1
|
Jordan LC, King AA, Kanter J, Lebensburger J, Ford AL, Varughese TE, Garrett L, Mullis L, Saint Jean L, Davis S, Dumas J, Kassim AA, Rodeghier M, Hikima MS, Suwaid MA, Saleh MK, DeBaun MR. Incidence and Risk Factors for New and Recurrent Infarcts in Adults With Sickle Cell Disease. J Am Heart Assoc 2024; 13:e033278. [PMID: 38842282 DOI: 10.1161/jaha.123.033278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/30/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Most adults with sickle cell disease will experience a silent cerebral infarction (SCI) or overt stroke. Identifying patient subgroups with increased stroke incidence is important for future clinical trials focused on stroke prevention. Our 3-center prospective cohort study tested the primary hypothesis that adults with sickle cell disease and SCIs have a greater incidence of new stroke or SCI compared with those without SCI. A secondary aim focused on identifying additional risk factors for progressive infarcts, particularly traditional risk factors for stroke in adults. METHODS AND RESULTS This observational study included adults with sickle cell disease and no history of stroke. Magnetic resonance imaging scans of the brain completed at baseline and >1 year later were reviewed by 3 radiologists for baseline SCIs and new or progressive infarcts on follow-up magnetic resonance imaging. Stroke risk factors were abstracted from the medical chart. Time-to-event analysis was utilized for progressive infarcts. Median age was 24.1 years; 45.3% of 95 participants had SCIs on baseline magnetic resonance imaging. Progressive infarcts were present in 17 participants (17.9%), and the median follow-up was 2.1 years. Incidence of new infarcts was 11.95 per 100 patient-years (6.17-20.88) versus 3.74 per 100 patient-years (1.21-8.73) in those with versus without prior SCI. Multivariable Cox regression showed that baseline SCI predicts progressive infarcts (hazard ratio, 3.46 [95% CI, 1.05-11.39]; P=0.041); baseline hypertension was also associated with progressive infarcts (hazard ratio, 3.23 [95% CI, 1.16-9.51]; P=0.025). CONCLUSIONS Selecting individuals with SCIs and hypertension for stroke prevention trials in sickle cell disease may enrich the study population with those at highest risk for infarct recurrence.
Collapse
Affiliation(s)
- Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics Vanderbilt University Medical Center Nashville TN
| | - Allison A King
- Division of Hematology & Oncology, Department of Pediatrics Washington University School of Medicine St. Louis MO
| | - Julie Kanter
- Division of Hematology-Oncology, Department of Medicine University of Alabama at Birmingham Heersink School of Medicine Birmingham AL
| | - Jeff Lebensburger
- Division of Hematology-Oncology, Department of Pediatrics University of Alabama at Birmingham, Heersink School of Medicine Birmingham AL
| | - Andria L Ford
- Department of Neurology Washington University School of Medicine St. Louis MO
| | - Taniya E Varughese
- Division of Hematology & Oncology, Department of Pediatrics Washington University School of Medicine St. Louis MO
| | - Lisa Garrett
- Division of Hematology, Department of Medicine Washington University School of Medicine St. Louis MO
| | - Lauren Mullis
- Division of Hematology-Oncology, Department of Pediatrics University of Alabama at Birmingham, Heersink School of Medicine Birmingham AL
| | - LeShana Saint Jean
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease Vanderbilt University Medical Center Nashville TN
| | - Samantha Davis
- Division of Pediatric Neurology, Department of Pediatrics Vanderbilt University Medical Center Nashville TN
| | - Jeanine Dumas
- Division of Hematology-Oncology, Department of Pediatrics University of Alabama at Birmingham, Heersink School of Medicine Birmingham AL
| | - Adetola A Kassim
- Division of Hematology/Oncology, Department of Medicine Vanderbilt University Medical Center Nashville TN
| | | | - Mustapha S Hikima
- Department of Radiology Muhammad Abdullahi Wase Teaching Hospital Kano Nigeria
| | | | - Mohammed K Saleh
- Department of Radiology Aminu Kano Teaching Hospital Kano Nigeria
| | - Michael R DeBaun
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease Vanderbilt University Medical Center Nashville TN
| |
Collapse
|
2
|
Light J, Boucher M, Baskin-Miller J, Winstead M. Managing the Cerebrovascular Complications of Sickle Cell Disease: Current Perspectives. J Blood Med 2023; 14:279-293. [PMID: 37082003 PMCID: PMC10112470 DOI: 10.2147/jbm.s383472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
The importance of protecting brain function for people with sickle cell disease (SCD) cannot be overstated. SCD is associated with multiple cerebrovascular complications that threaten neurocognitive function and life. Without screening and preventive management, 11% of children at 24% of adults with SCD have ischemic or hemorrhagic strokes. Stroke screening in children with SCD is well-established using transcranial Doppler ultrasound (TCD). TCD velocities above 200 cm/s significantly increase the risk of stroke, which can be prevented using chronic red blood cell (RBC) transfusion. RBC transfusion is also the cornerstone of acute stroke management and secondary stroke prevention. Chronic transfusion requires long-term management of complications like iron overload. Hydroxyurea can replace chronic transfusions for primary stroke prevention in a select group of patients or in populations where chronic transfusions are not feasible. Silent cerebral infarction (SCI) is even more common than stroke, affecting 39% of children and more than 50% of adults with SCD; management of SCI is individualized and includes careful neurocognitive evaluation. Hematopoietic stem cell transplant prevents cerebrovascular complications, despite the short- and long-term risks. Newer disease-modifying agents like voxelotor and crizanlizumab, as well as gene therapy, may treat cerebrovascular complications, but these approaches are investigational.
Collapse
Affiliation(s)
- Jennifer Light
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria Boucher
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jacquelyn Baskin-Miller
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mike Winstead
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Correspondence: Mike Winstead, Division of Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, USA, Tel +1 919-966-1178, Fax +1 919-966-7629, Email
| |
Collapse
|
3
|
Sayin ES, Sobczyk O, Poublanc J, Mikulis DJ, Fisher JA, Kuo KHM, Duffin J. Assessment of cerebrovascular function in patients with sickle cell disease using transfer function analysis. Physiol Rep 2022; 10:e15472. [PMID: 36200271 PMCID: PMC9535348 DOI: 10.14814/phy2.15472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/29/2022] [Accepted: 09/01/2022] [Indexed: 11/07/2022] Open
Abstract
In patients with sickle cell disease (SCD), the delivery of oxygen to the brain is compromised by anemia, abnormal rheology, and steno‐occlusive vascular disease. Successful compensation depends on an increase in oxygen supply such as that provided by an increase in cerebral blood flow (CBF). We used magnetic resonance imaging to provide a high‐resolution assessment of the ability of SCD patients to respond to a vasoactive stimulus in middle, anterior, and posterior cerebral artery territories for both white and gray matter. Cerebrovascular reactivity (CVR) was measured as the blood oxygen level dependent signal (a surrogate for CBF) response to an increase in the end tidal partial pressure of CO2 (PETCO2). The dynamic aspect of the response was measured as the time constant of the first order response kinetics (tau). To confirm and support these findings we used an alternative examination of the response, transfer function analysis (TFA), to measure the responsiveness (gain), the speed of response (phase), and the consistency of the response over time (coherence). We tested 34 patients with SCD and compared the results to those of 24 healthy controls participants. The results from a three‐way ANOVA showed that patients with SCD have reduced CVR (p < 0.001) and lower coherence (p < 0.001) in gray matter and white matter and reduced gain in gray matter only (p < 0.001). In terms of the speed of the response to CO2, tau (p < 0.001) and TFA phase (p < 0.001) were increased in SCD patients compared to healthy control subjects. These findings show that the cerebrovascular responsiveness to CO2 in patients with SCD is both decreased and slowed compared to healthy controls.
Collapse
Affiliation(s)
- Ece Su Sayin
- Department of PhysiologyUniversity of TorontoTorontoCanada,Departments of Anaesthesia and Pain ManagementUniversity Health NetworkTorontoCanada
| | - Olivia Sobczyk
- Department of PhysiologyUniversity of TorontoTorontoCanada,Departments of Anaesthesia and Pain ManagementUniversity Health NetworkTorontoCanada,Joint Department of Medical Imaging and the Functional Neuroimaging LaboratoryUniversity Health NetworkTorontoCanada
| | - Julien Poublanc
- Joint Department of Medical Imaging and the Functional Neuroimaging LaboratoryUniversity Health NetworkTorontoCanada
| | - David J. Mikulis
- Joint Department of Medical Imaging and the Functional Neuroimaging LaboratoryUniversity Health NetworkTorontoCanada,Institute of Medical SciencesUniversity of TorontoTorontoCanada
| | - Joseph A. Fisher
- Department of PhysiologyUniversity of TorontoTorontoCanada,Departments of Anaesthesia and Pain ManagementUniversity Health NetworkTorontoCanada
| | - Kevin H. M. Kuo
- Division of Medical Oncology and Hematology, Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - James Duffin
- Department of PhysiologyUniversity of TorontoTorontoCanada,Departments of Anaesthesia and Pain ManagementUniversity Health NetworkTorontoCanada
| |
Collapse
|
4
|
Ampomah MA, Drake JA, Anum A, Amponsah B, Dei-Adomakoh Y, Anie K, Mate-Kole CC, Jonassaint CR, Kirkham FJ. A case-control and seven-year longitudinal neurocognitive study of adults with sickle cell disease in Ghana. Br J Haematol 2022; 199:411-426. [PMID: 36017640 DOI: 10.1111/bjh.18386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 11/28/2022]
Abstract
Ageing in sickle cell disease (SCD) is associated with a myriad of end-organ complications, including cerebrovascular damage and cognitive impairment (CI). Although CI is very common in SCD, little is known about cognitive functioning and how it changes with age. This study examines cognitive patterns of 63 adults with SCD and 60 non-SCD, age- and education-matched controls in Ghana. Of those adults with SCD, 34 completed the neuropsychological battery at baseline and again seven years later. In cross-sectional data, adults with SCD performed worse than controls in all cognitive test domains (p < 0.01 for all). The seven-year follow-up data showed that the group exhibited a significant decline in visuospatial abilities (ranging from Cohen's d = 1.40 to 2.38), and to a lesser extent, in processing speed and executive functioning. Exploratory analyses showed a significant time-by-education interaction, indicating that education may be protective from decline in cognitive performance. These findings have implications for clinical practice. Early neuropsychological surveillance coupled with early assessment and remedial programmes will provide avenues for enhancing the quality of life of adults living with SCD in Ghana.
Collapse
Affiliation(s)
- Mary A Ampomah
- Family and Community Health, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Jermon A Drake
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adote Anum
- Department of Psychology, School of Social Sciences, University of Ghana, Legon, Ghana
| | - Benjamin Amponsah
- Department of Psychology, School of Social Sciences, University of Ghana, Legon, Ghana
| | - Yvonne Dei-Adomakoh
- Department of Haematology, School of Medicine and Dentistry, University of Ghana Medical School, Ghana Institute of Clinical Genetics, Accra, Ghana
| | - Kofi Anie
- School of Public Health, Imperial College London, London, UK.,London North West University Healthcare NHS Trust, London, UK
| | - Christopher C Mate-Kole
- Department of Psychology, School of Social Sciences, University of Ghana, Legon, Ghana.,Centre for Ageing Studies, College of Humanities, University of Ghana, Legon, Ghana
| | | | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK
| |
Collapse
|
5
|
Stotesbury H, Kawadler JM, Clayden JD, Saunders DE, Hood AM, Koelbel M, Sahota S, Rees DC, Wilkey O, Layton M, Pelidis M, Inusa BPD, Howard J, Chakravorty S, Clark CA, Kirkham FJ. Quantification of Silent Cerebral Infarction on High-Resolution FLAIR and Cognition in Sickle Cell Anemia. Front Neurol 2022; 13:867329. [PMID: 35847220 PMCID: PMC9277177 DOI: 10.3389/fneur.2022.867329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/27/2022] [Indexed: 01/18/2023] Open
Abstract
Research in sickle cell anemia (SCA) has used, with limited race-matched control data, binary categorization of patients according to the presence or absence of silent cerebral infarction (SCI). SCI have primarily been identified using low-resolution MRI, with radiological definitions varying in lesion length and the requirement for abnormality on both fluid attenuated inversion recovery (FLAIR) and T1-weighted images. We aimed to assess the effect of published SCI definitions on global, regional, and lobar lesion metrics and their value in predicting cognition. One hundred and six patients with SCA and 48 controls aged 8-30 years underwent 3T MRI with a high-resolution FLAIR sequence and Wechsler cognitive assessment. Prevalence, number, and volume of lesions were calculated using a semi-automated pipeline for SCI defined as: (1) Liberal: any length (L-SCI); (2) Traditional: >3 mm in greatest dimension (T-SCI); (3) Restrictive; >3 mm in greatest dimension with a corresponding T1-weighted hypo-intensity (R-SCI). Globally, as hypothesized, there were large effects of SCI definition on lesion metrics in patients and controls, with prevalence varying from 24-42% in patients, and 4-23% in controls. However, contrary to hypotheses, there was no effect of any global metric on cognition. Regionally, there was a consistent distribution of SCI in frontal and parietal deep and juxta-cortical regions across definitions and metrics in patients, but no consistent distribution in controls. Effects of regional SCI metrics on cognitive performance were of small magnitude; some were paradoxical. These findings expose the challenges associated with the widespread use of SCI presence as a biomarker of white-matter injury and cognitive dysfunction in cross-sectional high-resolution MRI studies in patients with SCA. The findings indicate that with high-resolution MRI: (1) radiological definitions have a large effect on resulting lesion groups, numbers, and volumes; (2) there is a non-negligible prevalence of lesions in young healthy controls; and (3) at the group-level, there is no cross-sectional association between global lesion metrics and general cognitive impairment irrespective of lesion definition and metric. With high-resolution multi-modal MRI, the dichotomy of presence or absence of SCI does not appear to be a sensitive biomarker for the detection of functionally significant pathology; the search for appropriate endpoints for clinical treatment trials should continue.
Collapse
Affiliation(s)
- Hanne Stotesbury
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jamie M Kawadler
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jonathan D Clayden
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Dawn E Saunders
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Anna M Hood
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Division of Psychology and Mental Health, Manchester Centre for Health Psychology, University of Manchester, Manchester, United Kingdom
| | - Melanie Koelbel
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Sati Sahota
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Olu Wilkey
- North Middlesex University Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark Layton
- Haematology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom
| | - Maria Pelidis
- Department of Haematology and Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Baba P D Inusa
- Department of Haematology and Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jo Howard
- Department of Haematology and Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Chris A Clark
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Fenella J Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Clinical and Experimental Sciences, University of Southampton, Southampton, United Kingdom
| |
Collapse
|
6
|
Hematologic Disorders and Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
7
|
Sathi BK, Yoshida Y, Weaver MR, Nolan LS, Gruner B, Balasa V, Altes T, Leiva-Salinas C. Unusually High Prevalence of Stroke and Cerebral Vasculopathy in Hemoglobin SC Disease: A Retrospective Single Institution Study. Acta Haematol 2021; 145:160-169. [PMID: 34749363 DOI: 10.1159/000519360] [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: 01/10/2021] [Accepted: 08/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Unlike homozygous hemoglobin SS (HbSS) disease, stroke is a rare complication in hemoglobin SC (HbSC) disease. However, recent studies have demonstrated a high prevalence of silent stroke in HbSC disease. The factors associated with stroke and cerebral vasculopathy in the HbSC population are unknown. METHODS We conducted a retrospective study of all patients with sickle cell disease treated at the University of Missouri, Columbia, over an 18-year period (2000-2018). The goal of the study was to characterize the silent, overt stroke, and cerebral vasculopathy in HbSC patients and compare them to patients with HbSS and HbS/β thalassemia1 (thal) in this cohort. We also analyzed the laboratory and clinical factors associated with stroke and cerebral vasculopathy in the HbSC population. RESULTS Of the 34 HbSC individuals, we found that the overall prevalence of stroke and cerebral vasculopathy was 17.7%. Only females had evidence of stroke or cerebral vasculopathy in our HbSC cohort (33.3%, p = 0.019). Time-averaged means of maximum velocities were lower in the HbSC group than the HbSS group and did not correlate with stroke outcome. Among HbSC individuals, those with stroke and cerebral vasculopathy had a marginally higher serum creatinine than those without these complications (0.77 mg/dL vs. 0.88 mg/dL, p = 0.08). Stroke outcome was associated with recurrent vaso-occlusive pain crises (Rec VOCs) (75 vs. 25%, p = 0.003) in HbSC patients. The predominant cerebrovascular lesions in HbSC included microhemorrhages and leukoencephalopathy. CONCLUSION There is a distinct subset of individuals with HbSC who developed overt, silent stroke, and cerebral vasculopathy. A female predominance and association with Rec VOCs were identified in our cohort; however, larger clinical trials are needed to identify and confirm specific clinical and laboratory markers associated with stroke and vasculopathy in HbSC disease.
Collapse
Affiliation(s)
- Bindu Kanathezhath Sathi
- Pediatric Hematology Oncology, Valley Children's Hospital, University of San Francisco-Fresno Program, Madera, California, USA
- Department of Child Health, University of Missouri, Columbia, South Carolina, USA
| | - Yilin Yoshida
- Department of Internal Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Michael Raymond Weaver
- Department of Child Health, University of Missouri, Columbia, South Carolina, USA
- University of South Florida, Tampa, Florida, USA
| | - Lila S Nolan
- Department of Child Health, University of Missouri, Columbia, South Carolina, USA
- Department of Pediatrics, Washington University, St. Louis, Missouri, USA
| | - Barbara Gruner
- Department of Child Health, University of Missouri, Columbia, South Carolina, USA
| | - Vinod Balasa
- Pediatric Hematology Oncology, Valley Children's Hospital, University of San Francisco-Fresno Program, Madera, California, USA
| | - Talissa Altes
- Department of Child Health, University of Missouri, Columbia, South Carolina, USA
- Department of Radiology, University of Missouri, Columbia, South Carolina, USA
| | | |
Collapse
|
8
|
American Society of Hematology 2020 guidelines for sickle cell disease: prevention, diagnosis, and treatment of cerebrovascular disease in children and adults. Blood Adv 2021; 4:1554-1588. [PMID: 32298430 DOI: 10.1182/bloodadvances.2019001142] [Citation(s) in RCA: 182] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/03/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Central nervous system (CNS) complications are among the most common, devastating sequelae of sickle cell disease (SCD) occurring throughout the lifespan. OBJECTIVE These evidence-based guidelines of the American Society of Hematology are intended to support the SCD community in decisions about prevention, diagnosis, and treatment of the most common neurological morbidities in SCD. METHODS The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic evidence reviews. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations. RESULTS The panel placed a higher value on maintaining cognitive function than on being alive with significantly less than baseline cognitive function. The panel developed 19 recommendations with evidence-based strategies to prevent, diagnose, and treat CNS complications of SCD in low-middle- and high-income settings. CONCLUSIONS Three of 19 recommendations immediately impact clinical care. These recommendations include: use of transcranial Doppler ultrasound screening and hydroxyurea for primary stroke prevention in children with hemoglobin SS (HbSS) and hemoglobin Sβ0 (HbSβ0) thalassemia living in low-middle-income settings; surveillance for developmental delay, cognitive impairments, and neurodevelopmental disorders in children; and use of magnetic resonance imaging of the brain without sedation to detect silent cerebral infarcts at least once in early-school-age children and once in adults with HbSS or HbSβ0 thalassemia. Individuals with SCD, their family members, and clinicians should become aware of and implement these recommendations to reduce the burden of CNS complications in children and adults with SCD.
Collapse
|
9
|
Jordan LC, DeBaun MR, Donahue MJ. Advances in neuroimaging to improve care in sickle cell disease. Lancet Neurol 2021; 20:398-408. [PMID: 33894194 DOI: 10.1016/s1474-4422(20)30490-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/26/2022]
Abstract
Sickle cell disease is associated with progressive and increased neurological morbidity throughout the lifespan. In people with sickle cell anaemia (the most common and severe type of sickle cell disease), silent cerebral infarcts are found in more than a third of adolescents by age 18 years and roughly half of young adults by age 30 years, many of whom have cognitive impairment despite having few or no conventional stroke risk factors. Common anatomical neuroimaging in individuals with sickle disease can assess structural brain injury, such as stroke and silent cerebral infarcts; however, emerging advanced neuroimaging methods can provide novel insights into the pathophysiology of sickle cell disease, including insights into the cerebral haemodynamic and metabolic contributors of neurological injury. Advanced neuroimaging methods, particularly methods that report on aberrant cerebral blood flow and oxygen delivery, have potential for triaging patients for appropriate disease-modifying or curative therapies before they have irreversible neurological injury, and for confirming the benefit of new therapies on brain health in clinical trials.
Collapse
Affiliation(s)
- Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
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.
Collapse
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.
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Yuan S, Jordan LC, Davis LT, Cogswell PM, Lee CA, Patel NJ, Waddle SL, Juttukonda M, Sky Jones R, Griffin A, Donahue MJ. A cross-sectional, case-control study of intracranial arterial wall thickness and complete blood count measures in sickle cell disease. Br J Haematol 2020; 192:769-777. [PMID: 33326595 DOI: 10.1111/bjh.17262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/25/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Abstract
In sickle cell disease (SCD), cerebral oxygen delivery is dependent on the cerebral vasculature's ability to increase blood flow and volume through relaxation of the smooth muscle that lines intracranial arteries. We hypothesised that anaemia extent and/or circulating markers of inflammation lead to concentric macrovascular arterial wall thickening, visible on intracranial vessel wall magnetic resonance imaging (VW-MRI). Adult and pediatric SCD (n = 69; age = 19.9 ± 8.6 years) participants and age- and sex-matched control participants (n = 38; age = 22.2 ± 8.9 years) underwent 3-Tesla VW-MRI; two raters measured basilar and bilateral supraclinoid internal carotid artery (ICA) wall thickness independently. Mean wall thickness was compared with demographic, cerebrovascular and haematological variables. Mean vessel wall thickness was elevated (P < 0·001) in SCD (1·07 ± 0·19 mm) compared to controls (0·97 ± 0·07 mm) after controlling for age and sex. Vessel wall thickness was higher in participants on chronic transfusions (P = 0·013). No significant relationship between vessel wall thickness and flow velocity, haematocrit, white blood cell count or platelet count was observed; however, trends (P < 0·10) for wall thickness increasing with decreasing haematocrit and increasing white blood cell count were noted. Findings are discussed in the context of how anaemia and circulating inflammatory markers may impact arterial wall morphology.
Collapse
Affiliation(s)
- Shuai Yuan
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lori C Jordan
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Larry T Davis
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Petrice M Cogswell
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Chelsea A Lee
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Niral J Patel
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Spencer L Waddle
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meher Juttukonda
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - R Sky Jones
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Allison Griffin
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Kauv P, Gaudré N, Hodel J, Tuilier T, Habibi A, Oppenheim C, Edjlali M, Hervé D, Calvet D, Bartolucci P. Characteristics of Moyamoya Syndrome in Sickle-Cell Disease by Magnetic Resonance Angiography: An Adult-Cohort Study. Front Neurol 2019; 10:15. [PMID: 30723452 PMCID: PMC6349744 DOI: 10.3389/fneur.2019.00015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/07/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Sickle cell disease (SCD) can be complicated by moyamoya syndrome. Brain magnetic resonance angiography (MRA) is a non-invasive method to diagnose this syndrome and, steno-occlusion and moyamoya vessels (MMV) scores have been proposed to evaluate its severity. Previous studies of SCD moyamoya syndrome did not evaluate the severity according to MRA scores. The objective was to assess the characteristics of moyamoya syndrome in an adult cohort of SCD using these MRA scores. Methods: Twenty-five SCD patients with moyamoya syndrome were included using MRA with 3D time of flight technique. We evaluate steno-occlusion score for each hemisphere (range 0–10) from: steno-occlusion severity of internal carotid (ICA) (0–3), anterior cerebral (ACA) (0–3), middle cerebral (MCA) (0–2), and posterior cerebral (PCA) (0–2) arteries. MMV score for each hemisphere (range 0–5) depended from 5 MMV areas: (1) anterior communicating artery (2) basal ganglia (3) ICA/MCA (4) posterior communicating artery/PCA (5) basilar artery. Results: Eight patients (32%) showed unilateral moyamoya syndrome. ICA steno-occlusion was involved in 22 patients (88%), MCA in 23 patients (92%), ACA in 9 patients (36%), and PCA in 3 patients (12%). MMV involved ACoA area in 10 patients (40%), basal ganglia in 13 patients (52%), PCoA/PCA in 10 patients (40%), MCA/ICA in 7 patients (28%), and BA in 1 patient (4%). Steno-occlusion and MMV mean hemisphere scores were 3.4/10 (± 1.42) and 1.6/5 (± 0.71), respectively. Conclusion: Frequent unilateral moyamoya syndrome, uncommon PCA involvement and, moderate steno-occlusion and MMV scores seem to be features of SCD moyamoya syndrome. In future studies, MRA scores could be collected to assess the follow-up in these patients.
Collapse
Affiliation(s)
- Paul Kauv
- Department of Neuroradiology, APHP, Hôpital Henri Mondor, UPEC, Créteil, France
| | - Noémie Gaudré
- Unité des Maladies Génétiques du Globule Rouge, Sickle-Cell Referral Center, Internal Medicine, APHP, Hôpital Henri Mondor, UPEC, Créteil, France
| | - Jérôme Hodel
- Department of Neuroradiology, APHP, Hôpital Henri Mondor, UPEC, Créteil, France
| | - Titien Tuilier
- Department of Neuroradiology, APHP, Hôpital Henri Mondor, UPEC, Créteil, France
| | - Anoosha Habibi
- Unité des Maladies Génétiques du Globule Rouge, Sickle-Cell Referral Center, Internal Medicine, APHP, Hôpital Henri Mondor, UPEC, Créteil, France
| | - Catherine Oppenheim
- Department of Neuroradiology, Hôpital Sainte-Anne, Université Paris Descartes, INSERM U894, Paris, France
| | - Myriam Edjlali
- Department of Neuroradiology, Hôpital Sainte-Anne, Université Paris Descartes, INSERM U894, Paris, France
| | - Dominique Hervé
- Department of Neurology, APHP, Hôpital Lariboisière, Paris, France
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Paris, France
| | - Pablo Bartolucci
- Unité des Maladies Génétiques du Globule Rouge, Sickle-Cell Referral Center, Internal Medicine, APHP, Hôpital Henri Mondor, UPEC, Créteil, France.,INSERM-U955, IMRB, Team 2: Transfusion et Maladies du Globule Rouge, Laboratoire d'Excellence, GRex, Créteil, France
| |
Collapse
|
17
|
Jordan LC, DeBaun MR. Cerebral hemodynamic assessment and neuroimaging across the lifespan in sickle cell disease. J Cereb Blood Flow Metab 2018; 38:1438-1448. [PMID: 28417646 PMCID: PMC6125971 DOI: 10.1177/0271678x17701763] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Children and adults with sickle cell anemia (SCA) have a higher risk of strokes compared to age- and race-matched peers. Velocity in the middle cerebral or distal internal carotid artery as measured by transcranial Doppler ultrasound is a recognized method to identify children but not adults with SCA at high-risk for first stroke. For both children and adults with SCA that have had a stroke, no methods clearly identify individuals at highest risk of recurrent strokes or an initial silent stroke, the most common neurological injury. Methods to assess cerebral hemodynamics in SCA have been utilized for decades but often required radiotracers making them not feasible for screening and longitudinal follow-up. MRI approaches that do not require exogenous contrast have been introduced and are appealing in both clinical and research scenarios. Improved neuroimaging strategies hold promise for identifying individuals with SCA at increased risk of initial and recurrent infarcts, justifying more aggressive risk-based therapy. We review the epidemiology of stroke in SCA, the impact of strokes, stroke mechanisms, and potential imaging strategies including regional and global oxygen extraction fraction, cerebral blood flow, and vessel wall imaging to identify individuals at high-risk of stroke.
Collapse
Affiliation(s)
- Lori C Jordan
- 1 Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael R DeBaun
- 2 Department of Pediatrics, Vanderbilt-Meharry Sickle Cell Disease Center of Excellence, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
18
|
Bush A, Chai Y, Choi SY, Vaclavu L, Holland S, Nederveen A, Coates T, Wood J. Pseudo continuous arterial spin labeling quantification in anemic subjects with hyperemic cerebral blood flow. Magn Reson Imaging 2017; 47:137-146. [PMID: 29229306 DOI: 10.1016/j.mri.2017.12.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/16/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate possible sources of quantification errors in global cerebral blood flow (CBF) measurements by comparing pseudo continuous arterial spin labeling (PCASL) and phase contrast (PC) MRI in anemic, hyperemic subjects. METHODS All studies were performed on a Philips 3T Achieva MRI scanner. PC and PCASL CBF examinations were performed in 10 healthy, young adult subjects and 18 young adults with chronic anemia syndromes including sickle cell disease and thalassemia. CBF estimates from single and two compartment ASL kinetic models were compared. Numerical simulation and flow phantom experiments were used to explore the effects of blood velocity and B1+ on CBF quantification and labeling efficiency. RESULTS PCASL CBF underestimated PC in both populations using a single compartment model (30.1±9.2% control, 45.2±17.2% anemia). Agreement substantially improved using a two-compartment model (-8.0±6.0% control, 11.7±12.3% anemia). Four of the anemic subjects exhibited venous outflow of ASL signal, suggestive of cerebrovascular shunt, possibly confounding PC-PCASL comparisons. Additionally, sub-study experiments demonstrated that B1+ was diminished at the labeling plane (82.9±5.1%), resulting in suboptimal labeling efficiency. Correcting labeling efficiency for diminished B1+, PCASL slightly overestimated PC CBF in controls (-15.4±6.8%) and resulted in better matching of CBF estimates in anemic subjects (0.7±10.0% without outflow, 10.5±9.4% with outflow). CONCLUSIONS This work demonstrates that a two-compartment model is critical for PCASL quantification in hyperemic subjects. Venous outflow and B1+ under-excitation may also contribute to flow underestimation, but further study of these effects is required.
Collapse
Affiliation(s)
- Adam Bush
- Department of Radiology, Stanford University, Palo Alto, CA, United States; Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, United States
| | - Yaqiong Chai
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, United States
| | - So Young Choi
- Neurosciences Program, University of Southern California, Los Angeles, CA, United States
| | - Lena Vaclavu
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Scott Holland
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Aart Nederveen
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Thomas Coates
- Division of Hematology, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - John Wood
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, United States; Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, United States.
| |
Collapse
|
19
|
Mazzucco S, Diomedi M, Qureshi A, Sainati L, Padayachee ST. Transcranial Doppler screening for stroke risk in children with sickle cell disease: a systematic review. Int J Stroke 2017; 12:580-588. [PMID: 28440126 DOI: 10.1177/1747493017706189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Sickle cell disease (SCD) is one of the most common causes of stroke in children worldwide. Based on the results of the Stroke Prevention Trial in Sickle Cell Anemia (STOP), annual transcranial Doppler ultrasound (TCD) screening for affected children is standard practice. However, the need for TCD surveillance programs could override the accuracy of the screening, affecting the correct stratification of stroke risk and subsequent clinical management of the target population. Aims To shed light on this issue, a systematic review of the literature on TCD screening for children and adolescents with SCD was carried out (CRD42016050549), according to a list of clinically relevant questions, with a particular focus on screening practices in European countries. Quality of the evidence was rated using the grading of recommendations assessment, development and evaluation. Summary of review Thirty-three studies published in English or French were included (5 randomized controlled trials, 8 experimental non-randomized, and 20 observational studies). The quality of the retrieved evidence ranged between low and high, but was rated as moderate or high most of the times. TCD is effective as a screening tool for the primary prevention of stroke in SCD children. There is no high-quality evidence on the effectiveness of alternative screening methods, such as imaging-TCD with or without angle correction or magnetic resonance angiography. No evidence was found on effectiveness of the screening on children on hydroxyurea and with genotypes other than HbSS and HbS/β0. No European data were found on screening rates or adherence of screening practices to the STOP protocol. Conclusions High-quality studies on alternative screening methods that are currently used in real-world practice, and on screening applicability to specific subgroups of patients are urgently needed. Considering the low awareness of the disease in European countries and the lack of data on screening practices and adherence, clinicians need up-to-date guidelines for more uniform and evidence-based surveillance of children with SCD.
Collapse
Affiliation(s)
- Sara Mazzucco
- 1 Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- 2 Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Marina Diomedi
- 3 Stroke Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Amrana Qureshi
- 4 Paediatric Haematology and Oncology Service, Children's Hospital-Oxford University Hospital Foundation Trust, Oxford, UK
| | - Laura Sainati
- 5 Pediatric Haematology and Oncology Service, Dipartimento della Donna e del Bambino, Padua University, Padova, Italy
| | - Soundrie T Padayachee
- 6 Ultrasonic Angiology Department, Guy's & St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
20
|
Transcranial color Doppler in stroke-free adult patients with sickle cell disease. Ann Hematol 2017; 96:1547-1555. [DOI: 10.1007/s00277-017-3071-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 07/10/2017] [Indexed: 02/02/2023]
|
21
|
Cichowitz C, Carroll PC, Strouse JJ, Haywood C, Lanzkron S. Utility of the Montreal Cognitive Assessment as a Screening Test for Neurocognitive Dysfunction in Adults with Sickle Cell Disease. South Med J 2017; 109:560-5. [PMID: 27598362 DOI: 10.14423/smj.0000000000000511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Neurocognitive dysfunction is an important complication of sickle cell disease (SCD), but little is published on the utility of screening tests for cognitive impairment in people with the disease. The purpose of this study was to evaluate the Montreal Cognitive Assessment (MoCA) as a screening tool and identify predictors of MoCA performance in adults with sickle cell disease. METHODS We conducted a retrospective, cross-sectional study of the first 100 adult patients with SCD who completed the MoCA as part of routine clinical care at the Johns Hopkins Sickle Cell Center for Adults. We abstracted demographic, laboratory, and clinical data from each participant's electronic medical record up to the date that the MoCA was administered. The factorial validity of each MoCA domain was analyzed using standard psychometric statistics. We evaluated the abstracted data for associations with the composite MoCA score and looked for independent predictors of performance using multivariable regressions. RESULTS Components of the MoCA performed well in psychometric analyses and identified deficits in executive function that were described in other studies. Forty-six percent of participants fell below the cutoff for mild cognitive impairment. Increased education was an independent predictor of increased MoCA score (3.1, 95% confidence interval [CI] 1.5-4.7), whereas cerebrovascular accidents and chronic kidney disease were independent predictors of decreased score (-3.3, 95% CI -5.7 to -0.97 and -3.2, 95% CI -6.2 to -0.11, respectively). When analysis was restricted to patients with SCA, increased education (3.7, 95% CI 2.2-5.2) and a history of hydroxyurea therapy (2.0, 95% CI -0.022 to 4.0) were independent predictors of a higher score, whereas chronic kidney disease (-3.3, 95% CI -6.4 to -0.24) and increased aspartate transaminase (-0.045, 95% CI -0.089 to -0.0010) were independent predictors of a decreased score. CONCLUSIONS The MoCA showed promise by identifying important cognitive deficits and associations with chronic complications and therapy.
Collapse
Affiliation(s)
- Cody Cichowitz
- From the Departments of Psychiatry and Behavioral Medicine, Pediatrics, and Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, and the Division of Hematology, Duke University School of Medicine, Durham, North Carolina
| | - Patrick C Carroll
- From the Departments of Psychiatry and Behavioral Medicine, Pediatrics, and Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, and the Division of Hematology, Duke University School of Medicine, Durham, North Carolina
| | - John J Strouse
- From the Departments of Psychiatry and Behavioral Medicine, Pediatrics, and Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, and the Division of Hematology, Duke University School of Medicine, Durham, North Carolina
| | - Carlton Haywood
- From the Departments of Psychiatry and Behavioral Medicine, Pediatrics, and Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, and the Division of Hematology, Duke University School of Medicine, Durham, North Carolina
| | - Sophie Lanzkron
- From the Departments of Psychiatry and Behavioral Medicine, Pediatrics, and Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, and the Division of Hematology, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
22
|
Jordan LC, Gindville MC, Scott AO, Juttukonda MR, Strother MK, Kassim AA, Chen SC, Lu H, Pruthi S, Shyr Y, Donahue MJ. Non-invasive imaging of oxygen extraction fraction in adults with sickle cell anaemia. Brain 2016; 139:738-50. [PMID: 26823369 DOI: 10.1093/brain/awv397] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/30/2015] [Indexed: 11/12/2022] Open
Abstract
Sickle cell anaemia is a monogenetic disorder with a high incidence of stroke. While stroke screening procedures exist for children with sickle cell anaemia, no accepted screening procedures exist for assessing stroke risk in adults. The purpose of this study is to use novel magnetic resonance imaging methods to evaluate physiological relationships between oxygen extraction fraction, cerebral blood flow, and clinical markers of cerebrovascular impairment in adults with sickle cell anaemia. The specific goal is to determine to what extent elevated oxygen extraction fraction may be uniquely present in patients with higher levels of clinical impairment and therefore may represent a candidate biomarker of stroke risk. Neurological evaluation, structural imaging, and the non-invasive T2-relaxation-under-spin-tagging magnetic resonance imaging method were applied in sickle cell anaemia (n = 34) and healthy race-matched control (n = 11) volunteers without sickle cell trait to assess whole-brain oxygen extraction fraction, cerebral blood flow, degree of vasculopathy, severity of anaemia, and presence of prior infarct; findings were interpreted in the context of physiological models. Cerebral blood flow and oxygen extraction fraction were elevated (P < 0.05) in participants with sickle cell anaemia (n = 27) not receiving monthly blood transfusions (interquartile range cerebral blood flow = 46.2-56.8 ml/100 g/min; oxygen extraction fraction = 0.39-0.50) relative to controls (interquartile range cerebral blood flow = 40.8-46.3 ml/100 g/min; oxygen extraction fraction = 0.33-0.38). Oxygen extraction fraction (P < 0.0001) but not cerebral blood flow was increased in participants with higher levels of clinical impairment. These data provide support for T2-relaxation-under-spin-tagging being able to quickly and non-invasively detect elevated oxygen extraction fraction in individuals with sickle cell anaemia with higher levels of clinical impairment. Our results support the premise that magnetic resonance imaging-based assessment of elevated oxygen extraction fraction might be a viable screening tool for evaluating stroke risk in adults with sickle cell anaemia.
Collapse
Affiliation(s)
- Lori C Jordan
- 1 Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa C Gindville
- 1 Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Allison O Scott
- 2 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meher R Juttukonda
- 2 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Megan K Strother
- 2 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adetola A Kassim
- 3 Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sheau-Chiann Chen
- 4 Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hanzhang Lu
- 5 Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sumit Pruthi
- 2 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yu Shyr
- 4 Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- 2 Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA 6 Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA 7 Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
23
|
Adegoke SA, Figueiredo MS, Vicari P, Carrete H, Idagawa MH, Massaro AR, Silva GS. Posterior Circulation Evaluation in Patients with Sickle Cell Anemia. J Stroke Cerebrovasc Dis 2016; 25:717-21. [PMID: 26774870 DOI: 10.1016/j.jstrokecerebrovasdis.2015.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/08/2015] [Accepted: 11/05/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The role of transcranial Doppler (TCD) ultrasonography in identifying children with sickle cell anemia (SCA) at risk for stroke is well known; however, the major studies that evaluated TCD velocities in children with SCA did not report posterior circulation evaluation data. The objective of our study was to describe the pattern of blood flow velocities in the posterior circulation of patients with SCA and to examine their relationship with findings on magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA). METHODS All adult patients with SCA followed in the outpatient clinic of our hospital were evaluated with TCD and MRI/MRA. The highest velocities of the middle cerebral arteries or internal carotid arteries were taken as the time-averaged maximum mean (TAMM) velocity for each patient and the maximum mean flow velocities in the posterior circulation (TAMMpost) were recorded. RESULTS Fifty-six patients with SCA and 56 healthy nonanemic volunteers were evaluated. The mean TAMMpost in the basilar, vertebral, and posterior cerebral arteries (PCAs) were significantly higher among cases than controls (P < .01). In patients with SCA, the TAMMpost in all posterior circulation arteries had a positive correlation with TAMM. Only 1 patient with stenosis in the posterior circulation (right PCA) was identified. CONCLUSION We found a low frequency of stenosis but high blood flow velocities in the posterior circulation in patients with SCA. The role of increased TCD velocities in the posterior circulation upon stroke risk in patients with SCA should be further examined.
Collapse
Affiliation(s)
- Samuel Ademola Adegoke
- Department of Pediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria; Department of Hematology, UNIFESP, São Paulo, SP, Brazil
| | | | - Perla Vicari
- Department of Hematology, UNIFESP, São Paulo, SP, Brazil
| | | | | | | | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, UNIFESP, São Paulo, SP, Brazil; Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| |
Collapse
|
24
|
Hematologic Disorders and Stroke. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00042-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
25
|
|
26
|
Cancio MI, Helton KJ, Schreiber JE, Smeltzer MP, Kang G, Wang WC. Silent cerebral infarcts in very young children with sickle cell anaemia are associated with a higher risk of stroke. Br J Haematol 2015; 171:120-9. [PMID: 26058476 DOI: 10.1111/bjh.13525] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/22/2015] [Indexed: 11/29/2022]
Abstract
Silent cerebral infarctions (SCI) are the most common neurological injury in children with sickle cell anaemia (SCA), but their incidence/prognosis in early childhood has not been well described. We report clinical, neuroradiological, psychometric and academic follow-up over an average period of 14 years in 37 children with SCA who had magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain between ages 7 and 48 months. Ten patients (27%) younger than age 5 years (Group I) had SCI, as did 12 (32%) older than 5 years (Group II). Fifteen (41%) had no lesions (Group III). Overt stroke or transient ischaemic attack occurred in 5/9 (56%) in Group I. Most Group I patients had progressive MRI abnormalities, concurrent stenosis, decreased cognitive ability, attention/executive function deficits and hindered academic attainment. The proportions of subjects in Group I with subsequent neurological events (P ≤ 0·006), progressive ischaemia (P ≤ 0·001) and vascular stenosis (P ≤ 0·006) were greater than in Groups II and III. Thus, SCI in young children with SCA may predict overt central nervous system events, progressive MRI abnormalities, stenosis, cognitive dysfunction and poor academic performance. Children younger than 5 years may benefit from MRI/MRA testing and should be considered for aggressive intervention when SCI are detected.
Collapse
Affiliation(s)
- Maria I Cancio
- Departments of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kathleen J Helton
- Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jane E Schreiber
- Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Matthew P Smeltzer
- Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA.,University of Memphis School of Public Health, Memphis, TN, USA
| | - Guolian Kang
- Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Winfred C Wang
- Departments of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
| |
Collapse
|
27
|
Quinn CT. Breakthrough: new guidance for silent cerebral ischemia and infarction in sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:438-443. [PMID: 25696891 DOI: 10.1182/asheducation-2014.1.438] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Silent cerebral infarction (SCI) is a highly prevalent and morbid condition in sickle cell disease (SCD). SCI can occur beginning in the first year of life and becomes more common with increasing age. Potentially modifiable risk factors for SCI include anemia and blood pressure. Headache does not appear to be associated with SCI, so neurologically normal children with headache do not necessarily warrant screening MRI for SCI. SCI does affect cognition, but biological determinants of cognition are not more important than socioeconomic factors. The recent identification of acute silent cerebral ischemic events indicates that the total burden of ischemic injury to the brain in SCD is far greater than previously realized. Acute anemic events appear to increase the risk of acute silent cerebral ischemic events and SCI dramatically. The medical management of SCI is not yet defined, but documentation of the presence of SCI may qualify affected individuals for special resources because comprehensive interventions are needed to optimize patients' academic and vocational outcomes.
Collapse
Affiliation(s)
- Charles T Quinn
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
28
|
Arkuszewski M, Krejza J, Chen R, Ichord R, Kwiatkowski JL, Bilello M, Zimmerman R, Ohene-Frempong K, Melhem ER. Sickle cell anemia: intracranial stenosis and silent cerebral infarcts in children with low risk of stroke. Adv Med Sci 2014; 59:108-13. [PMID: 24797985 DOI: 10.1016/j.advms.2013.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 09/13/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Children with sickle cell anemia (SCA), who have mean blood flow velocities <170 cm/s in the terminal internal carotid (tICA) or middle cerebral (MCA) arteries on transcranial Doppler ultrasonography (TCD), are considered to be at low risk of stroke. The prevalence of intracranial stenosis, which raises the risk of stroke, is not known in these children. Here, we estimated the prevalence of stenosis and explored its association with silent cerebral infarcts determined based on Magnetic Resonance (MR) scans. PATIENTS/METHODS We studied prospectively a cohort of 67 children with SCA without prior clinically overt stroke or TIA (median age 8.8 years; range limits 2.3-13.1 years; 33 females) and with TCD mean velocity <170 cm/s. They underwent MR imaging of the brain and MR angiography of intracranial arteries. RESULTS In 7 children (10.5%, 95% CI: 4.9-20.3%) we found 10 stenoses, including 4 with isolated left tICA stenosis and 3 with multiple stenoses. We found silent infarcts in 26 children (37.7%, 95% CI: 27.2-49.5%). The median number of infarcts in an affected child was 2 (range limits: 1-9), median volume of infarcts was 171 mm(3) (range limits: 7-1060 mm(3)), and median infarct volume in relation to total brain volume was 0.020% (range limits: 0.001-0.101%). The number and volume of infarcts were significantly higher in children with arterial stenosis (both p=0.023). CONCLUSIONS The prevalence of intracranial arterial stenosis in children with SCA classified as at low risk of stroke by TCD mean velocity <170 cm/s is high. Children with stenosis are at higher risk of brain parenchymal injury as they have more silent cerebral infarcts.
Collapse
|
29
|
|
30
|
Venkataraman A, Adams RJ. Neurologic complications of sickle cell disease. HANDBOOK OF CLINICAL NEUROLOGY 2014; 120:1015-25. [PMID: 24365368 DOI: 10.1016/b978-0-7020-4087-0.00068-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Sickle cell disease (SCD) is a group of genetic blood disorders that vary in severity, but the most severe forms, primarily homozygous sickle cell anemia, are associated with neurologic complications. Over the last 90 years it has become established that some patients will develop severe arterial disease of the intracranial brain arteries and suffer brain infarction. Smaller infarctions and brain atrophy may also be seen and over time there appear to be negative cognitive effects in some patients, with or without abnormal brain imaging. Focal mononeuropathies and pneumococcal meningitis are also more common in these patients. Brain infarction in children can largely be prevented screening children beginning at age 2 years and instituting regular blood transfusion when the Doppler indicates high stroke risk (>200cm/sec). Iron overload and the uncertain duration of transfusion are disadvantages but overall this approach, tested in a randomized clinical trial, reduced first stroke by over 90%. Secondary stroke prevention has not been subjected to a randomized controlled trial except for one recently stopped comparison of regular transfusions compared to hydroxuyrea (results favored transfusion). The usual stroke prevention agents (such as aspirin or warfarin) have not been rigorously tested. Magnetic resonance imaging and positron emission tomography give evidence of subtle and sometimes overt brain injury due to stroke in many adults, but a preventive strategy for adults with SCD has not been developed. Bone marrow transplantation is the only cure, but some non-neurologic symptoms can be controlled in adults with hydroxuyrea.
Collapse
Affiliation(s)
- Akila Venkataraman
- Pediatric Neurology and Epilepsy Division, Lutheran Medical Center, Brooklyn, NY, USA
| | - Robert J Adams
- South Carolina Stroke Center of Economic Excellence and Medical University of South Carolina Stroke Center, Charleston, SC, USA.
| |
Collapse
|
31
|
Abboud M, Maakaron J, Khoury R, Tamim H, Shehab M, Haddad F, Adams R, Taher A. Intracranial blood flow velocities in patients with sickle cell disease and β-thalassemia intermedia. Am J Hematol 2013; 88:825. [PMID: 23733527 DOI: 10.1002/ajh.23496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 05/20/2013] [Indexed: 11/08/2022]
Affiliation(s)
- M.R. Abboud
- Department of Pediatrics and Adolescent Medicine; American University of Beirut Medical Center; Beirut; Lebanon
| | - J.E. Maakaron
- Department of Internal Medicine; American University of Beirut Medical Center; Beirut; Lebanon
| | - R.A. Khoury
- Department of Pediatrics and Adolescent Medicine; American University of Beirut Medical Center; Beirut; Lebanon
| | - H.M. Tamim
- Department of Internal Medicine; American University of Beirut Medical Center; Beirut; Lebanon
| | - M. Shehab
- Department of Surgery; American University of Beirut; Beirut; Lebanon
| | - F. Haddad
- Department of Surgery; American University of Beirut; Beirut; Lebanon
| | - R.J. Adams
- Department of Neurosciences; Medical University of South Carolina Charleston; South Carolina
| | - A.T. Taher
- Department of Internal Medicine; American University of Beirut Medical Center; Beirut; Lebanon
| |
Collapse
|
32
|
Solomou E, Kraniotis P, Kourakli A, Petsas T. Extent of silent cerebral infarcts in adult sickle-cell disease patients on magnetic resonance imaging: is there a correlation with the clinical severity of disease? Hematol Rep 2013; 5:8-12. [PMID: 23888239 PMCID: PMC3719106 DOI: 10.4081/hr.2013.e3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 12/11/2012] [Accepted: 01/07/2013] [Indexed: 11/22/2022] Open
Abstract
The aim of this paper is to correlate the extent of silent cerebral infarcts (SCIs) on magnetic resonance imaging (MRI) with the clinical severity of sickle cell disease (SCD) in adult patients. Twenty-four consecutive adult asymptomatic SCD patients (11 male and 13 female) with a mean age of 38.4 years (range 20-59) were submitted to brain MRI on a 1 Tesla Gyroscan Intera, Philips MR scanner with a dedicated head coil. The protocol consisted of TSE T2-weighted and FLAIR images on the axial and coronal planes. MRI readings were undertaken by two radiologists and consensus readings. Patients were compound heterozygotes (HbS/β-thal). The extent of SCIs was classified from 0-2 with 0 designating no lesions. Clinical severity was graded as 0-2 by the hematologist, according to the frequency and severity of vaso-occlusive crises. There was no statistically significant correlation between the severity of clinical disease and the extent of SCIs on MR imaging. The extent of SCI lesions did not differ statistically between younger and older patients. Patients receiving hydroxyurea had no statistically significant difference in the extent of SCI lesions. The extent of SCIs in heterozygous (HbS/β-thal) SCD patients is not age related and may be quite severe even in younger (<38.4 years) patients. However the extent of SCIs is not correlated with the severity of clinical disease.
Collapse
|
33
|
Lobo CLDC, Cançado RD, Leite ACCB, Dos Anjos ACM, Pinto ACS, Matta APDC, Silva CM, Silva GS, Friedrisch JR, Braga JAP, Lange MC, Figueiredo MS, Rugani MÁ, Veloso O, Moura PG, Cortez PI, Adams R, Gualandro SFM, de Castilho SL, Thomé U, Zetola VF. Brazilian Guidelines for transcranial doppler in children and adolescents with sickle cell disease. Rev Bras Hematol Hemoter 2013; 33:43-8. [PMID: 23284243 PMCID: PMC3521435 DOI: 10.5581/1516-8484.20110014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 11/23/2010] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Sickle cell disease is the most common monogenic hereditary disease in Brazil. Although strokes are one of the main causes of morbidity and mortality in these patients, the use of transcranial Doppler to identify children at risk is not universally used. OBJECTIVE To develop Brazilian guidelines for the use of transcranial Doppler in sickle cell disease children and adolescents, so that related health policies can be expanded, and thus contribute to reduce morbidity and mortality. METHODS The guidelines were formulated in a consensus meeting of experts in transcranial Doppler and sickle cell disease. The issues discussed were previously formulated and scientific articles in databases (MEDLINE, SciELO and Cochrane) were carefully analyzed. The consensus for each question was obtained by a vote of experts on the specific theme. RESULTS Recommendations were made, including indications for the use of transcranial Doppler according to the sickle cell disease genotype and patients age; the necessary conditions to perform the exam and its periodicity depending on exam results; the criteria for the indication of blood transfusions and iron chelation therapy; the indication of hydroxyurea; and the therapeutic approach in cases of conditional transcranial Doppler. CONCLUSION The Brazilian guidelines on the use of transcranial doppler in sickle cell disease patients may reduce the risk of strokes, and thus reduce the morbidity and mortality and improve the quality of life of sickle cell disease patients.
Collapse
|
34
|
Abstract
Changes on Transcranial Doppler (TCD) ultrasonography have been proposed as significant predictors of cerebrovascular complications in sickle cell disease (SCD). However, consensus with regards to the TCD criteria to recognize abnormalities in cerebral vasculature is lacking. We studied the TCD characteristics of cerebral arteries among Omani patients with SCD and correlated them with cerebrovascular events. TCD was performed through the temporal and suboccipital windows using a 2 MHz probe (DWL). Thirty-three of 59 patients (56%) with SCD had neurological symptoms including stroke--12 (20%) and epilepsy--7. Fifteen patients (25%) had significant TCD abnormalities including: markedly increased velocities--11 (3 with stroke); turbulent flow--2; and reversal of flow--2. No patient had a time averaged maximum mean velocity of >200 cm/s in anterior circulation. On applying a modified definition of "abnormal TCD" to anterior and posterior circulation studies, increased TCD velocities in posterior circulation correlated with history of stroke (P < 0.05). TCD velocities in the 18 adult patients ( older than 15 y) were significantly lower than in children. Logistic regression analysis revealed abnormal TCD in the left posterior cerebral artery to be an independent predictor of stroke in this cohort (P = 0.035).
Collapse
|
35
|
Arkuszewski M, Krejza J, Chen R, Kwiatkowski JL, Ichord R, Zimmerman R, Ohene-Frempong K, Melhem ER. Sickle cell disease in children: accuracy of imaging transcranial Doppler ultrasonography in detection of intracranial arterial stenosis. Neuroradiol J 2012; 25:402-10. [PMID: 24029032 DOI: 10.1177/197140091202500402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 06/09/2012] [Indexed: 11/17/2022] Open
Abstract
This study aimed to determine the accuracy of imaging transcranial Doppler sonography in detection of intracranial arterial stenosis in children with sickle cell disease using three-dimensional MR angiography as a reference standard. Sixty-one children (mean age 102±39 months, 30 males), who had no history of overt stroke, and were classified as at lowest risk of stroke by mean flow velocity criterion <170 cm/s, underwent conventional and imaging transcranial Doppler ultrasonographic examinations. We employed the area under the receiver operating characteristic curve (AUC) to determine the accuracy of flow velocity measurements obtained with imaging ultrasonography with and without correction for the angle of insonation as well as with conventional ultrasonography. We also established the most efficacious velocity thresholds for detection of the stenosis. We found ten intracranial stenoses in six patients on MR angiography, but we calculated AUC only for detection of stenosis (n=6) of the left intracranial internal carotid artery. The accuracy of flow velocity with angle correction was lower than the accuracy of velocity without angle correction (AUC=0.73, 95% CI, 0.53-0.93 versus AUC=0.87, 95% CI, 0.74-1.00; p=0.017). The accuracy of flow velocity obtained with conventional ultrasonography (AUC=0.82, 95% CI, 0.67-0.97) was not different from the accuracy of flow velocities obtained with imaging ultrasonography. We found that the threshold of 165 cm/s of mean velocity without angle correction is associated with highest efficiency for imaging (92%) and conventional ultrasonography (90%). Velocity measurements without angle-correction provide good accuracy in detection of stenosis of the terminal internal carotid artery, whereas angle-corrected velocities have lower accuracy.
Collapse
Affiliation(s)
- M Arkuszewski
- Department of Radiology, Division of Neuroradiology, University of Pennsylvania; Philadelphia, PA, USA - Department of Neurology, Medical University of Silesia; Katowice, Poland -
| | | | | | | | | | | | | | | |
Collapse
|
36
|
DeBaun MR, Armstrong FD, McKinstry RC, Ware RE, Vichinsky E, Kirkham FJ. Silent cerebral infarcts: a review on a prevalent and progressive cause of neurologic injury in sickle cell anemia. Blood 2012; 119:4587-96. [PMID: 22354000 PMCID: PMC3367871 DOI: 10.1182/blood-2011-02-272682] [Citation(s) in RCA: 218] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 01/05/2012] [Indexed: 11/20/2022] Open
Abstract
Silent cerebral infarct (SCI) is the most common form of neurologic disease in children with sickle cell anemia (SCA). SCI is defined as abnormal magnetic resonance imaging (MRI) of the brain in the setting of a normal neurologic examination without a history or physical findings associated with an overt stroke. SCI occurs in 27% of this population before their sixth, and 37% by their 14th birthdays. In adults with SCA, the clinical history of SCI is poorly defined, although recent evidence suggests that they too may have ongoing risk of progressive injury. Risk factors for SCI include male sex, lower baseline hemoglobin concentration, higher baseline systolic blood pressure, and previous seizures. Specific morbidity associated with SCI includes a decrement in general intellectual abilities, poor academic achievement, progression to overt stroke, and progressive SCI. In addition, children with previous stroke continue to have both overt strokes and new SCI despite receiving regular blood transfusion therapy for secondary stroke prevention. Studies that only include overt stroke as a measure of CNS injury significantly underestimate the total cerebral injury burden in this population. In this review, we describe the epidemiology, natural history, morbidity, medical management, and potential therapeutic options for SCI in SCA.
Collapse
Affiliation(s)
- Michael R DeBaun
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
| | | | | | | | | | | |
Collapse
|
37
|
|
38
|
Strouse JJ, Lanzkron S, Urrutia V. The epidemiology, evaluation and treatment of stroke in adults with sickle cell disease. Expert Rev Hematol 2011; 4:597-606. [PMID: 22077524 PMCID: PMC3267235 DOI: 10.1586/ehm.11.61] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Stroke is a frequent and severe complication in adults with sickle cell disease. Ischemic stroke often causes physical and cognitive disability, while hemorrhagic stroke has a high mortality rate. As more children survive, the number of strokes in adults is increasing, yet stroke remains poorly understood. We review the epidemiology of ischemic and hemorrhagic stroke in adults with sickle cell disease and outline a practical approach to the evaluation of stroke including both sickle cell disease specific and general risk factors. We discuss the acute treatment and secondary prevention of stroke in this population based on the evidence in children with sickle cell disease and the general population, in addition to the limited studies in adults with sickle cell disease.
Collapse
Affiliation(s)
- John J Strouse
- Division of Pediatric Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | | |
Collapse
|
39
|
Dion J, Bachmeyer C, Favrole P, Marro B, Lionnet F. [Moya-moya in an adult with sickle cell anemia]. Presse Med 2010; 40:450-1. [PMID: 21051184 DOI: 10.1016/j.lpm.2010.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 09/14/2010] [Accepted: 09/15/2010] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jérémie Dion
- AP-HP, hôpital Tenon, service de médecine interne, 75020 Paris, France
| | | | | | | | | |
Collapse
|
40
|
Vichinsky EP, Neumayr LD, Gold JI, Weiner MW, Rule RR, Truran D, Kasten J, Eggleston B, Kesler K, McMahon L, Orringer EP, Harrington T, Kalinyak K, De Castro LM, Kutlar A, Rutherford CJ, Johnson C, Bessman JD, Jordan LB, Armstrong FD. Neuropsychological dysfunction and neuroimaging abnormalities in neurologically intact adults with sickle cell anemia. JAMA 2010; 303:1823-31. [PMID: 20460621 PMCID: PMC2892214 DOI: 10.1001/jama.2010.562] [Citation(s) in RCA: 208] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Sickle cell anemia (SCA) is a chronic illness causing progressive deterioration in quality of life. Brain dysfunction may be the most important and least studied problem affecting individuals with this disease. OBJECTIVE To measure neurocognitive dysfunction in neurologically asymptomatic adults with SCA vs healthy control individuals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study comparing neuropsychological function and neuroimaging findings in neurologically asymptomatic adults with SCA and controls from 12 SCA centers, conducted between December 2004 and May 2008. Participants were patients with SCA (hemoglobin [Hb] SS and hemoglobin level < or = 10 mg/dL) aged 19 to 55 years and of African descent (n = 149) or community controls (Hb AA and normal hemoglobin level) (n = 47). Participants were stratified on age, sex, and education. MAIN OUTCOME MEASURES The primary outcome measure was nonverbal function assessed by the Wechsler Adult Intelligence Scale, third edition (WAIS-III) Performance IQ Index. Secondary exploratory outcomes included performance on neurocognitive tests of executive function, memory, attention, and language and magnetic resonance imaging measurement of total intracranial and hippocampal volume, cortical gray and white matter, and lacunae. RESULTS The mean WAIS-III Performance IQ score of patients with SCA was significantly lower than that of controls (adjusted mean, 86.69 for patients with SCA vs 95.19 for controls [mean difference, -5.50; 95% confidence interval {CI}, -9.55 to -1.44]; P = .008), with 33% performing more than 1 SD (<85) below the population mean. Among secondary measures, differences were observed in adjusted mean values for global cognitive function (full-scale IQ) (90.47 for patients with SCA vs 95.66 for controls [mean difference, -5.19; 95% CI, -9.24 to -1.13]; P = .01), working memory (90.75 vs 95.25 [mean difference, -4.50; 95% CI, -8.55 to -0.45]; P = .03), processing speed (86.50 vs 97.95 [mean difference, -11.46; 95% CI, -15.51 to -7.40]; P < .001), and measures of executive function. Anemia was associated with poorer neurocognitive function in older patients. No differences in total gray matter or hippocampal volume were observed. Lacunae were more frequent in patients with SCA but not independently related to neurocognitive function. CONCLUSION Compared with healthy controls, adults with SCA had poorer cognitive performance, which was associated with anemia and age.
Collapse
Affiliation(s)
- Elliott P Vichinsky
- Department of Hematology/Oncology, Children's Hospital & Research Center Oakland, 747 52nd St, Oakland, CA 94609, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|