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Oni MO, Brito M, Rotman C, Archer NM. Genetic Modifiers of Stroke in Patients with Sickle Cell Disease-A Scoping Review. Int J Mol Sci 2024; 25:6317. [PMID: 38928024 PMCID: PMC11203960 DOI: 10.3390/ijms25126317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/29/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Sickle cell disease (SCD) clinically manifests itself with a myriad of complications. Stroke, both ischemic and hemorrhagic, as well as silent white matter changes, occurs at a relatively high prevalence. Understanding why and in whom stroke is most likely to occur is critical to the effective prevention and treatment of individuals with SCD. Genetic studies, including genome- and exome-wide association studies (GWAS and EWAS), have found several key modifiers associated with increased stroke/stroke risk in SCD via mechanisms including Hemoglobin F (HbF) modulation, inflammation, cellular adhesion, endothelial disruption, and hemolysis. We present a review on the modifiers that have most clearly demonstrated an association to date. More studies are needed to validate other potential polymorphisms and identify new ones. Incorporating gene-focused screenings in clinical care could provide avenues for more targeted, more effective, and less toxic prevention of stroke in this population. The data from this review will be used to inform the initial GWAS performed by the International Hemoglobinopathy Research Network (INHERENT) consortium.
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Affiliation(s)
- Morohuntodun O. Oni
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02115, USA;
| | - Miguel Brito
- H&TRC—Health & Technology Research Center, ESTeSL—Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-092 Lisbon, Portugal;
| | - Chloe Rotman
- Medical Library, Boston Children’s Hospital, Boston, MA 02115, USA;
| | - Natasha M. Archer
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA 02115, USA;
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2
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Kirkham JK, Estepp JH, Weiss MJ, Rashkin SR. Genetic Variation and Sickle Cell Disease Severity: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2337484. [PMID: 37851445 PMCID: PMC10585422 DOI: 10.1001/jamanetworkopen.2023.37484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/30/2023] [Indexed: 10/19/2023] Open
Abstract
Importance Sickle cell disease (SCD) is a monogenic disorder, yet clinical outcomes are influenced by additional genetic factors. Despite decades of research, the genetics of SCD remain poorly understood. Objective To assess all reported genetic modifiers of SCD, evaluate the design of associated studies, and provide guidelines for future analyses according to modern genetic study recommendations. Data Sources PubMed, Web of Science, and Scopus were searched through May 16, 2023, identifying 5290 publications. Study Selection At least 2 reviewers identified 571 original, peer-reviewed English-language publications reporting genetic modifiers of human SCD phenotypes, wherein the outcome was not treatment response, and the comparison was not between SCD subtypes or including healthy controls. Data Extraction and Synthesis Data relevant to all genetic modifiers of SCD were extracted, evaluated, and presented following STREGA and PRISMA guidelines. Weighted z score meta-analyses and pathway analyses were conducted. Main Outcomes and Measures Outcomes were aggregated into 25 categories, grouped as acute complications, chronic conditions, hematologic parameters or biomarkers, and general or mixed measures of SCD severity. Results The 571 included studies reported on 29 670 unique individuals (50% ≤ 18 years of age) from 43 countries. Of the 17 757 extracted results (4890 significant) in 1552 genes, 3675 results met the study criteria for meta-analysis: reported phenotype and genotype, association size and direction, variability measure, sample size, and statistical test. Only 173 results for 62 associations could be cross-study combined. The remaining associations could not be aggregated because they were only reported once or methods (eg, study design, reporting practice) and genotype or phenotype definitions were insufficiently harmonized. Gene variants regulating fetal hemoglobin and α-thalassemia (important markers for SCD severity) were frequently identified: 19 single-nucleotide variants in BCL11A, HBS1L-MYB, and HBG2 were significantly associated with fetal hemoglobin (absolute value of Z = 4.00 to 20.66; P = 8.63 × 10-95 to 6.19 × 10-5), and α-thalassemia deletions were significantly associated with increased hemoglobin level and reduced risk of albuminuria, abnormal transcranial Doppler velocity, and stroke (absolute value of Z = 3.43 to 5.16; P = 2.42 × 10-7 to 6.00 × 10-4). However, other associations remain unconfirmed. Pathway analyses of significant genes highlighted the importance of cellular adhesion, inflammation, oxidative and toxic stress, and blood vessel regulation in SCD (23 of the top 25 Gene Ontology pathways involve these processes) and suggested future research areas. Conclusions and Relevance The findings of this comprehensive systematic review and meta-analysis of all published genetic modifiers of SCD indicated that implementation of standardized phenotypes, statistical methods, and reporting practices should accelerate discovery and validation of genetic modifiers and development of clinically actionable genetic profiles.
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Affiliation(s)
- Justin K. Kirkham
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Jeremie H. Estepp
- Department of Hematology, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
- Now with Agios Pharmaceuticals, Cambridge, Massachusetts
| | - Mitch J. Weiss
- Department of Hematology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Sara R. Rashkin
- Department of Hematology, St Jude Children’s Research Hospital, Memphis, Tennessee
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3
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Karkoska KA, Gollamudi J, Hyacinth HI. Molecular and environmental contributors to neurological complications in sickle cell disease. Exp Biol Med (Maywood) 2023; 248:1319-1332. [PMID: 37688519 PMCID: PMC10625341 DOI: 10.1177/15353702231187646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2023] Open
Abstract
Sickle cell disease (SCD) is an inherited hemoglobinopathy in which affected hemoglobin polymerizes under hypoxic conditions resulting in red cell distortion and chronic hemolytic anemia. SCD affects millions of people worldwide, primarily in Sub-Saharan Africa and the Indian subcontinent. Due to vaso-occlusion of sickled red cells within the microvasculature, SCD affects virtually every organ system and causes significant morbidity and early mortality. The neurological complications of SCD are particularly devastating and diverse, ranging from overt stroke to covert cerebral injury, including silent cerebral infarctions and blood vessel tortuosity. However, even individuals without evidence of neuroanatomical changes in brain imaging have evidence of cognitive deficits compared to matched healthy controls likely due to chronic cerebral hypoxemia and neuroinflammation. In this review, we first examined the biological contributors to SCD-related neurological complications and then discussed the equally important socioenvironmental contributors. We then discuss the evidence for neuroprotection from the two primary disease-modifying therapies, chronic monthly blood transfusions and hydroxyurea, and end with several experimental therapies designed to specifically target these complications.
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Affiliation(s)
- Kristine A Karkoska
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45219-0525, USA
| | - Jahnavi Gollamudi
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45219-0525, USA
| | - Hyacinth I Hyacinth
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0525, USA
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4
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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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5
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Dai Y, Hu L. HSPB1 overexpression improves hypoxic-ischemic brain damage by attenuating ferroptosis in rats through promoting G6PD expression. J Neurophysiol 2022; 128:1507-1517. [PMID: 36321738 DOI: 10.1152/jn.00306.2022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Heat-shock protein B (HSPB1) has a neuroprotective effect on brain injury and is a negative regulator of ferroptosis. Therefore, we infer that HSPB1 plays a protective role in hypoxic-ischemic (HI) brain damage by inhibiting ferroptosis. A neonatal rat model of hypoxic-ischemic (HI) brain damage was established. HSPB1 overexpression plasmid and the negative control were injected into the lateral ventricle of rats 48 h before HI brain damage surgery. HSPB1 and glucose-6-phosphate dehydrogenase (G6PD) levels, infarction rate, iron accumulation, apoptosis, and ferroptosis-related markers were estimated with the assistance of qRT-PCR, 2,3,5-triphenyl tetrazolium chloride (TTC) staining, Prussian blue staining, iron assay kit, TUNEL staining, and Western blot. In vitro, after transfection, HSPB1 and G6PD levels, oxygen-glucose deprivation (OGD)-mediated hippocampal neuron cell viability, apoptosis, iron content, and ferroptosis-related markers were assessed using qRT-PCR, MTT, flow cytometry, iron assay kit, and Western blot. HSPB1 and G6PD were overexpressed in the hippocampus tissues of HI rats. High expression of HSPB1 in HI rats lessened infarction rate and ferritin level, hindered iron accumulation and apoptosis, and promoted GPX4, SLC7A11, and TFR1 levels. In OGD-mediated hippocampal neuron cells, HSPB1 upregulation intensified the viability and repressed apoptosis and ferroptosis, whereas G6PD silencing reversed the effects of HSPB1 upregulation. We documented that HSPB1 overexpression unleashes neuroprotective effects via modulating G6PD expression, which offers a novel target for the prevention and treatment of HI brain damage.NEW & NOTEWORTHY HSPB1 and G6PD were overexpressed in the hippocampus tissues of HI rats. High expression of HSPB1 in HI rats mitigated infarction rate and iron accumulation. HSPB1 overexpression reduced ferritin level, attenuated apoptosis, yet augmented GPX4, SLC7A11, and TFR1 levels in the hippocampus tissues of HI rats. G6PD deletion impaired the protective role of HSPB1 overexpression against HI brain damage-induced ferroptosis.
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Affiliation(s)
- Yi Dai
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, People's Republic of China
| | - Lan Hu
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, People's Republic of China
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6
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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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7
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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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8
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Esperti S, Boisson C, Robert M, Nader E, Cibiel A, Renoux C, Horrand F, Gauthier A, Poutrel S, Joly P, Connes P. Does G6PD deficiency cause further damage to red blood cells of patients with sickle cell anaemia? Br J Haematol 2022; 199:289-291. [PMID: 35973746 DOI: 10.1111/bjh.18417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/03/2022] [Accepted: 08/07/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Sofia Esperti
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team "Vascular Biology and Red Blood Cell" Universié Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France.,Erytech Pharma, Lyon, France
| | - Camille Boisson
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team "Vascular Biology and Red Blood Cell" Universié Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France
| | - Mélanie Robert
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team "Vascular Biology and Red Blood Cell" Universié Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France.,Erytech Pharma, Lyon, France
| | - Elie Nader
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team "Vascular Biology and Red Blood Cell" Universié Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France
| | | | - Céline Renoux
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team "Vascular Biology and Red Blood Cell" Universié Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France.,Laboratoire de Biochimie et de Biologie Moléculaire, UF de Biochimie des Pathologies Erythrocytaires, Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, Bron, France
| | | | - Alexandra Gauthier
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team "Vascular Biology and Red Blood Cell" Universié Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France.,Institut d'Hématologique et d'Oncologique Pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Solène Poutrel
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team "Vascular Biology and Red Blood Cell" Universié Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France.,Service de Médecine Interne, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Philippe Joly
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team "Vascular Biology and Red Blood Cell" Universié Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France.,Laboratoire de Biochimie et de Biologie Moléculaire, UF de Biochimie des Pathologies Erythrocytaires, Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, Bron, France
| | - Philippe Connes
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team "Vascular Biology and Red Blood Cell" Universié Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France
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9
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Fields ME, Mirro AE, Binkley MM, Guilliams KP, Lewis JB, Fellah S, Chen Y, Hulbert ML, An H, Ford AL, Lee J. Cerebral oxygen metabolic stress is increased in children with sickle cell anemia compared to anemic controls. Am J Hematol 2022; 97:682-690. [PMID: 35113471 DOI: 10.1002/ajh.26485] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/22/2022] [Accepted: 01/29/2022] [Indexed: 01/28/2023]
Abstract
Patients with sickle cell anemia (SCA) experience cerebral metabolic stress with an increase in oxygen extraction fraction (OEF) to compensate for reduced oxygen carrying capacity due to anemia. It remains unclear if anemia alone drives this metabolic stress. Using MRI, we collected voxel-wise OEF measurements to test our hypothesis that OEF would be elevated in anemic controls without SCA (AC) compared to healthy controls (HC), but OEF would be even higher in SCA compared to AC. Brain MRIs (N = 159) were obtained in 120 participants (34 HC, 27 AC, 59 SCA). While hemoglobin was lower in AC versus HC (p < 0.001), hemoglobin was not different between AC and SCA cohorts (p = 0.459). Whole brain OEF was higher in AC compared to HC (p < 0.001), but lower compared to SCA (p = 0.001). Whole brain OEF remained significantly higher in SCA compared to HC (p = 0.001) while there was no longer a difference between AC versus HC (p = 0.935) in a multivariate model controlling for age and hemoglobin. OEF peaked within the border zone regions of the brain in both SCA and AC cohorts, but the volume of white matter with regionally elevated OEF in AC was smaller (1.8%) than SCA (58.0%). While infarcts colocalized within regions of elevated OEF, more SCA participants had infarcts than AC (p < 0.001). We conclude that children with SCA experience elevated OEF compared to AC and HC after controlling for the impact of anemia, suggesting that there are other pathophysiologic factors besides anemia contributing to cerebral metabolic stress in children with SCA.
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Affiliation(s)
- Melanie E. Fields
- Department of Pediatrics Washington University School of Medicine St. Louis Missouri USA
- Department of Neurology Washington University School of Medicine St. Louis Missouri USA
| | - Amy E. Mirro
- Department of Pediatrics Washington University School of Medicine St. Louis Missouri USA
| | - Michael M. Binkley
- Department of Neurology Washington University School of Medicine St. Louis Missouri USA
| | - Kristin P. Guilliams
- Department of Pediatrics Washington University School of Medicine St. Louis Missouri USA
- Department of Neurology Washington University School of Medicine St. Louis Missouri USA
- Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis Missouri USA
| | - Josiah B. Lewis
- Department of Neurology Washington University School of Medicine St. Louis Missouri USA
| | - Slim Fellah
- Department of Neurology Washington University School of Medicine St. Louis Missouri USA
| | - Yasheng Chen
- Department of Neurology Washington University School of Medicine St. Louis Missouri USA
| | - Monica L. Hulbert
- Department of Pediatrics Washington University School of Medicine St. Louis Missouri USA
| | - Hongyu An
- Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis Missouri USA
| | - Andria L. Ford
- Department of Neurology Washington University School of Medicine St. Louis Missouri USA
- Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis Missouri USA
| | - Jin‐Moo Lee
- Department of Neurology Washington University School of Medicine St. Louis Missouri USA
- Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis Missouri USA
- Department of Biomedical Engineering Washington University School of Medicine St. Louis Missouri USA
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10
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Kirkham FJ, Lagunju IA. Epidemiology of Stroke in Sickle Cell Disease. J Clin Med 2021; 10:4232. [PMID: 34575342 PMCID: PMC8469588 DOI: 10.3390/jcm10184232] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 12/18/2022] Open
Abstract
Sickle cell disease is the most common cause of stroke in childhood, both ischaemic and haemorrhagic, and it also affects adults with the condition. Without any screening or preventative treatment, the incidence appears to fall within the range 0.5 to 0.9 per 100 patient years of observation. Newborn screening with Penicillin prophylaxis and vaccination leading to reduced bacterial infection may have reduced the incidence, alongside increasing hydroxyurea prescription. Transcranial Doppler screening and prophylactic chronic transfusion for at least an initial year has reduced the incidence of stroke by up to 10-fold in children with time averaged mean of the maximum velocity >200 cm/s. Hydroxyurea also appears to reduce the incidence of first stroke to a similar extent in the same group but the optimal dose remains controversial. The prevention of haemorrhagic stroke at all ages and ischaemic stroke in adults has not yet received the same degree of attention. Although there are fewer studies, silent cerebral infarction on magnetic resonance imaging (MRI), and other neurological conditions, including headache, epilepsy and cognitive dysfunction, are also more prevalent in sickle cell disease compared with age matched controls. Clinical, neuropsychological and quantitative MRI screening may prove useful for understanding epidemiology and aetiology.
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Affiliation(s)
- Fenella Jane Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, Faculty of Population Health Sciences, 30 Guilford Street, London WC1N 1EH, UK
- Child Health, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton and University Hospital Southampton, Southampton SO16 6YD, UK
- Paediatric Neurosciences, King’s College Hospital, London SE5 9RS, UK
| | - Ikeoluwa A. Lagunju
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan PMB 3017, Nigeria;
- Department of Paediatrics, University College Hospital, Ibadan PMB 5116, Nigeria
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11
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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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12
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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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13
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Mallon D, Doig D, Dixon L, Gontsarova A, Jan W, Tona F. Neuroimaging in Sickle Cell Disease: A Review. J Neuroimaging 2021; 30:725-735. [PMID: 33463866 DOI: 10.1111/jon.12766] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022] Open
Abstract
Sickle cell disease is the most common hereditary hemoglobinopathy, which results in abnormally shaped and rigid red blood cells. These sickle-shaped red blood cells cause vaso-occlusion and ischemic phenomena that can affect any organ in the body. As a common cause of disability, the neurological manifestations of sickle cell disease are particularly important. Neuroimaging has a crucial role in the diagnosis, management, and prevention of the complications of sickle cell disease. These complications can affect the brain parenchyma, vasculature, and skull and can be ascribed directly or indirectly to a vasculopathy of small and large vessels. Vaso-occlusion can cause ischemic stroke. Ischemic damage in the absence of an acute neurological deficit, and therefore only apparent on neuroimaging, is termed silent cerebral ischemia. Weakening of the arterial walls can cause aneurysms. In its most severe form, a vasculopathy of the terminal internal carotid arteries can progress to moyamoya syndrome, characterized by steno-occlusive disease and the formation of friable collateral arteries. Rupture of aneurysms or friable collateral arteries is a potential cause of intracranial hemorrhage. The skull and vertebrae may be affected by extra-medullary hematopoiesis, due to severe anemia, or iron deposition, due to chronic red blood cell transfusion. Impaired blood supply to bone is associated with osteomyelitis and osteonecrosis. Fat embolization syndrome is a rare complication of osteonecrosis, which may cause devastating neurological impairment. Awareness and early recognition of the diverse manifestations of sickle cell disease on neuroimaging is crucial to ensure optimal treatment in a complex patient cohort.
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Affiliation(s)
- Dermot Mallon
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
| | - David Doig
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
| | - Luke Dixon
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
| | | | - Wajanat Jan
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
| | - Francesca Tona
- Imperial College NHS Healthcare Trust, Charing Cross Hospital, London, UK
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14
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Schlotman AA, Donahue MJ, Kassim AA, Lee CA, Waddle SL, Pruthi S, Davis LT, Rodeghier M, DeBaun MR, Jordan LC. Intracranial and Extracranial Vascular Stenosis as Risk Factors for Stroke in Sickle Cell Disease. Pediatr Neurol 2021; 114:29-34. [PMID: 33190070 PMCID: PMC7770030 DOI: 10.1016/j.pediatrneurol.2020.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prevalence and contribution of intracranial and extracranial arterial stenosis to stroke risk were assessed prospectively in children and young adults with sickle cell disease. METHODS In this cross-sectional study, children and young adults (mean = 19.4 years) with sickle cell disease underwent neurological examination, brain MRI, and magnetic resonance angiography of the head and neck. Two neuroradiologists independently recorded infarcts and arterial stenosis. Clinical features and stroke outcomes were compared between participants with and without stenosis and between children and young adults. Logistic regression analysis assessed the association of variables of interest with overt stroke and silent cerebral infarct. RESULTS Of 167 participants (79 children and 88 young adults), 20 (12.0%) had intracranial stenosis, all in the anterior circulation, and nine had concurrent extracranial stenosis. No participants had isolated extracranial stenosis. Participants with intracranial stenosis were more likely than those without stenosis to have an overt stroke (70% vs 5%, P < 0.001) or silent cerebral infarct (95% vs 35%, P < 0.001). Logistic regression analysis indicated that intracranial stenosis was strongly associated with overt stroke when compared with participants with silent cerebral infarct alone and strongly associated with silent cerebral infarct when compared with participants with normal brain MRI; male sex and age were also significant predictors of silent cerebral infarct. CONCLUSIONS Intracranial stenosis was strongly associated with both overt stroke and silent cerebral infarct; prevalence of intracranial stenosis was similar to prior estimates in sickle cell disease. Extracranial stenosis without concurrent intracranial stenosis did not occur and thus could not be evaluated as an independent risk factor for stroke.
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Affiliation(s)
| | - Manus J Donahue
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN,Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - Adetola A Kassim
- Department of Internal Medicine, Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Chelsea A Lee
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Spencer L Waddle
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN
| | - Sumit Pruthi
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN
| | - L Taylor Davis
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Michael R DeBaun
- Department of Internal Medicine, Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN,Department of Pediatrics, Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
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15
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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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16
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Chen Y, Li J, Ou Z, Zhang Y, Liang Z, Deng W, Huang W, Wu Z, Jiang H, Liu Q, Ouyang F, Xing S, Zeng J. Safety and efficacy of low-dose aspirin in ischemic stroke patients with different G6PD conditions. Int J Stroke 2020; 16:411-419. [PMID: 32878589 DOI: 10.1177/1747493020950903] [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] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Aspirin is the first recommended antiplatelet agent to prevention secondary stroke, but its safety and efficacy in stroke patients with glucose-6-phosphate dehydrogenase deficiency remain unclear. We sought to evaluate its safety and efficacy in ischemic stroke patients with and without glucose-6-phosphate dehydrogenase deficiency. METHODS Patients with ischemic stroke receiving aspirin (100 mg/day) for three months were recruited for a multicenter, prospective, cohort study. Blood glucose-6-phosphate dehydrogenase activity was examined after stroke. Safety outcomes including acute hemolysis, moderate-to-severe bleeding, and death (vascular, all-cause), and efficacy outcome indicated as stroke recurrence were evaluated at three months. Risk factors associated with moderate-to-severe bleeding and all-cause death were determined using multivariate or Cox regression analysis. RESULTS Among the included 1121 patients, 81 of 130 glucose-6-phosphate dehydrogenase deficient and 576 of 991 glucose-6-phosphate dehydrogenase normal patients received aspirin for three months. Acute hemolysis was observed in one of the glucose-6-phosphate dehydrogenase deficient and in none of the glucose-6-phosphate dehydrogenase normal patients (p = 0.876). The rates of moderate-to-severe bleeding were 2.5% and 0.3% (p = 0.045), and the percentages of all-cause death were 6.2% and 1.4% (p = 0.008) in the glucose-6-phosphate dehydrogenase deficient and glucose-6-phosphate dehydrogenase normal patients. Stroke recurrence rate was similar in the two groups (2.5% vs. 1.7%; p = 0.608). Glucose-6-phosphate dehydrogenase deficiency was significantly associated with increased risk of moderate-to-severe bleeding (adjust p = 0.048) and all-cause death during aspirin use (adjust p = 0.008). CONCLUSIONS Long-term low-dose aspirin therapy might relate to worse safety outcomes in patients with glucose-6-phosphate dehydrogenase deficiency and large clinical trials are needed to further confirm these findings.
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Affiliation(s)
- Yicong Chen
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jianle Li
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Zilin Ou
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Yusheng Zhang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Weisheng Deng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Weixian Huang
- Department of Neurology, Meizhou People's Hospital, Meizhou, China
| | - Zhengdong Wu
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Haihong Jiang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Qinghua Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Fubing Ouyang
- Department of Neurology, Meizhou People's Hospital, Meizhou, China
| | - Shihui Xing
- Section II, Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Jinsheng Zeng
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
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17
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Gilyard SN, Hamlin SL, Johnson JO, Herr KD. Imaging review of sickle cell disease for the emergency radiologist. Emerg Radiol 2020; 28:153-164. [PMID: 32734483 DOI: 10.1007/s10140-020-01828-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/21/2020] [Indexed: 02/08/2023]
Abstract
Sickle cell disease (SCD), one of the most common inherited genetic syndromes in the USA, is characterized by recurring episodes of acute illness and progressive multisystem organ injury. Individuals with SCD frequently present to the emergency department for a spectrum of complications, such as vaso-occlusive crises, infection, cholecystitis, and stroke. Imaging correlates for most of these presentations exist, positioning the emergency radiologist to play a pivotal role in facilitating patient care. Using a systems-based approach, we describe the acute and chronic imaging manifestations of SCD that an emergency radiologist can expect to encounter in most practice settings, highlighting the unique pathophysiology of this disorder that typically underlies the imaging findings.
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Affiliation(s)
- Shenise N Gilyard
- Emory University School of Medicine, Atlanta, USA. .,Division of Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital, 1364 Clifton Road NE Suite #D112, Atlanta, USA.
| | - Scott L Hamlin
- Emory University School of Medicine, Atlanta, USA.,Division of Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital, 1364 Clifton Road NE Suite #D112, Atlanta, USA
| | - Jamlik-Omari Johnson
- Emory University School of Medicine, Atlanta, USA.,Division of Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital, 1364 Clifton Road NE Suite #D112, Atlanta, USA
| | - Keith D Herr
- Emory University School of Medicine, Atlanta, USA.,Division of Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital, 1364 Clifton Road NE Suite #D112, Atlanta, USA
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18
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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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Estcourt LJ, Kimber C, Hopewell S, Trivella M, Doree C, Abboud MR. Interventions for preventing silent cerebral infarcts in people with sickle cell disease. Cochrane Database Syst Rev 2020; 4:CD012389. [PMID: 32250453 PMCID: PMC7134371 DOI: 10.1002/14651858.cd012389.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) is one of the commonest severe monogenic disorders in the world, due to the inheritance of two abnormal haemoglobin (beta globin) genes. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Silent cerebral infarcts are the commonest neurological complication in children and probably adults with SCD. Silent cerebral infarcts also affect academic performance, increase cognitive deficits and may lower intelligence quotient. OBJECTIVES To assess the effectiveness of interventions to reduce or prevent silent cerebral infarcts in people with SCD. SEARCH METHODS We searched for relevant trials in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1980), and ongoing trial databases; all searches current to 14 November 2019. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register: 07 October 2019. SELECTION CRITERIA Randomised controlled trials comparing interventions to prevent silent cerebral infarcts in people with SCD. There were no restrictions by outcomes examined, language or publication status. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS We included five trials (660 children or adolescents) published between 1998 and 2016. Four of the five trials were terminated early. The vast majority of participants had the haemoglobin (Hb)SS form of SCD. One trial focused on preventing silent cerebral infarcts or stroke; three trials were for primary stroke prevention and one trial dealt with secondary stroke prevention. Three trials compared the use of regular long-term red blood cell transfusions to standard care. Two of these trials included children with no previous long-term transfusions: one in children with normal transcranial doppler (TCD) velocities; and one in children with abnormal TCD velocities. The third trial included children and adolescents on long-term transfusion. Two trials compared the drug hydroxyurea and phlebotomy to long-term transfusions and iron chelation therapy: one in primary prevention (children), and one in secondary prevention (children and adolescents). The quality of the evidence was moderate to very low across different outcomes according to GRADE methodology. This was due to trials being at high risk of bias because they were unblinded; indirectness (available evidence was only for children with HbSS); and imprecise outcome estimates. Long-term red blood cell transfusions versus standard care Children with no previous long-term transfusions and higher risk of stroke (abnormal TCD velocities or previous history of silent cerebral infarcts) Long-term red blood cell transfusions may reduce the incidence of silent cerebral infarcts in children with abnormal TCD velocities, risk ratio (RR) 0.11 (95% confidence interval (CI) 0.02 to 0.86) (one trial, 124 participants, low-quality evidence); but make little or no difference to the incidence of silent cerebral infarcts in children with previous silent cerebral infarcts on magnetic resonance imaging and normal or conditional TCDs, RR 0.70 (95% CI 0.23 to 2.13) (one trial, 196 participants, low-quality evidence). No deaths were reported in either trial. Long-term red blood cell transfusions may reduce the incidence of: acute chest syndrome, RR 0.24 (95% CI 0.12 to 0.49) (two trials, 326 participants, low-quality evidence); and painful crisis, RR 0.63 (95% CI 0.42 to 0.95) (two trials, 326 participants, low-quality evidence); and probably reduces the incidence of clinical stroke, RR 0.12 (95% CI 0.03 to 0.49) (two trials, 326 participants, moderate-quality evidence). Long-term red blood cell transfusions may improve quality of life in children with previous silent cerebral infarcts (difference estimate -0.54; 95% confidence interval -0.92 to -0.17; one trial; 166 participants), but may have no effect on cognitive function (least squares means: 1.7, 95% CI -1.1 to 4.4) (one trial, 166 participants, low-quality evidence). Transfusions continued versus transfusions halted: children and adolescents with normalised TCD velocities (79 participants; one trial) Continuing red blood cell transfusions may reduce the incidence of silent cerebral infarcts, RR 0.29 (95% CI 0.09 to 0.97 (low-quality evidence). We are very uncertain whether continuing red blood cell transfusions has any effect on all-cause mortality, Peto odds ratio (OR) 8.00 (95% CI 0.16 to 404.12); or clinical stroke, RR 0.22 (95% CI 0.01 to 4.35) (very low-quality evidence). The trial did not report: comparative numbers for SCD-related adverse events; quality of life; or cognitive function. Hydroxyurea and phlebotomy versus transfusions and chelation Primary prevention, children (121 participants; one trial) We are very uncertain whether switching to hydroxyurea and phlebotomy has any effect on: silent cerebral infarcts (no infarcts); all-cause mortality (no deaths); risk of stroke (no strokes); or SCD-related complications, RR 1.52 (95% CI 0.58 to 4.02) (very low-quality evidence). Secondary prevention, children and adolescents with a history of stroke (133 participants; one trial) We are very uncertain whether switching to hydroxyurea and phlebotomy has any effect on: silent cerebral infarcts, Peto OR 7.28 (95% CI 0.14 to 366.91); all-cause mortality, Peto OR 1.02 (95%CI 0.06 to 16.41); or clinical stroke, RR 14.78 (95% CI 0.86 to 253.66) (very low-quality evidence). Switching to hydroxyurea and phlebotomy may increase the risk of SCD-related complications, RR 3.10 (95% CI 1.42 to 6.75) (low-quality evidence). Neither trial reported on quality of life or cognitive function. AUTHORS' CONCLUSIONS We identified no trials for preventing silent cerebral infarcts in adults, or in children who do not have HbSS SCD. Long-term red blood cell transfusions may reduce the incidence of silent cerebral infarcts in children with abnormal TCD velocities, but may have little or no effect on children with normal TCD velocities. In children who are at higher risk of stroke and have not had previous long-term transfusions, long-term red blood cell transfusions probably reduce the risk of stroke, and other SCD-related complications (acute chest syndrome and painful crises). In children and adolescents at high risk of stroke whose TCD velocities have normalised, continuing red blood cell transfusions may reduce the risk of silent cerebral infarcts. No treatment duration threshold has been established for stopping transfusions. Switching to hydroxyurea with phlebotomy may increase the risk of silent cerebral infarcts and SCD-related serious adverse events in secondary stroke prevention. All other evidence in this review is of very low-quality.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | | | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Miguel R Abboud
- American University of Beirut Medical CenterDepartment of Pediatrics and Adolescent MedicineBeirutLebanon
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20
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Jordan LC, Kassim AA, Wilkerson KL, Lee CA, Waddle SL, Donahue MJ. Using novel magnetic resonance imaging methods to predict stroke risk in individuals with sickle cell anemia. Hematol Oncol Stem Cell Ther 2020; 13:76-84. [PMID: 32192979 DOI: 10.1016/j.hemonc.2019.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/11/2019] [Indexed: 11/28/2022] Open
Abstract
Sickle cell anemia (SCA) is a well-characterized monogenetic disorder with a high prevalence of cerebral vasculopathy, silent cerebral infarcts, and strokes. A significant mechanism for cerebral infarction in SCA is hemodynamic imbalance. To compensate for reduced oxygen-carrying capacity due to anemia, individuals with SCA have chronically elevated cerebral blood flow to maintain viable oxygen delivery to the brain tissue. Often the oxygen extraction fraction (ratio of oxygen consumed to oxygen delivered) is increased in more severely affected individuals. Subsequently, cerebrovascular reserve capacity, the ability of arterioles to dilate and further increase the cerebral blood volume and flow, will be reduced. These hemodynamic profiles have been associated with prior cerebral infarcts and increased evidence of disease severity. These cerebral hemodynamic parameters can be assessed noninvasively with noncontrast magnetic resonance imaging (MRI) of the brain utilizing specific MRI methods. This review focuses on using advanced neuroimaging methods to assess stroke risk in individuals with SCA, and such methods may be utilized before and after bone marrow or hematopoietic stem cell transplant to assess cerebral hemodynamic response. This manuscript is part of the Proceeding of The European Group for Blood and Marrow Transplantation (EBMT) Congress on Sickle Cell Disease, 16th-17 May 2019, Regensburg, Germany.
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Affiliation(s)
- Lori C Jordan
- Pediatrics-Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Adetola A Kassim
- Medicine-Division of Hematology/Stem Cell Transplantation, Vanderbilt-Meharry Sickle Cell Center for Excellence, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karina L Wilkerson
- Medicine-Division of Hematology/Stem Cell Transplantation, Vanderbilt-Meharry Sickle Cell Center for Excellence, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A Lee
- Pediatrics-Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Spencer L Waddle
- Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA; Physics and Astronomy, Vanderbilt University, Nashville, TN, USA
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21
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Jacob M, Stotesbury H, Kawadler JM, Lapadaire W, Saunders DE, Sangeda RZ, Chamba C, Kazema R, Makani J, Kirkham FJ, Clark CA. White Matter Integrity in Tanzanian Children With Sickle Cell Anemia: A Diffusion Tensor Imaging Study. Stroke 2020; 51:1166-1173. [PMID: 32138633 DOI: 10.1161/strokeaha.119.027097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background and Purpose- Widespread reductions in white matter integrity are associated with cognitive dysfunction in sickle cell anemia. Silent cerebral infarction (SCI), vasculopathy (VSC), and low hemoglobin concentration (Hb) are implicated; we aimed to determine independent contributions to microstructural white matter injury and whether white matter integrity differs across arterial territories. Methods- Sixty two children with sickle cell anemia aged 6 to 19 years were prospectively studied at Muhimbili National Hospital, Tanzania. SCI± and VSC± were identified on magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) scans by 2 neuroradiologists. Tract-based spatial statistics tested for voxel-wise differences in diffusion tensor imaging metrics (ie, fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity) between SCI± and VSC± groups, with correlations between diffusion tensor imaging metrics and Hb. In tract-based spatial statistics analyses, potentially mediating factors (ie, age, sex, as well as Hb, SCI, and/or vasculopathy) were covariates. Differences in mean diffusion tensor imaging metrics across regions of interest in arterial territories were explored. Results- Compared with SCI- patients (n=45), SCI+ patients (n=17) exhibited increased radial diffusivity in multiple regions; negative relationships were observed between mean diffusivity, axial diffusivity, and Hb (P<0.005). Compared with VSC- patients (n=49), mild (n=6) or moderate (n=7) VSC+ patients exhibited reduced fractional anisotropy in widespread regions (P<0.05) including the anterior longitudinal fasciculi, corpus callosum, internal capsule, corona radiata, and corticospinal tracts. Overall, the posterior cerebral arterial territory had higher mean mean diffusivity and mean radial diffusivity than the anterior and middle cerebral arterial territories, although no patient had vasculopathy in this area. There was an interaction between territory and vasculopathy. Conclusions- SCI, vasculopathy, and Hb are independent risk factors, and thus treatment targets, for diffuse white matter injury in patients with sickle cell anemia. Exacerbation of hemodynamic stress may play a role.
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Affiliation(s)
- Mboka Jacob
- From the Department of Radiology and Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania (M.J., R.K.).,Muhimbili Sickle Cell Program (M.J., R.Z.S., J.M.), Muhimbili University of Health and Allied Sciences
| | - Hanne Stotesbury
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
| | - Winok Lapadaire
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
| | - Dawn E Saunders
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
| | - Raphael Z Sangeda
- Muhimbili Sickle Cell Program (M.J., R.Z.S., J.M.), Muhimbili University of Health and Allied Sciences.,Department of Pharmaceutical Microbiology (R.Z.S.), Muhimbili University of Health and Allied Sciences
| | - Clara Chamba
- Department of Haematology and Blood Transfusion (C.C., J.M.), Muhimbili University of Health and Allied Sciences
| | - Ramadhan Kazema
- From the Department of Radiology and Imaging, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania (M.J., R.K.)
| | - Julie Makani
- Muhimbili Sickle Cell Program (M.J., R.Z.S., J.M.), Muhimbili University of Health and Allied Sciences.,Department of Haematology and Blood Transfusion (C.C., J.M.), Muhimbili University of Health and Allied Sciences
| | - Fenella J Kirkham
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom.,Biomedical Research Unit (F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom.,Clinical Experimental Sciences, University of Southampton, University Hospital Southampton NHS Foundation Trust, United Kingdom (F.J.K.).,King's College Hospital, London, United Kingdom (F.J.K.)
| | - Chris A Clark
- Developmental Neurosciences Section (H.S., J.M.K., W.L., D.E.S., F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom.,Biomedical Research Unit (F.J.K., C.A.C.), UCL Great Ormond Street Hospital for Children, London, United Kingdom
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22
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Dolatkhah R, Dastgiri S. Blood transfusions for treating acute chest syndrome in people with sickle cell disease. Cochrane Database Syst Rev 2020; 1:CD007843. [PMID: 31942751 PMCID: PMC6984655 DOI: 10.1002/14651858.cd007843.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Sickle cell disease is an inherited autosomal recessive blood condition and is one of the most prevalent genetic blood diseases worldwide. Acute chest syndrome is a frequent complication of sickle cell disease, as well as a major cause of morbidity and the greatest single cause of mortality in children with sickle cell disease. Standard treatment may include intravenous hydration, oxygen as treatment for hypoxia, antibiotics to treat the infectious cause and blood transfusions may be given. This is an update of a Cochrane Review first published in 2010 and updated in 2016. OBJECTIVES To assess the effectiveness of blood transfusions, simple and exchange, for treating acute chest syndrome by comparing improvement in symptoms and clinical outcomes against standard care. SEARCH METHODS We searched The Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register, which comprises references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. Date of the most recent search: 30 May 2019. SELECTION CRITERIA Randomised controlled trials and quasi-randomised controlled trials comparing either simple or exchange transfusion versus standard care (no transfusion) in people with sickle cell disease suffering from acute chest syndrome. DATA COLLECTION AND ANALYSIS Both authors independently selected trials and assessed the risk of bias, no data could be extracted. MAIN RESULTS One trial was eligible for inclusion in the review. While in the multicentre trial 237 people were enrolled (169 SCC, 42 SC, 15 Sβ⁰-thalassaemia, 11Sβ+-thalassaemia); the majority were recruited to an observational arm and only ten participants met the inclusion criteria for randomisation. Of these, four were randomised to the transfusion arm and received a single transfusion of 7 to 13 mL/kg packed red blood cells, and six were randomised to standard care. None of the four participants who received packed red blood cells developed acute chest syndrome, while 33% (two participants) developed acute chest syndrome in standard care arm. No data for any pre-defined outcomes were available. AUTHORS' CONCLUSIONS We found only one very small randomised controlled trial; this is not enough to make any reliable conclusion to support the use of blood transfusion. Whilst there appears to be some indication that chronic blood transfusion may play a roll in reducing the incidence of acute chest syndrome in people with sickle cell disease and albeit offering transfusions may be a widely accepted clinical practice, there is currently no reliable evidence to support or refute the perceived benefits of these as treatment options; very limited information about any of the potential harms associated with these interventions or indeed guidance that can be used to aid clinical decision making. Clinicians should therefore base any treatment decisions on a combination of; their clinical experience, individual circumstances and the unique characteristics and preferences of adequately informed people with sickle cell disease who are suffering with acute chest syndrome. This review highlights the need of further high quality research to provide reliable evidence for the effectiveness of these interventions for the relief of the symptoms of acute chest syndrome in people with sickle cell disease.
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Affiliation(s)
- Roya Dolatkhah
- Tabriz University of Medical SciencesLiver and Gastrointestinal Diseases Research CenterTabrizIran
| | - Saeed Dastgiri
- Tabriz University of Medical SciencesTabriz Health Services Management Research CenterTabrizIran5166615739
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23
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The clinical impact of glucose-6-phosphate dehydrogenase deficiency in patients with sickle cell disease. Curr Opin Hematol 2019; 25:494-499. [PMID: 30239377 DOI: 10.1097/moh.0000000000000455] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Glucose-6-phosphate dehydrogenase (G6PD) deficiency and sickle cell disease (SCD) cause hemolysis, often occurring in individuals of African descent. These disorders co-occur frequently, and possibly interact, altering clinical outcomes in SCD. However, epidemiological investigations of SCD with G6PD deficiency have produced variable results. This contribution reviews the available data about the interaction of G6PD deficiency and SCD. RECENT FINDINGS Overall, G6PD deficiency contributes few, if any, effects to laboratory values and clinical outcomes in SCD patients, but may impact transfusion efficacy. This observation is most likely because of the relatively increased G6PD activity in the young red blood cell (RBC) population seen in SCD patients with or without G6PD deficiency. In addition, G6PD deficiency possibly interacts with other genetic modifiers, such as α thalassemia, hemoglobin F levels and SCD haplotype. SUMMARY Although G6PD deficiency is relatively common, it does not appear to clinically impact patients with SCD. Nonetheless, it is important to evaluate G6PD status in patients with SCD to avoid the use of medications that may cause hemolysis. Future studies evaluating the clinical impact of transfusions from G6PD-deficient RBC donors would be of the greatest benefit to the current literature.
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24
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Stotesbury H, Kawadler JM, Hales PW, Saunders DE, Clark CA, Kirkham FJ. Vascular Instability and Neurological Morbidity in Sickle Cell Disease: An Integrative Framework. Front Neurol 2019; 10:871. [PMID: 31474929 PMCID: PMC6705232 DOI: 10.3389/fneur.2019.00871] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/26/2019] [Indexed: 12/20/2022] Open
Abstract
It is well-established that patients with sickle cell disease (SCD) are at substantial risk of neurological complications, including overt and silent stroke, microstructural injury, and cognitive difficulties. Yet the underlying mechanisms remain poorly understood, partly because findings have largely been considered in isolation. Here, we review mechanistic pathways for which there is accumulating evidence and propose an integrative systems-biology framework for understanding neurological risk. Drawing upon work from other vascular beds in SCD, as well as the wider stroke literature, we propose that macro-circulatory hyper-perfusion, regions of relative micro-circulatory hypo-perfusion, and an exhaustion of cerebral reserve mechanisms, together lead to a state of cerebral vascular instability. We suggest that in this state, tissue oxygen supply is fragile and easily perturbed by changes in clinical condition, with the potential for stroke and/or microstructural injury if metabolic demand exceeds tissue oxygenation. This framework brings together recent developments in the field, highlights outstanding questions, and offers a first step toward a linking pathophysiological explanation of neurological risk that may help inform future screening and treatment strategies.
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Affiliation(s)
- Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Patrick W Hales
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Dawn E Saunders
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom.,Department of Radiology, Great Ormond Hospital, London, United Kingdom
| | - Christopher A Clark
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Institute of Child Health, London, United Kingdom.,Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom.,Department of Child Health, University Hospital Southampton, Southampton, United Kingdom.,Department of Paediatric Neurology, Kings College Hospital NHS Foundation Trust, London, United Kingdom
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25
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Kija EN, Saunders DE, Munubhi E, Darekar A, Barker S, Cox TCS, Mango M, Soka D, Komba J, Nkya DA, Cox SE, Kirkham FJ, Newton CRJC. Transcranial Doppler and Magnetic Resonance in Tanzanian Children With Sickle Cell Disease. Stroke 2019; 50:1719-1726. [PMID: 31195937 PMCID: PMC6594727 DOI: 10.1161/strokeaha.118.018920] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— We determined prevalences of neurological complications, vascular abnormality, and infarction in Tanzanian children with sickle cell disease. Methods— Children with sickle cell disease were consecutively enrolled for transcranial Doppler; those with slightly elevated (>150 cm/s), low (<50 cm/s) or absent cerebral blood flow velocity (CBFv) were invited for brain magnetic resonance imaging and magnetic resonance angiography. Results— Of 200 children (median age 9; range 6–13 years; 105 [2.5%] boys), 21 (11%) and 15 (8%) had previous seizures and unilateral weakness, respectively. Twenty-eight (14%) had elevated and 39 (20%) had low/absent CBFv, all associated with lower hemoglobin level, but not higher indirect bilirubin level. On multivariable analysis, CBFv>150 cm/s was associated with frequent painful crises and low hemoglobin level. Absent/low CBFv was associated with low hemoglobin level and history of unilateral weakness. In 49 out of 67 children with low/absent/elevated transcranial Doppler undergoing magnetic resonance imaging, 43% had infarction, whereas 24 out of 48 (50%) magnetic resonance angiographies were abnormal. One had hemorrhagic infarction; none had microbleeds. Posterior circulation infarcts occurred in 14%. Of 11 children with previous seizure undergoing magnetic resonance imaging, 10 (91%) had infarction (5 silent) compared with 11 out of 38 (29%) of the remainder (P=0.003). Of 7 children with clinical stroke, 2 had recurrent stroke and 3 died; 4 out of 5 had absent CBFv. Of 193 without stroke, 1 died and 1 had a stroke; both had absent CBFv. Conclusions— In one-third of Tanzanian children with sickle cell disease, CBFv is outside the normal range, associated with frequent painful crises and low hemoglobin level, but not hemolysis. Half have abnormal magnetic resonance angiography. African children with sickle cell disease should be evaluated with transcranial Doppler; those with low/absent/elevated CBFv should undergo magnetic resonance imaging/magnetic resonance angiography.
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Affiliation(s)
- Edward N Kija
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.).,Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (E.N.K., M.M., D.S., C.R.J.C.N.)
| | - Dawn E Saunders
- Developmental Neurosciences and Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, United Kingdom (D.E.S., T.C.S.C., F.J.K.)
| | - Emmanuel Munubhi
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.)
| | - Angela Darekar
- University Hospital Southampton, United Kingdom (A.D., S.B., F.J.K.)
| | - Simon Barker
- University Hospital Southampton, United Kingdom (A.D., S.B., F.J.K.)
| | - Timothy C S Cox
- Developmental Neurosciences and Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, United Kingdom (D.E.S., T.C.S.C., F.J.K.)
| | - Mechris Mango
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (E.N.K., M.M., D.S., C.R.J.C.N.)
| | - Deogratias Soka
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.).,Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (E.N.K., M.M., D.S., C.R.J.C.N.)
| | - Joyce Komba
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.)
| | - Deogratias A Nkya
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.)
| | - Sharon E Cox
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.).,London School of Hygiene and Tropical Medicine, United Kingdom (S.E.C.).,Nagasaki University School of Tropical Medicine and Global Health, Japan (S.E.C.)
| | - Fenella J Kirkham
- Developmental Neurosciences and Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, United Kingdom (D.E.S., T.C.S.C., F.J.K.).,Clinical and Experimental Sciences, University of Southampton, United Kingdom (F.J.K.).,University Hospital Southampton, United Kingdom (A.D., S.B., F.J.K.)
| | - Charles R J C Newton
- From the Muhimbili Wellcome Programme, Dar es Salaam, Tanzania (E.N.K., E.M., D.S., J.K., D.A.N., S.E.C., C.R.J.C.N.).,Department of Psychiatry, University of Oxford, United Kingdom (C.R.J.C.N.)
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26
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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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Juttukonda MR, Donahue MJ, Davis LT, Gindville MC, Lee CA, Patel NJ, Kassim AA, Pruthi S, Hendrikse J, Jordan LC. Preliminary evidence for cerebral capillary shunting in adults with sickle cell anemia. J Cereb Blood Flow Metab 2019; 39:1099-1110. [PMID: 29260615 PMCID: PMC6547194 DOI: 10.1177/0271678x17746808] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Elevated flow velocities in adults with sickle cell anemia (SCA) may cause rapid erythrocyte transit through capillaries. This phenomenon could present as dural venous sinus hyperintensity on arterial spin labeling (ASL)-MRI and could be indicative of capillary shunting. Here, the prevalence of ASL venous hyperintensities and association with relevant physiology in adults with SCA was investigated. SCA ( n = 46) and age-matched control ( n = 16) volunteers were recruited for 3.0 T MRI. Pseudo-continuous ASL-MRI was acquired for cerebral blood flow (CBF) calculation and venous hyperintensity determination; venous signal intensity and a categorical venous score (three raters; 0 = no hyperintensity, 1 = focal hyperintensity, and 2 = diffuse hyperintensity) were recorded. Flow velocity in cervical internal carotid artery segments was determined from phase contrast data (venc = 40 cm/s) and whole-brain oxygen extraction fraction (OEF) was determined from T2-relaxation-under-spin-tagging MRI. Cerebral metabolic rate of oxygen was calculated as the product of OEF, CBF, and blood oxygen content. ASL venous hyperintensities were significantly ( p < 0.001) more prevalent in SCA (65%) relative to control (6%) participants and were associated with elevated flow velocities ( p = 0.03). CBF ( p < 0.001), but not OEF, increased with increasing hyperintensity score. Prospective trials that evaluate this construct as a possible marker of impaired oxygen delivery and stroke risk may be warranted.
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Affiliation(s)
- Meher R Juttukonda
- 1 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- 1 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,2 Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,3 Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.,4 Department of Physics and Astronomy, Vanderbilt University, Nashville, TN, USA
| | - Larry T Davis
- 1 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa C Gindville
- 5 Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A Lee
- 5 Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Niral J Patel
- 5 Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adetola A Kassim
- 6 Department of Medicine, Division of Hematology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sumit Pruthi
- 1 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeroen Hendrikse
- 7 Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lori C Jordan
- 2 Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,5 Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
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Guilliams KP, Fields ME, Dowling MM. Advances in Understanding Ischemic Stroke Physiology and the Impact of Vasculopathy in Children With Sickle Cell Disease. Stroke 2019; 50:266-273. [PMID: 30661504 PMCID: PMC6385587 DOI: 10.1161/strokeaha.118.020482] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 11/28/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Kristin P Guilliams
- From the Department of Neurology (K.P.G.), Washington University School of Medicine, St Louis, MO
- Department of Pediatrics (K.P.G., M.E.F.), Washington University School of Medicine, St Louis, MO
| | - Melanie E Fields
- Department of Pediatrics (K.P.G., M.E.F.), Washington University School of Medicine, St Louis, MO
| | - Michael M Dowling
- Department of Pediatrics and Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas (M.M.D.)
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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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Choudhury NA, DeBaun MR, Ponisio MR, Jordan LC, Rodeghier M, Pruthi S, McKinstry RC. Intracranial vasculopathy and infarct recurrence in children with sickle cell anaemia, silent cerebral infarcts and normal transcranial Doppler velocities. Br J Haematol 2018; 183:324-326. [PMID: 29076125 PMCID: PMC7133121 DOI: 10.1111/bjh.14979] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We aimed to test the hypothesis that in children with sickle cell anemia (SCA), silent cerebral infarcts (SCIs), and normal transcranial Doppler (TCD) velocities, baseline intracranial vasculopathy (defined by magnetic resonance angiography (MRA)) is associated with cerebral infarct recurrence. A total of 110 children with median age of 9.4 years (range 5 to 14 years), enrolled in the Silent Cerebral Infarct Transfusion (SIT) Trial, had MRAs performed at baseline; vasculopathy was present in 2% (2 of 110). Due to the low prevalence, MRA-defined intracranial vasculopathy is not a predictor of cerebral infarct recurrence in children with SCA, SCIs, and normal TCD velocities.
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Affiliation(s)
- Natasha A. Choudhury
- Meharry Medical College, School of Medicine, Nashville, TN
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
| | - Michael R. DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
| | - Maria R. Ponisio
- Department of Radiology, Division of Nuclear Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Lori C. Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Sumit Pruthi
- Department of Radiology, Divisions of Pediatric Radiology and Neuroradiology, Vanderbilt University Medical Center, Nashville, TN
| | - Robert C. McKinstry
- Pediatric Radiology and Neuroradiology Sections, Washington University School of Medicine, Saint Louis, MO
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The Genetic Landscape of Cerebral Steno-Occlusive Arteriopathy and Stroke in Sickle Cell Anemia. J Stroke Cerebrovasc Dis 2018; 27:2897-2904. [PMID: 30076115 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/28/2018] [Accepted: 06/02/2018] [Indexed: 11/24/2022] Open
Abstract
Sickle cell disease (SCD) is one of the most common autosomal recessive diseases in humans, occurring at a frequency of 1 in 365 African-American and 1 in 50 sub-Saharan African births. Despite progress in managing complications of SCD, these remain a major health burden worldwide. Stroke is a common and serious complication of SCD, most often associated with steno-occlusive cerebral arteriopathy, but little is known about its pathogenesis. Transcranial Doppler ultrasonography is currently the only predictive test for future development of stroke in patients with sickle cell anemia and is used to guide preventative treatment. However, transcranial Doppler ultrasonography does not identify all patients at increased risk for stroke, and progressive arteriopathy may occur despite preventative treatment. While sibling studies have shown a strong genetic contribution to the development of steno-occlusive arteriopathy (SOA) in SCD, the only genome-wide association study compared a relatively small cohort of 177 patients with stroke to 335 patients with no history of stroke. This single study detected variants in only 2 genes, ENPP1 and GOLGB1, and only one of these was confirmed in a subsequent independent study. Thus, the underlying genes and pathogenesis of SOA in SCD remain poorly understood, greatly limiting the ability to develop more effective preventive therapies. Dissecting the molecular causes of stroke in SCD will provide valuable information that can be used to better prevent stroke, stratify risk of SOA, and optimize personalized medicine approaches.
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Wu X, Fu R, Tang Y, Shi L, Rong X, Guo J, Li J, Shen Q. Intravenous Thrombolysis for Stroke Patients with G6PD Deficiency. J Stroke Cerebrovasc Dis 2018; 27:2026-2031. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 02/10/2018] [Accepted: 02/28/2018] [Indexed: 11/16/2022] Open
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Chen S, Yin W, Bi K, Lu B. MicroRNA‑497 attenuates cerebral infarction in patients via the TLR4 and CREB signaling pathways. Int J Mol Med 2018; 42:547-556. [PMID: 29620142 DOI: 10.3892/ijmm.2018.3611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/01/2018] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to investigate the function and mechanism of microRNA‑497 (miRNA/miR‑149) in the regulation of cerebral infarction. In patients with cerebral infarction, the serum of microRNA‑497 expression was upregulated compared with that in healthy controls. In N2A cells, overexpression of miR‑497 induced cell proliferation, decreased apoptosis and caspase‑3 and caspase‑9 activities, and suppressed Bax protein expression compared with that in the negative control group. Overexpression of miR‑497 reduced inflammation factors, and suppressed the Toll‑like receptor 4 (TLR4), myeloid differentiation primary response protein MyD88 (MyD88) and nuclear factor‑κB (NF‑κB) protein expression of the N2A cells. Next, miR‑497 overexpression suppressed the protein expression of interleukin‑1 receptor associated kinase (IRAK1) and phosphorylated cyclic AMP response element binding protein (p-CREB) in the N2A cells. Following miR‑497 overexpression, TLR4 inhibitor was found to suppress the inflammation factors, suppress the TLR4, MyD88 and NF‑κB protein expression, and reduce the IRAK1 and p‑CREB protein expression of the N2A cells. Lastly, CREB inhibitor also suppressed p‑CREB protein expression, induced cell proliferation, decreased apoptosis and caspase‑3 and caspase‑9 activities, and suppressed Bax protein expression in the N2A cells following miR‑497 overexpression. Taken together, these data demonstrated that miR‑497 attenuated cerebral infarction in patients by regulating the TLR4 and CREB signaling pathways.
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Affiliation(s)
- Si Chen
- Department of First Neurosurgery, Tangshan Worker Hospital, Tangshan, Hebei 063000, P.R. China
| | - Wenwei Yin
- Department of First Neurosurgery, Tangshan Worker Hospital, Tangshan, Hebei 063000, P.R. China
| | - Kun Bi
- Department of First Neurosurgery, Tangshan Worker Hospital, Tangshan, Hebei 063000, P.R. China
| | - Bin Lu
- Department of First Neurosurgery, Tangshan Worker Hospital, Tangshan, Hebei 063000, P.R. China
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34
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Belisário AR, Silva CM, Velloso-Rodrigues C, Viana MB. Genetic, laboratory and clinical risk factors in the development of overt ischemic stroke in children with sickle cell disease. Hematol Transfus Cell Ther 2018; 40:166-181. [PMID: 30057991 PMCID: PMC6003005 DOI: 10.1016/j.bjhh.2017.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 08/30/2017] [Indexed: 12/22/2022] Open
Abstract
Cerebrovascular disease, particularly stroke, is one of the most severe clinical complications associated with sickle cell disease and is a significant cause of morbidity in both children and adults. Over the past two decades, considerable advances have been made in the understanding of its natural history and enabled early identification and treatment of children at the highest risk. Transcranial Doppler screening and regular blood transfusions have markedly reduced the risk of stroke in children. However, transcranial Doppler has a limited positive predictive value and the pathophysiology of cerebrovascular disease is not completely understood. In this review, we will focus on the current state of knowledge about risk factors associated with ischemic stroke in patients with sickle cell disease. A search of PubMed was performed to identify studies. Full texts of the included articles were reviewed and data were summarized in a table. The coinheritance of alpha-thalassemia plays a protective role against ischemic stroke. The influence of other genetic risk factors is controversial, still preliminary, and requires confirmatory studies. Recent advances have established the reticulocyte count as the most important laboratory risk factor. Clinical features associated with acute hypoxemia as well as silent infarcts seem to influence the development of strokes in children. However, transcranial Doppler remains the only available clinical prognostic tool to have been validated. If our understanding of the many risk factors associated with stroke advances further, it may be possible to develop useful tools to detect patients at the highest risk early, improving the selection of children requiring intensification therapy.
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Affiliation(s)
- André Rolim Belisário
- Centro de Tecidos Biológicos de Minas Gerais, Fundação Hemominas, Lagoa Santa, MG, Brazil
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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Dlamini N, Saunders DE, Bynevelt M, Trompeter S, Cox TC, Bucks RS, Kirkham FJ. Nocturnal oxyhemoglobin desaturation and arteriopathy in a pediatric sickle cell disease cohort. Neurology 2017; 89:2406-2412. [PMID: 29117957 PMCID: PMC5729796 DOI: 10.1212/wnl.0000000000004728] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/05/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The purpose of this study of sickle cell disease (SCD) was to determine whether arteriopathy, measurable as intracranial vessel signal loss on magnetic resonance angiography (MRA), was associated with low nocturnal hemoglobin oxygen saturation (SpO2) or hemolytic rate, measurable as reticulocytosis or unconjugated hyperbilirubinemia. METHODS Ninety-five East London children with SCD without prior stroke had overnight pulse oximetry, of whom 47 (26 boys, 39 hemoglobin SS; mean age 9.1 ± 3.1 years) also had MRA, transcranial Doppler (TCD), steady-state hemoglobin, and reticulocytes within 34 months. Two radiologists blinded to the other data graded arteriopathy on MRA as 0 (none) or as increasing severity grades 1, 2, or 3. RESULTS Grades 2 or 3 arteriopathy (n = 24; 2 with abnormal TCD) predicted stroke/TIA compared with grades 0 and 1 (log-rank χ2 [1, n = 47] = 8.1, p = 0.004). Mean overnight SpO2 correlated negatively with reticulocyte percentage (r = -0.387; p = 0.007). Despite no significant differences across the degrees of arteriopathy in genotype, mean overnight SpO2 was higher (p < 0.01) in those with grade 0 (97.0% ± 1.6%) than those with grades 2 (93.9 ± 3.7%) or 3 (93.5% ± 3.0%) arteriopathy. Unconjugated bilirubin was not associated but reticulocyte percentage was lower (p < 0.001) in those with grade 0 than those with grades 2 and 3 arteriopathy. In multivariable logistic regression, lower mean overnight SpO2 (odds ratio 0.50, 95% confidence interval 0.26-0.96; p < 0.01) predicted arteriopathy independent of reticulocyte percentage (odds ratio 1.47, 95% confidence interval 1.15-1.87; p = 0.003). CONCLUSION Low nocturnal SpO2 and reticulocytosis are associated with intracranial arteriopathy in children with SCD. Preventative strategies might reduce stroke risk.
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Affiliation(s)
- Nomazulu Dlamini
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Dawn E Saunders
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Michael Bynevelt
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Sara Trompeter
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Timothy C Cox
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Romola S Bucks
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK
| | - Fenella J Kirkham
- From Developmental Neurosciences (N.D., F.J.K.), UCL Great Ormond Street Institute of Child Health, London, UK; Hospital for Sick Children (N.D.), Toronto, Canada; Department of Radiology (D.E.S., M.B., T.C.C.), Great Ormond Street Hospital for Children NHS Trust, London, UK; University of Western Australia (M.B., R.S.B.), Perth; and Department of Haematology (S.T.), University College London Hospital, UK.
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Low fetal hemoglobin percentage is associated with silent brain lesions in adults with homozygous sickle cell disease. Blood Adv 2017; 1:2503-2509. [PMID: 29296901 DOI: 10.1182/bloodadvances.2017005504] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 09/08/2017] [Indexed: 01/05/2023] Open
Abstract
Silent white matter changes (WMCs) on brain imaging are common in individuals with sickle cell disease (SCD) and are associated with cognitive deficits in children. We investigated the factors predictive of WMCs in adults with homozygous SCD and no history of neurological conditions. Patients were recruited from a cohort of adults with homozygous SCD followed up at an adult sickle cell referral center for which steady-state measurements of biological parameters and magnetic resonance imaging scans of the brain were available. WMCs were rated by consensus, on a validated age-related WMC scale. The prevalence of WMCs was 49% (95% confidence interval [CI], 39%-60%) in the 83 patients without vasculopathy included. In univariable analysis, the patients who had WMCs were more likely to be older (P = .003) and to have hypertension (P = .02), a lower mean corpuscular volume (P = .005), a lower corpuscular hemoglobin concentration (P = .008), and a lower fetal hemoglobin percentage (%HbF) (P = .003). In multivariable analysis, only a lower %HbF remained associated with the presence of WMCs (odds ratio [OR] per 1% increase in %HbF, 0.84; 95% CI, 0.72-0.97; P = .021). %HbF was also associated with WMC burden (P for trend = .007). Multivariable ordinal logistic regression showed an inverse relationship between WMC burden (age-related WMC score divided into 4 strata) and HbF level (OR for 1% increase in %HbF, 0.89; 95% CI, 0.79-0.99; P = .039). Our study suggests that HbF may protect against silent WMCs, decreasing the likelihood of WMCs being present and their severity. It may therefore be beneficial to increase HbF levels in patients with WMCs.
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Belisário AR, Sales RR, Toledo NE, Velloso-Rodrigues C, Silva CM, Viana MB. Interleukin-10 haplotypes are not associated with acute cerebral ischemia or high-risk transcranial Doppler in a newborn cohort of 395 children with sickle cell anemia. Rev Bras Hematol Hemoter 2017; 39:108-114. [PMID: 28577646 PMCID: PMC5457462 DOI: 10.1016/j.bjhh.2016.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/26/2016] [Accepted: 09/22/2016] [Indexed: 12/20/2022] Open
Abstract
Background The etiology of stroke, a severe complication of sickle cell anemia, involves inflammatory processes. However, the pathogenetic mechanisms are unknown. The aim of this study was to evaluate the influence of interleukin-10 polymorphisms and haplotypes on the risk of acute cerebral ischemia and high-risk transcranial Doppler in 395 children with sickle cell anemia from the state of Minas Gerais, Brazil. Methods Interleukin-10 haplotypes were determined by polymerase chain reaction-restriction fragment length polymorphism and sequencing. The outcomes studied were acute cerebral ischemia and high-risk transcranial Doppler. Clinical data were retrieved from the children's records. Results There was no statistically significant difference in the frequencies of polymorphisms and haplotypes between children with and without acute cerebral ischemia or children with or without high-risk transcranial Doppler. These data are consistent with a previous report that showed an absence of association between interleukin-10 plasma levels and high-risk transcranial Doppler velocity in children with sickle cell anemia. Conclusion Interleukin-10 haplotypes were not associated with the risk of acute cerebral ischemia or high-risk transcranial Doppler velocity in children with sickle cell anemia from the state of Minas Gerais, Brazil.
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Affiliation(s)
- André Rolim Belisário
- Fundação Hemominas, Centro de Tecidos Biológicos de Minas Gerais, Lagoa Santa, MG, Brazil; Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Belo Horizonte, MG, Brazil.
| | - Rahyssa Rodrigues Sales
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Belo Horizonte, MG, Brazil
| | | | | | | | - Marcos Borato Viana
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Belo Horizonte, MG, Brazil
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Meier ER, Fasano RM, Levett PR. A systematic review of the literature for severity predictors in children with sickle cell anemia. Blood Cells Mol Dis 2017; 65:86-94. [DOI: 10.1016/j.bcmd.2017.01.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 01/27/2017] [Accepted: 01/28/2017] [Indexed: 12/19/2022]
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Estcourt LJ, Fortin PM, Hopewell S, Trivella M, Doree C, Abboud MR. Interventions for preventing silent cerebral infarcts in people with sickle cell disease. Cochrane Database Syst Rev 2017; 5:CD012389. [PMID: 28500860 PMCID: PMC5460750 DOI: 10.1002/14651858.cd012389.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) is one of the commonest severe monogenic disorders in the world, due to the inheritance of two abnormal haemoglobin (beta globin) genes. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Silent cerebral infarcts are the commonest neurological complication in children and probably adults with SCD. Silent cerebral infarcts also affect academic performance, increase cognitive deficits and may lower intelligence quotient. OBJECTIVES To assess the effectiveness of interventions to reduce or prevent silent cerebral infarcts in people with SCD. SEARCH METHODS We searched for relevant trials in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1980), and ongoing trial databases; all searches current to 19 September 2016. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register: 06 October 2016. SELECTION CRITERIA Randomised controlled trials comparing interventions to prevent silent cerebral infarcts in people with SCD. There were no restrictions by outcomes examined, language or publication status. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS We included five trials (660 children or adolescents) published between 1998 and 2016. Four of the five trials were terminated early. The vast majority of participants had the haemoglobin (Hb)SS form of SCD. One trial focused on preventing silent cerebral infarcts or stroke; three trials were for primary stroke prevention and one trial dealt with secondary stroke prevention.Three trials compared the use of regular long-term red blood cell transfusions to standard care. Two of these trials included children with no previous long-term transfusions: one in children with normal transcranial doppler (TCD) velocities; and one in children with abnormal TCD velocities. The third trial included children and adolescents on long-term transfusion.Two trials compared the drug hydroxyurea and phlebotomy to long-term transfusions and iron chelation therapy: one in primary prevention (children), and one in secondary prevention (children and adolescents).The quality of the evidence was moderate to very low across different outcomes according to GRADE methodology. This was due to trials being at high risk of bias because they were unblinded; indirectness (available evidence was only for children with HbSS); and imprecise outcome estimates. Long-term red blood cell transfusions versus standard care Children with no previous long-term transfusions and higher risk of stroke (abnormal TCD velocities or previous history of silent cerebral infarcts) Long-term red blood cell transfusions may reduce the incidence of silent cerebral infarcts in children with abnormal TCD velocities, risk ratio (RR) 0.11 (95% confidence interval (CI) 0.02 to 0.86) (one trial, 124 participants, low-quality evidence); but make little or no difference to the incidence of silent cerebral infarcts in children with previous silent cerebral infarcts on magnetic resonance imaging and normal or conditional TCDs, RR 0.70 (95% CI 0.23 to 2.13) (one trial, 196 participants, low-quality evidence).No deaths were reported in either trial.Long-term red blood cell transfusions may reduce the incidence of: acute chest syndrome, RR 0.24 (95% CI 0.12 to 0.49) (two trials, 326 participants, low-quality evidence); and painful crisis, RR 0.63 (95% CI 0.42 to 0.95) (two trials, 326 participants, low-quality evidence); and probably reduces the incidence of clinical stroke, RR 0.12 (95% CI 0.03 to 0.49) (two trials, 326 participants, moderate-quality evidence).Long-term red blood cell transfusions may improve quality of life in children with previous silent cerebral infarcts (difference estimate -0.54; 95% confidence interval -0.92 to -0.17; one trial; 166 participants), but may have no effect on cognitive function (least squares means: 1.7, 95% CI -1.1 to 4.4) (one trial, 166 participants, low-quality evidence). Transfusions continued versus transfusions halted: children and adolescents with normalised TCD velocities (79 participants; one trial)Continuing red blood cell transfusions may reduce the incidence of silent cerebral infarcts, RR 0.29 (95% CI 0.09 to 0.97 (low-quality evidence).We are very uncertain whether continuing red blood cell transfusions has any effect on all-cause mortality, Peto odds ratio (OR) 8.00 (95% CI 0.16 to 404.12); or clinical stroke, RR 0.22 (95% CI 0.01 to 4.35) (very low-quality evidence).The trial did not report: comparative numbers for SCD-related adverse events; quality of life; or cognitive function. Hydroxyurea and phlebotomy versus transfusions and chelation Primary prevention, children (121 participants; one trial)We are very uncertain whether switching to hydroxyurea and phlebotomy has any effect on: silent cerebral infarcts (no infarcts); all-cause mortality (no deaths); risk of stroke (no strokes); or SCD-related complications, RR 1.52 (95% CI 0.58 to 4.02) (very low-quality evidence). Secondary prevention, children and adolescents with a history of stroke (133 participants; one trial)We are very uncertain whether switching to hydroxyurea and phlebotomy has any effect on: silent cerebral infarcts, Peto OR 7.28 (95% CI 0.14 to 366.91); all-cause mortality, Peto OR 1.02 (95%CI 0.06 to 16.41); or clinical stroke, RR 14.78 (95% CI 0.86 to 253.66) (very low-quality evidence).Switching to hydroxyurea and phlebotomy may increase the risk of SCD-related complications, RR 3.10 (95% CI 1.42 to 6.75) (low-quality evidence).Neither trial reported on quality of life or cognitive function. AUTHORS' CONCLUSIONS We identified no trials for preventing silent cerebral infarcts in adults, or in children who do not have HbSS SCD.Long-term red blood cell transfusions may reduce the incidence of silent cerebral infarcts in children with abnormal TCD velocities, but may have little or no effect on children with normal TCD velocities. In children who are at higher risk of stroke and have not had previous long-term transfusions, long-term red blood cell transfusions probably reduce the risk of stroke, and other SCD-related complications (acute chest syndrome and painful crises).In children and adolescents at high risk of stroke whose TCD velocities have normalised, continuing red blood cell transfusions may reduce the risk of silent cerebral infarcts. No treatment duration threshold has been established for stopping transfusions.Switching to hydroxyurea with phlebotomy may increase the risk of silent cerebral infarcts and SCD-related serious adverse events in secondary stroke prevention.All other evidence in this review is of very low-quality.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Patricia M Fortin
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Sally Hopewell
- University of OxfordOxford Clinical Trials Research UnitNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesWindmill RoadOxfordUKOX3 7LD
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Miguel R Abboud
- American University of Beirut Medical CenterDepartment of Pediatrics and Adolescent MedicineBeirutLebanon
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Guilliams KP, Fields ME, Ragan DK, Chen Y, Eldeniz C, Hulbert ML, Binkley MM, Rhodes JN, Shimony JS, McKinstry RC, Vo K, An H, Lee JM, Ford AL. Large-Vessel Vasculopathy in Children With Sickle Cell Disease: A Magnetic Resonance Imaging Study of Infarct Topography and Focal Atrophy. Pediatr Neurol 2017; 69:49-57. [PMID: 28159432 PMCID: PMC5365370 DOI: 10.1016/j.pediatrneurol.2016.11.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/16/2016] [Accepted: 11/24/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Large-vessel vasculopathy (LVV) increases stroke risk in pediatric sickle cell disease beyond the baseline elevated stroke risk in this vulnerable population. The mechanisms underlying this added risk and its unique impact on the developing brain are not established. METHODS We analyzed magnetic resonance imaging and angiography scans of 66 children with sickle cell disease and infarcts by infarct density heatmaps and Jacobian determinants, a metric utilized to delineate focal volume change, to investigate if infarct location, volume, frequency, and cerebral atrophy differed among hemispheres with and without LVV. RESULTS Infarct density heatmaps demonstrated infarct "hot spots" within the deep white matter internal border zone region in both LVV and non-LVV hemispheres, but with greater infarct density and larger infarct volumes in LVV hemispheres (2.2 mL versus 0.25 mL, P < 0.001). Additional scattered cortical infarcts in the internal carotid artery territory occurred in LVV hemispheres, but were rare in non-LVV hemispheres. Jacobian determinants revealed greater atrophy in gray and white matter of the parietal lobes of LVV compared with non-LVV hemispheres. CONCLUSION Large-vessel vasculopathy in sickle cell disease appears to increase ischemic vulnerability in the borderzone region, as demonstrated by the increased frequency and extent of infarction within deep white matter, and increased risk of focal atrophy. Scattered infarctions across the LVV-affected hemispheres suggest additional stroke etiologies of vasculopathy (i.e., thromboembolism) in addition to chronic hypoxia-ischemia.
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Affiliation(s)
- Kristin P Guilliams
- Department of Neurology, Washington University School of Medicine,Department of Pediatrics, Washington University School of Medicine
| | - Melanie E Fields
- Department of Pediatrics, Washington University School of Medicine
| | - Dustin K Ragan
- Department of Neurology, Washington University School of Medicine
| | - Yasheng Chen
- Department of Neurology, Washington University School of Medicine
| | - Cihat Eldeniz
- Department of Radiology, Washington University School of Medicine
| | - Monica L Hulbert
- Department of Pediatrics, Washington University School of Medicine
| | | | | | - Joshua S Shimony
- Department of Pediatrics, Washington University School of Medicine,Department of Radiology, Washington University School of Medicine
| | - Robert C McKinstry
- Department of Pediatrics, Washington University School of Medicine,Department of Radiology, Washington University School of Medicine
| | - Katie Vo
- Department of Radiology, Washington University School of Medicine
| | - Hongyu An
- Department of Radiology, Washington University School of Medicine
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, Saint Louis, Missouri; Department of Radiology, Washington University School of Medicine, Saint Louis, Missouri.
| | - Andria L Ford
- Department of Neurology, Washington University School of Medicine, Saint Louis, Missouri.
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Belisário AR, Sales RR, Toledo NE, Muniz MBDSR, Velloso-Rodrigues C, Silva CM, Viana MB. Reticulocyte count is the most important predictor of acute cerebral ischemia and high-risk transcranial Doppler in a newborn cohort of 395 children with sickle cell anemia. Ann Hematol 2016; 95:1869-80. [PMID: 27520094 DOI: 10.1007/s00277-016-2789-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
Stroke is a severe clinical manifestation of sickle cell anemia (SCA). Despite the prognostic relevance of transcranial Doppler (TCD), more accurate tools to assess stroke risk in children with SCA are required. Here, we describe the effect of clinical, laboratory, and molecular features on the risk of stroke and high-risk TCD in children from the newborn cohort of Minas Gerais, Brazil. Outcomes studied were acute cerebral ischemia and high-risk TCD. Clinical and hematological data were retrieved from children's records. Genetic markers, which were known for their association with stroke risk, were genotyped by polymerase chain reaction/restriction fragment length polymorphism and sequencing. The cumulative incidence of acute cerebral ischemia by the age of 8 years was 7.4 % and that of high-risk TCD by the age of 11.5 years was 14.2 %. The final multivariate model for acute cerebral ischemia risk included high white blood cell count and reticulocyte count, acute chest syndrome rate, and the single nucleotide polymorphisms (SNPs) TEK rs489347 and TNF-α rs1800629. The model for high-risk TCD included high reticulocyte count and the SNPs TEK rs489347 and TGFBR3 rs284875. Children with risk factors should be considered for intensive risk monitoring and for intervention therapy.
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Affiliation(s)
- André Rolim Belisário
- Centro de Tecidos Biológicos de Minas Gerais, Fundação Hemominas, Rua das Goiabeiras, 779, Lagoa Santa, Minas Gerais, 33400-000, Brazil. .,Faculdade de Medicina/NUPAD, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | | | | | | | - Cibele Velloso-Rodrigues
- Departamento Básico-Área de Saúde, Universidade Federal de Juiz de Fora (UFJF), Governador Valadares, Minas Gerais, Brazil
| | - Célia Maria Silva
- Serviço de Pesquisa, Fundação Hemominas, Belo Horizonte, Minas Gerais, Brazil
| | - Marcos Borato Viana
- Faculdade de Medicina/NUPAD, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
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Belisário AR, Rodrigues Sales R, Evelin Toledo N, Velloso-Rodrigues C, Maria Silva C, Borato Viana M. Glucose-6-Phosphate Dehydrogenase Deficiency in Brazilian Children With Sickle Cell Anemia is not Associated With Clinical Ischemic Stroke or High-Risk Transcranial Doppler. Pediatr Blood Cancer 2016; 63:1046-9. [PMID: 26840990 DOI: 10.1002/pbc.25924] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/05/2016] [Accepted: 01/05/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Stroke is a severe complication of sickle cell anemia (SCA). The role of glucose-6-phosphate dehydrogenase (G6PD) deficiency in the development of stroke in children with SCA is controversial. PROCEDURE The aim of this study was to investigate the association of clinical ischemic stroke, high-risk transcranial Doppler measurements (TCD), and hematological features with molecular variants usually linked to G6PD deficiency or with the biochemical activity of G6PD in a cohort of 395 Brazilian children with SCA. G6PD activity was quantitatively determined using an enzymatic-colorimetric assay. G6PD mutations were determined by PCR-RFLP and sequencing. Clinical and hematological data were retrieved from the children's records. RESULTS The prevalence of molecularly defined deficiency (hereafter, molecular deficiency) was 4.3% (95% confidence interval: 2.3-6.3%). The mean G6PD activity was 16.88 U/g hemoglobin (Hb) (standard error of the mean [SEM] 0.28) in the group without G6PD molecular deficiency and 8.43 (SEM 1.01) U/g Hb in the group with G6PD A(-) molecular deficiency. G6PD molecular deficiency was not associated with any hematological features. No effects of G6PD molecular deficiency on clinical ischemic stroke or high-risk TCD were detected. The mean G6PD activity was similar in children who had clinical ischemic stroke and in those without stroke. Similar results were obtained in analyses comparing children who had high-risk TCD and those without high-risk TCD. CONCLUSIONS Our study demonstrated that G6PD molecular deficiency was not associated either with clinical ischemic stroke or high-risk TCD. Similarly, we found no associations between G6PD enzyme activity and stroke or high-risk TCD. Small sample size precludes definitive conclusions.
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Affiliation(s)
- André Rolim Belisário
- Centro de Tecidos Biológicos de Minas Gerais, Fundação Hemominas, Lagoa Santa, Minas Gerais, Brasil.,Faculdade de Medicina/NUPAD, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brasil
| | | | | | - Cibele Velloso-Rodrigues
- Departamento Básico-Área de Saúde, Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, Minas Gerais, Brasil
| | - Célia Maria Silva
- Serviço de Pesquisa, Fundação Hemominas, Belo Horizonte, Minas Gerais, Brasil
| | - Marcos Borato Viana
- Faculdade de Medicina/NUPAD, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brasil
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Quinn CT. Minireview: Clinical severity in sickle cell disease: the challenges of definition and prognostication. Exp Biol Med (Maywood) 2016; 241:679-88. [PMID: 27013545 PMCID: PMC4871738 DOI: 10.1177/1535370216640385] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Sickle cell disease (SCD) is a monogenic, yet highly phenotypically variable disease with multisystem pathology. This manuscript provides an overview of many of the known determinants, modifiers, and correlates of disease severity in SCD. Despite this wealth of data, modeling the variable and multisystem pathology of SCD continues to be difficult. The current status of prediction of specific adverse outcomes and global disease severity in SCD is also reviewed, highlighting recent successes and ongoing challenges.
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Affiliation(s)
- Charles T Quinn
- Division of Hematology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45220, USA
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Silent cerebral infarcts and cerebral aneurysms are prevalent in adults with sickle cell anemia. Blood 2016; 127:2038-40. [PMID: 26941400 DOI: 10.1182/blood-2016-01-694562] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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45
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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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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
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Joly P, Garnier N, Kebaili K, Renoux C, Dony A, Cheikh N, Renard C, Ceraulo A, Cuzzubbo D, Pondarré C, Martin C, Pialoux V, Francina A, Bertrand Y, Connes P. G6PD deficiency and absence of α-thalassemia increase the risk for cerebral vasculopathy in children with sickle cell anemia. Eur J Haematol 2015; 96:404-8. [PMID: 26072930 DOI: 10.1111/ejh.12607] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2015] [Indexed: 02/04/2023]
Abstract
The aim of this study was to test the association between hematological/genetic factors and cerebral vasculopathy in children with sickle cell anemia (SCA). A group with cerebral vasculopathy (VASC) was composed of children who had stroke (n = 6), silent infarct (n = 11), or an abnormal transcranial Doppler (n = 5). Eighty-four patients had neither positive history of stroke or silent infarct, nor abnormal transcranial Doppler (NORM group). An intermediate group (COND; n = 15) was composed of SCA children with a conditional transcranial Doppler. Biological analyses were performed on samples obtained at steady state and before the beginning of any chronic treatment. The comparisons of the three groups demonstrated a protective effect of α-thalassemia against cerebral vasculopathy through its effects on hemoglobin and reticulocyte levels. Moreover, we observed higher frequency of G6PD deficiency in the VASC group compared with the other groups. Our study confirms the key role of α-thalassemia and G6PD status in the pathophysiology of cerebral vasculopathy in SCA children.
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Affiliation(s)
- Philippe Joly
- Unité de Pathologie Moléculaire du Globule Rouge, Laboratoire de Biochimie et de Biologie Moléculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Laboratoire CRIS EA 647, Section "Vascular Biology and Red Blood Cell", Université Claude Bernard Lyon 1, Lyon, France
| | - Nathalie Garnier
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Kamila Kebaili
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Céline Renoux
- Unité de Pathologie Moléculaire du Globule Rouge, Laboratoire de Biochimie et de Biologie Moléculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Laboratoire CRIS EA 647, Section "Vascular Biology and Red Blood Cell", Université Claude Bernard Lyon 1, Lyon, France
| | - Arthur Dony
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Nathalie Cheikh
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Cécile Renard
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Antony Ceraulo
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Daniela Cuzzubbo
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Corinne Pondarré
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France.,Centre Hospitalier Intercommunal de Créteil, Université Paris Est Créteil, Créteil, France
| | - Cyril Martin
- Laboratoire CRIS EA 647, Section "Vascular Biology and Red Blood Cell", Université Claude Bernard Lyon 1, Lyon, France
| | - Vincent Pialoux
- Laboratoire CRIS EA 647, Section "Vascular Biology and Red Blood Cell", Université Claude Bernard Lyon 1, Lyon, France.,Institut Universitaire de France (IUF), Paris, France
| | - Alain Francina
- Unité de Pathologie Moléculaire du Globule Rouge, Laboratoire de Biochimie et de Biologie Moléculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Yves Bertrand
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Lyon, France
| | - Philippe Connes
- Laboratoire CRIS EA 647, Section "Vascular Biology and Red Blood Cell", Université Claude Bernard Lyon 1, Lyon, France.,Institut Universitaire de France (IUF), Paris, France
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49
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Fasano RM, Meier ER, Hulbert ML. Cerebral vasculopathy in children with sickle cell anemia. Blood Cells Mol Dis 2015; 54:17-25. [DOI: 10.1016/j.bcmd.2014.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 08/28/2014] [Indexed: 01/14/2023]
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Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MSV, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:3754-832. [PMID: 25355838 PMCID: PMC5020564 DOI: 10.1161/str.0000000000000046] [Citation(s) in RCA: 993] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.
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