2nd year of life before any intensive therapy to predict the risk of cerebral arteriopathy and treat patients with severe baseline anemia.
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Affiliation(s)
- Françoise Bernaudin
- Department of Pediatrics, Referral Center for Sickle Cell Disease, Intercommunal Créteil Hospital, University Paris Est, Créteil, France
- Clinical Research Center, Intercommunal Créteil Hospital, University Paris Est, Créteil, France
- *Correspondence: Françoise Bernaudin
| | - Cécile Arnaud
- Department of Pediatrics, Referral Center for Sickle Cell Disease, Intercommunal Créteil Hospital, University Paris Est, Créteil, France
| | - Annie Kamdem
- Department of Pediatrics, Referral Center for Sickle Cell Disease, Intercommunal Créteil Hospital, University Paris Est, Créteil, France
| | - Isabelle Hau
- Department of Pediatrics, Intercommunal Créteil Hospital, University Paris Est, Créteil, France
| | - Fouad Madhi
- Department of Pediatrics, Intercommunal Créteil Hospital, University Paris Est, Créteil, France
| | - Camille Jung
- Clinical Research Center, Intercommunal Créteil Hospital, University Paris Est, Créteil, France
| | - Ralph Epaud
- Department of Pediatrics, Intercommunal Créteil Hospital, University Paris Est, Créteil, France
| | - Suzanne Verlhac
- Department of Medical Imaging, Referral Center for Sickle Cell Disease, Intercommunal Créteil Hospital, Créteil, France
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7
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Champlin G, Hwang SN, Heitzer A, Ding J, Jacola L, Estepp JH, Wang W, Ataga KI, Owens CL, Newman J, King AA, Davis R, Kang G, Hankins JS. Progression of central nervous system disease from pediatric to young adulthood in sickle cell anemia. Exp Biol Med (Maywood) 2021; 246:2473-2479. [PMID: 34407676 DOI: 10.1177/15353702211035778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Silent cerebral infarcts and arteriopathy are common and progressive in individuals with sickle cell anemia. However, most data describing brain lesions in sickle cell anemia are cross-sectional or derive from pediatric cohorts with short follow-up. We investigated the progression of silent cerebral infarct and cerebral vessel stenosis on brain MRI and MRA, respectively, by describing the incidence of new or worsening lesions over a period of up to 25 years among young adults with sickle cell anemia and explored risk factors for progression. Forty-four adults with sickle cell anemia (HbSS or HbSβ0thalassemia), exposed to chronic transfusions (n = 12) or hydroxyurea (n = 32), median age 19.2 years (range 18.0-31.5), received a screening brain MRI/MRA and their results were compared with a clinical exam performed during childhood and adolescence. We used exact log-rank test to compare MRI and MRA progression among any two groups. The hazard ratio (HR) and 95% confidence interval (CI) were calculated from Cox regression analyses. Progression of MRI and MRA occurred in 12 (27%) and 4 (9%) young adults, respectively, relative to their pediatric exams. MRI progression risk was high among participants with abnormal pediatric exams (HR: 11.6, 95% CI: 2.5-54.7) and conditional or abnormal transcranial Doppler ultrasound velocities (HR: 3.9, 95% CI: 1.0-15.1). Among individuals treated with hydroxyurea, high fetal hemoglobin measured in childhood was associated with lower hazard of MRI progression (HR: 0.86, 95% CI: 0.76-0.98). MRA progression occurred more frequently among those with prior stroke (HR: 8.6, 95% CI: 1.2-64), abnormal pediatric exam (P = 0.00084), and elevated transcranial Doppler ultrasound velocities (P = 0.004). Brain MRI/MRA imaging in pediatrics can identify high-risk patients for CNS disease progression in young adulthood, prompting consideration for early aggressive treatments.
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Affiliation(s)
- Grace Champlin
- Department of Clinical Education and Training, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Scott N Hwang
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Andrew Heitzer
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Juan Ding
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Lisa Jacola
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Jeremie H Estepp
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.,Global Medicine, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Winfred Wang
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Kenneth I Ataga
- University of Tennessee Health Science Center (UTHSC), Center for Sickle Cell Disease, Memphis, TN 38163, USA.,Methodist University Comprehensive Sickle Cell Center, Memphis, TN 38104, USA
| | - Curtis L Owens
- Methodist University Comprehensive Sickle Cell Center, Memphis, TN 38104, USA
| | - Justin Newman
- Memphis Radiological Professional Corporation, Memphis, TN 38138, USA
| | - Allison A King
- Washington University School of Medicine, St. Louis, MO 63130, USA
| | - Robert Davis
- Center in Biomedical Informatics at UTHSC, Memphis, TN 38163, USA
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
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8
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Houwing ME, Grohssteiner RL, Dremmen MHG, Atiq F, Bramer WM, de Pagter APJ, Zwaan CM, White TJH, Vernooij MW, Cnossen MH. Silent cerebral infarcts in patients with sickle cell disease: a systematic review and meta-analysis. BMC Med 2020; 18:393. [PMID: 33349253 PMCID: PMC7754589 DOI: 10.1186/s12916-020-01864-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND PURPOSE Silent cerebral infarcts (SCIs) are the most common neurological complication in children and adults with sickle cell disease (SCD). In this systematic review, we provide an overview of studies that have detected SCIs in patients with SCD by cerebral magnetic resonance imaging (MRI). We focus on the frequency of SCIs, the risk factors involved in their development and their clinical consequences. METHODS The databases of Embase, MEDLINE ALL via Ovid, Web of Science Core Collection, Cochrane Central Register of Trials via Wiley and Google Scholar were searched from inception to June 1, 2019. RESULTS The search yielded 651 results of which 69 studies met the eligibility criteria. The prevalence of SCIs in patients with SCD ranges from 5.6 to 80.6% with most studies reported in the 20 to 50% range. The pooled prevalence of SCIs in HbSS and HbSβ0 SCD patients is 29.5%. SCIs occur more often in patients with the HbSS and HbSβ0 genotype in comparison with other SCD genotypes, as SCIs are found in 9.2% of HbSC and HbSβ+ patients. Control subjects showed a mean pooled prevalence of SCIs of 9.8%. Data from included studies showed a statistically significant association between increasing mean age of the study population and mean SCI prevalence. Thirty-three studies examined the risk factors for SCIs. The majority of the risk factors show no clear association with prevalence, since more or less equal numbers of studies give evidence for and against the causal association. CONCLUSIONS This systematic review and meta-analysis shows SCIs are common in patients with SCD. No clear risk factors for their development were identified. Larger, prospective and controlled clinical, neuropsychological and neuroimaging studies are needed to understand how SCD and SCIs affect cognition.
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Affiliation(s)
- Maite E Houwing
- Department of Pediatric Haematology and Oncology, Erasmus MC - Sophia Children's Hospital, NC-825, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - Rowena L Grohssteiner
- Department of Pediatric Haematology and Oncology, Erasmus MC - Sophia Children's Hospital, NC-825, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Marjolein H G Dremmen
- Department of Pediatric Radiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ferdows Atiq
- Department of Haematology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Anne P J de Pagter
- Department of Pediatric Haematology and Oncology, Erasmus MC - Sophia Children's Hospital, NC-825, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - C Michel Zwaan
- Department of Pediatric Haematology and Oncology, Erasmus MC - Sophia Children's Hospital, NC-825, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Tonya J H White
- Department of Child and Adolescent Psychiatry, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Meike W Vernooij
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Haematology and Oncology, Erasmus MC - Sophia Children's Hospital, NC-825, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
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9
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Verlhac S, Gabor F, Paillard C, Chateil JF, Jubert C, Petras M, Grevent D, Brousse V, Petit P, Thuret I, Arnaud C, Kamdem A, Pondarré C, Gauthier A, de Montalembert M, Divialle-Doumdo L, Elmaleh M, Missud F, Guitton C, Bernaudin F. Improved stenosis outcome in stroke-free sickle cell anemia children after transplantation compared to chronic transfusion. Br J Haematol 2020; 193:188-193. [PMID: 33216975 DOI: 10.1111/bjh.17178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/16/2020] [Indexed: 11/29/2022]
Abstract
We report here the 3-year stenosis outcome in 60 stroke-free children with sickle cell anaemia (SCA) and an abnormal transcranial Doppler history, enrolled in the DREPAGREFFE trial, which compared stem cell transplantation (SCT) with standard-care (chronic transfusion for 1-year minimum). Twenty-eight patients with matched sibling donors were transplanted, while 32 remained on standard-care. Stenosis scores were calculated after performing cerebral/cervical 3D time-of-flight magnetic resonance angiography. Fourteen patients had stenosis at enrollment, but only five SCT versus 10 standard-care patients still had stenosis at 3 years. Stenosis scores remained stable on standard-care, but significantly improved after SCT (P = 0·006). No patient developed stenosis after SCT, while two on standard-care did, indicating better stenosis prevention and improved outcome after SCT.
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Affiliation(s)
- Suzanne Verlhac
- Referral Center for Sickle Cell Disease, Intercommunal Créteil Hospital, Robert-Debré Hospital APHP Paris, University Paris-Diderot, Paris, France
| | - Flaviu Gabor
- Department of Medical Imaging, Hautepierre Hospital, Strasbourg University, Strasbourg, France
| | - Catherine Paillard
- Department of Pediatric Hematology, Hautepierre Hospital, Strasbourg University, Strasbourg, France
| | | | - Charlotte Jubert
- Department of Pediatric Hematology, Bordeaux Hospital, Bordeaux, France
| | - Marie Petras
- Referral Center for Sickle Cell Disease, Pointe à Pitre, Guadeloupe, France
| | - David Grevent
- Department of Medical Imaging, Department of Pediatrics, Necker Hospital, University Paris-Descartes, Paris, France
| | - Valentine Brousse
- Referral Center for Sickle Cell Disease, Department of Pediatrics, Necker Hospital, University Paris-Descartes, Paris, France
| | - Philippe Petit
- Department of Medical Imaging, La Timone Hospital, Marseille University, Marseille, France
| | - Isabelle Thuret
- Department of Pediatric Hematology, La Timone Hospital, Marseille University, Marseille, France
| | - Cécile Arnaud
- Referral Center for Sickle Cell Disease, Department of Pediatrics, Intercommunal Créteil Hospital, University Paris Est, Creteil, France
| | - Annie Kamdem
- Referral Center for Sickle Cell Disease, Department of Pediatrics, Intercommunal Créteil Hospital, University Paris Est, Creteil, France
| | - Corinne Pondarré
- Referral Center for Sickle Cell Disease, Department of Pediatrics, Intercommunal Créteil Hospital, University Paris Est, Creteil, France.,Department of Pediatric Hematology, HIOP, Lyon, France
| | | | - Mariane de Montalembert
- Referral Center for Sickle Cell Disease, Department of Pediatrics, Necker Hospital, University Paris-Descartes, Paris, France
| | | | - Monique Elmaleh
- Department of Medical Imaging, Intercommunal Créteil Hospital, Robert-Debré Hospital APHP Paris, University Paris-Diderot, Paris, France
| | - Florence Missud
- Department of Pediatrics, Intercommunal Créteil Hospital, Robert-Debré Hospital APHP Paris, University Paris-Diderot, Paris, France
| | - Corinne Guitton
- Referral Center for Sickle Cell Disease, Department of Pediatrics, Kremlin-Bicêtre Hospital, University Paris-Sud, Le Kremlin-Bicêtre, France
| | - Françoise Bernaudin
- Referral Center for Sickle Cell Disease, Department of Pediatrics, Intercommunal Créteil Hospital, University Paris Est, Creteil, France
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10
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Jacob M, Saunders DE, Sangeda RZ, Ahmed M, Tutuba H, Kussaga F, Musa B, Mmbando B, Slee AE, Kawadler JM, Makani J, Kirkham FJ. Cerebral Infarcts and Vasculopathy in Tanzanian Children With Sickle Cell Anemia. Pediatr Neurol 2020; 107:64-70. [PMID: 32111561 DOI: 10.1016/j.pediatrneurol.2019.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/09/2019] [Accepted: 12/14/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cerebral infarcts and vasculopathy in neurologically asymptomatic children with sickle cell anemia (SCA) have received little attention in African settings. This study aimed to establish the prevalence of silent cerebral infarcts (SCI) and vasculopathy and determine associations with exposure to chronic hemolysis, anemia, and hypoxia. METHODS We prospectively studied 224 children with SCA with transcranial Doppler (TCD), and magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). Regressions were undertaken with contemporaneous hemoglobin, reticulocyte count, mean prior hemoglobin, oxygen content, reticulocyte count, and indirect bilirubin. RESULTS Prevalence of SCI was 27% (61 of 224); cerebral blood flow velocity was abnormal (>200 cm/s) in three and conditional (>170<200 cm/s) in one. Vasculopathy grades 2 (stenosis) and 3 (occlusion) occurred in 16 (7%) and two (1%), respectively; none had grade 4 (moyamoya). SCI was associated with vasculopathy on MRA (odds ratio 2.68; 95% confidence intervals [95% CI] 1.32 to 5.46; P = 0.007) and mean prior indirect bilirubin (odds ratio 1.02, 95% CI 1.00 to 1.03, P = 0.024; n = 83) but not age, sex, non-normal TCD, or contemporaneous hemoglobin. Vasculopathy was associated with mean prior values for hemoglobin (odds ratio 0.33, 95% CI 0.16 to 0.69, P = 0.003; n = 87), oxygen content (odds ratio 0.43, 95% CI 0.25 to 0.74, P = 0.003), reticulocytes (odds ratio 1.20, 95% CI 1.01-1.42, P = 0.041; n = 77), and indirect bilirubin (odds ratio 1.02, 95% CI 1.01 to 1.04, P = 0.009). CONCLUSIONS SCI and vasculopathy on MRA are common in neurologically asymptomatic children with SCA living in Africa, even when TCD is normal. Children with vasculopathy on MRA are at increased risk of SCI. Longitudinal exposure to anemia, hypoxia, and hemolysis appear to be risk factors for vasculopathy.
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Affiliation(s)
- Mboka Jacob
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania.
| | - Dawn E Saunders
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Raphael Z Sangeda
- Department of Pharmaceutical Microbiology, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Magda Ahmed
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Hilda Tutuba
- Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Frank Kussaga
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Balowa Musa
- Department of Radiology & Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Bruno Mmbando
- Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania; Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences & National Institute for Medical Research, Tanga Center, Tanga, Tanzania
| | - April E Slee
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Julie Makani
- Department of Heamatology and Blood Transfusion, Muhimbili Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania; Muhimbili Sickle Cell Program & Department of Hematology and Blood Transfusion, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Fenella J Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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11
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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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12
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Juttukonda MR, Donahue MJ. Neuroimaging of vascular reserve in patients with cerebrovascular diseases. Neuroimage 2019; 187:192-208. [PMID: 29031532 PMCID: PMC5897191 DOI: 10.1016/j.neuroimage.2017.10.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/01/2017] [Accepted: 10/07/2017] [Indexed: 12/21/2022] Open
Abstract
Cerebrovascular reactivity, defined broadly as the ability of brain parenchyma to adjust cerebral blood flow in response to altered metabolic demand or a vasoactive stimulus, is being measured with increasing frequency and may have a use for portending new or recurrent stroke risk in patients with cerebrovascular disease. The purpose of this review is to outline (i) the physiological basis of variations in cerebrovascular reactivity, (ii) available approaches for measuring cerebrovascular reactivity in research and clinical settings, and (iii) clinically-relevant cerebrovascular reactivity findings in the context of patients with cerebrovascular disease, including atherosclerotic arterial steno-occlusion, non-atherosclerotic arterial steno-occlusion, anemia, and aging. Literature references summarizing safety considerations for these procedures and future directions for standardizing protocols and post-processing procedures across centers are presented in the specific context of major unmet needs in the setting of cerebrovascular disease.
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Affiliation(s)
- Meher R Juttukonda
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physics and Astronomy, Vanderbilt University, Nashville, TN, USA.
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13
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Ford AL, Ragan DK, Fellah S, Binkley MM, Fields ME, Guilliams KP, An H, Jordan LC, McKinstry RC, Lee JM, DeBaun MR. Silent infarcts in sickle cell disease occur in the border zone region and are associated with low cerebral blood flow. Blood 2018; 132:1714-1723. [PMID: 30061156 PMCID: PMC6194388 DOI: 10.1182/blood-2018-04-841247] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 07/17/2018] [Indexed: 11/20/2022] Open
Abstract
Silent cerebral infarcts (SCIs) are associated with cognitive impairment in sickle cell anemia (SCA). SCI risk factors include low hemoglobin and elevated systolic blood pressure; however, mechanisms underlying their development are unclear. Using the largest prospective study evaluating SCIs in pediatric SCA, we identified brain regions with increased SCI density. We tested the hypothesis that infarct density is greatest within regions in which cerebral blood flow is lowest, further restricting cerebral oxygen delivery in the setting of chronic anemia. Neuroradiology and neurology committees reached a consensus of SCIs in 286 children in the Silent Infarct Transfusion (SIT) Trial. Each infarct was outlined and coregistered to a brain atlas to create an infarct density map. To evaluate cerebral blood flow as a function of infarct density, pseudocontinuous arterial spin labeling was performed in an independent pediatric SCA cohort. Blood flow maps were aligned to the SIT Trial infarct density map. Mean blood flow within low, moderate, and high infarct density regions from the SIT Trial were compared. Logistic regression evaluated clinical and imaging predictors of overt stroke at 3-year follow-up. The SIT Trial infarct density map revealed increased SCI density in the deep white matter of the frontal and parietal lobes. A relatively small region, measuring 5.6% of brain volume, encompassed SCIs from 90% of children. Cerebral blood flow was lowest in the region of highest infarct density (P < .001). Baseline infarct volume and reticulocyte count predicted overt stroke. In pediatric SCA, SCIs are symmetrically located in the deep white matter where minimum cerebral blood flow occurs.
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Affiliation(s)
| | | | | | | | | | | | - Hongyu An
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; and
| | - Lori C Jordan
- Department of Pediatrics, Vanderbilt University, Nashville, TN
| | - Robert C McKinstry
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; and
| | - Jin-Moo Lee
- Department of Neurology
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO; and
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14
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Corvest V, Blais S, Dahmani B, De Tersant M, Etienney AC, Maroni A, Ormières C, Roussel A, Pondarré C. [Cerebral vasculopathy in children with sickle cell disease: Key issues and the latest data]. Arch Pediatr 2017; 25:63-71. [PMID: 29254735 DOI: 10.1016/j.arcped.2017.11.015] [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: 02/15/2017] [Revised: 09/07/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022]
Abstract
Cerebral vasculopathy is a common and severe complication of sickle cell disease in children. The pathophysiology consists of progressive damage to the basal intracranial arteries and cerebral microcirculation, while chronic anemia worsens exposure to cerebral hypoxia. It results in stroke and subclinical or poorly symptomatic ischemic lesions. Many clinical, biological, and radiological risk factors have been identified. The prevention strategy through systematic transcranial Doppler screening of large-vessel vasculopathy has revolutionized the management of this disease and has greatly decreased the risk of developing stroke. MRI-MRA is a complementary diagnostic tool for anatomical analysis of parenchymal and vascular lesions, which is used for chronic disease monitoring or in the context of an acute neurological event. New exploration opportunities are offered by submandibular Doppler sonography and indirect evaluation methods of cerebral oxygenation and perfusion. If chronic blood transfusion therapy is used to prevent the occurrence and recurrence of cerebral complications of sickle cell disease, only allogeneic hematopoietic stem cell transplantation can safely and definitively stop the transfusion program. It should therefore be proposed early, before irreversible cerebral or vascular lesions occur. Hydroxycarbamide treatment has recently emerged as a potential substitute for chronic transfusions for the maintenance of transcranial Doppler velocities, but only after an initial treatment by transfusions and provided there is close follow-up. In the long run, cerebral vascular damage can cause progressive cognitive impairment and disability, even in children without radiologically identified lesions, indicating the importance of systematic and repeated neuropsychological testing.
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Affiliation(s)
- V Corvest
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - S Blais
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - B Dahmani
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - M De Tersant
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - A-C Etienney
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - A Maroni
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - C Ormières
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - A Roussel
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - C Pondarré
- Université Paris-XII, centre hospitalier intercommunal de Créteil (CHIC), service de pédiatrie, 40, avenue de Verdun, 94000 Créteil, France.
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15
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Removal of Arterial Vessel Contributions in Susceptibility-Weighted Images for Quantification of Normalized Visible Venous Volume in Children with Sickle Cell Disease. JOURNAL OF HEALTHCARE ENGINEERING 2017; 2017:5369385. [PMID: 29065618 PMCID: PMC5592388 DOI: 10.1155/2017/5369385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 07/25/2017] [Accepted: 08/13/2017] [Indexed: 11/26/2022]
Abstract
Purpose To evaluate a new postprocessing framework that eliminates arterial vessel signal contributions in the quantification of normalized visible venous volume (NVVV, a ratio between venous and brain volume) in susceptibility-weighted imaging (SWI) exams in patients with sickle cell disease (SCD). Materials and Methods We conducted a retrospective study and qualitatively reviewed for hypointense arterial vessel contamination in SWI exams from 21 children with SCD. We developed a postprocessing framework using magnetic resonance angiography in combination with SWI to provide a more accurate quantification of NVVV. NVVV was calculated before and after removing arterial vessel contributions to determine the error from hypointense arterial vessels in quantifying NVVV. Results Hypointense arterial vessel contamination was observed in 86% SWI exams and was successfully corrected by the proposed method. The contributions of hypointense arterial vessels in the original SWI were significant and accounted for approximately 33% of the NVVV [uncorrected NVVV = 0.012 ± 0.005 versus corrected NVVV = 0.008 ± 0.003 (mean ± SD), P < 0.01]. Conclusion Hypointense arterial vessel contamination occurred in the majority of SWI exams and led to a sizeable overestimation of the visible venous volume. A prospective longitudinal study is needed to evaluate if quantitation of NVVV was improved and to assess the role of NVVV as a biomarker of SCD severity or stroke risk.
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16
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Central nervous system complications and management in sickle cell disease. Blood 2016; 127:829-38. [DOI: 10.1182/blood-2015-09-618579] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/25/2015] [Indexed: 02/07/2023] Open
Abstract
Abstract
With advances in brain imaging and completion of randomized clinical trials (RCTs) for primary and secondary stroke prevention, the natural history of central nervous system (CNS) complications in sickle cell disease (SCD) is evolving. In order of current prevalence, the primary CNS complications include silent cerebral infarcts (39% by 18 years), headache (both acute and chronic: 36% in children with sickle cell anemia [SCA]), ischemic stroke (as low as 1% in children with SCA with effective screening and prophylaxis, but ∼11% in children with SCA without screening), and hemorrhagic stroke in children and adults with SCA (3% and 10%, respectively). In high-income countries, RCTs (Stroke Prevention in Sickle Cell Anemia [STOP], STOP II) have demonstrated that regular blood transfusion therapy (typically monthly) achieves primary stroke prevention in children with SCA and high transcranial Doppler (TCD) velocities; after at least a year, hydroxycarbamide may be substituted (TCD With Transfusions Changing to Hydroxyurea [TWiTCH]). Also in high-income countries, RCTs have demonstrated that regular blood transfusion is the optimal current therapy for secondary prevention of infarcts for children with SCA and strokes (Stroke With Transfusions Changing to Hydroxyurea [SWiTCH]) or silent cerebral infarcts (Silent Infarct Transfusion [SIT] Trial). For adults with SCD, CNS complications continue to be a major cause of morbidity and mortality, with no evidence-based strategy for prevention.
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17
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18
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Griessenauer CJ, Lebensburger JD, Chua MH, Fisher WS, Hilliard L, Bemrich-Stolz CJ, Howard TH, Johnston JM. Encephaloduroarteriosynangiosis and encephalomyoarteriosynangiosis for treatment of moyamoya syndrome in pediatric patients with sickle cell disease. J Neurosurg Pediatr 2015; 16:64-73. [PMID: 25837886 DOI: 10.3171/2014.12.peds14522] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Pediatric patients with sickle cell disease (SCD) and moyamoya syndrome (MMS) are at significant risk for cerebrovascular accidents despite chronic transfusion therapy. Encephaloduroarteriosynangiosis (EDAS) and encephalomyoarteriosynangiosis (EMAS) are additional therapeutic options for these patients. To date, the incidence of complications after and efficacy of EDAS and EMAS in stroke prevention in this population have been described in several institutional case series reports, but no randomized prospective trials have been reported. METHODS The authors retrospectively reviewed the cases of all pediatric patients at the University of Alabama at Birmingham with a history of homozygous hemoglobin S (HbS) and sickle cell/β-thalassemia (SB0 thalassemia) and on chronic transfusion therapy, including 14 patients with MMS who underwent EDAS or EMAS. RESULTS Sixty-two patients with SCD and on chronic transfusion therapy were identified. After exclusion of patients on chronic transfusion therapy for indications other than stroke prevention, 48 patients (77.4%) remained. Of those patients, 14 (29.1%) underwent EDAS or EMAS. Nine (18.8%) and 25 (52.1%) patients were on chronic transfusion therapy for primary or secondary stroke prevention, respectively, but did not undergo EDAS or EMAS. The 14 patients with SCD and radiological evidence of MMS and on chronic transfusion therapy for primary or secondary stroke prevention underwent 21 EDAS or EMAS procedures for progressive vascular disease (92.9% of patients), stroke (71.4%), and/or seizure (7.1%). The mean (± SD) time from initiation of chronic transfusion therapy to EDAS or EMAS was 76.8 ± 58.8 months. Complications included 1 perioperative stroke, 1 symptomatic subdural hygroma, 1 postoperative seizure, and 1 case of intraoperative cerebral edema that required subsequent cranioplasty. Before EDAS or EMAS, the stroke rate was calculated to be 1 stroke per 7.8 patient-years. One additional stroke occurred during the follow-up period (mean follow-up time 33.7 ± 19.6 months), resulting in a post-EDAS/EMAS stroke rate of 1 stroke per 39.3 patient-years, a 5-fold reduction compared with that in the pre-EDAS/EMAS period. The patients' mean pre-EDAS/EMAS HbS level of 29.5% ± 6.4% was comparable to the mean post-EDAS/EMAS HbS level of 25.5% ± 6.1% (p = 0.104). CONCLUSIONS The results of this retrospective case series in a large cohort of pediatric patients with SCD and MMS suggest that EDAS/EMAS provides a stroke-prevention benefit with an acceptably low morbidity rate. Given the combined experience with EDAS and EMAS for this indication at this and other institutions, a prospective clinical trial to assess their efficacy compared with that of chronic transfusion therapy alone is warranted.
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Affiliation(s)
| | | | | | | | - Lee Hilliard
- Pediatric Hematology Oncology, University of Alabama at Birmingham, Alabama; and
| | | | - Thomas H Howard
- Pediatric Hematology Oncology, University of Alabama at Birmingham, Alabama; and
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19
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Chen R, Arkuszewski M, Krejza J, Zimmerman RA, Herskovits EH, Melhem ER. A prospective longitudinal brain morphometry study of children with sickle cell disease. AJNR Am J Neuroradiol 2014; 36:403-10. [PMID: 25234033 DOI: 10.3174/ajnr.a4101] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Age-related changes in brain morphology are crucial to understanding the neurobiology of sickle cell disease. We hypothesized that the growth trajectories for total GM volume, total WM volume, and regional GM volumes are altered in children with sickle cell disease compared with controls. MATERIALS AND METHODS We analyzed T1-weighted images of the brains of 28 children with sickle cell disease (mean baseline age, 98 months; female/male ratio, 15:13) and 28 healthy age- and sex-matched controls (mean baseline age, 99 months; female/male ratio, 16:12). The total number of MR imaging examinations was 141 (2-4 for each subject with sickle cell disease, 2-3 for each control subject). Total GM volume, total WM volume, and regional GM volumes were measured by using an automated method. We used the multilevel-model-for-change approach to model growth trajectories. RESULTS Total GM volume in subjects with sickle cell disease decreased linearly at a rate of 411 mm(3) per month. For controls, the trajectory of total GM volume was quadratic; we did not observe a significant linear decline. For subjects with sickle cell disease, we found 35 brain structures that demonstrated age-related GM volume reduction. Total WM volume in subjects with sickle cell disease increased at a rate of 452 mm(3) per month, while the trajectory of controls was quadratic. CONCLUSIONS There was a significant age-related decrease in total GM volume in children with sickle cell disease. The GM volume reduction was spatially distributed widely across the brain, primarily in the frontal, parietal, and occipital lobes. Total WM volume in subjects with sickle cell disease increased at a lower rate than for controls.
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Affiliation(s)
- R Chen
- From the Department of Diagnostic Radiology and Nuclear Medicine (R.C., J.K., E.H.H., E.R.M.), University of Maryland, Baltimore, Maryland Department of Radiology (R.C., R.A.Z.), Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - M Arkuszewski
- Department of Neurology (M.A.), Medical University of Silesia, Katowice, Poland
| | - J Krejza
- From the Department of Diagnostic Radiology and Nuclear Medicine (R.C., J.K., E.H.H., E.R.M.), University of Maryland, Baltimore, Maryland
| | - R A Zimmerman
- Department of Radiology (R.A.Z.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania Department of Radiology (R.C., R.A.Z.), Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - E H Herskovits
- From the Department of Diagnostic Radiology and Nuclear Medicine (R.C., J.K., E.H.H., E.R.M.), University of Maryland, Baltimore, Maryland
| | - E R Melhem
- From the Department of Diagnostic Radiology and Nuclear Medicine (R.C., J.K., E.H.H., E.R.M.), University of Maryland, Baltimore, Maryland
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