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Utilization of TCD screening for primary stroke prevention in children with sickle cell disease

From the Departments of Neurology and Pediatrics (J.A.-W., H.J.F.) and Epidemiology and Biostatistics (B.G., S.C.S.), University of California San Francisco; Division of Research (S.S.), Kaiser Permanente Medical Care Program, Oakland, CA; Division of Pediatric Hematology (D.K.), Kaiser Permanente Medical Care Program, San Francisco, CA; and Department of Neurology (R.J.A.), Medical University of South Carolina, Charleston.

Address correspondence and reprint requests to Dr. Heather J. Fullerton, University of California, San Francisco, Department of Neurology, Box 0114, 505 Parnassus Avenue, San Francisco, CA 94143-0114 fullertonh{at}neuropeds.ucsf.edu

Background: In 1998, the Stroke Prevention Trial in Sickle Cell Anemia showed a >90% reduction in stroke rates after blood transfusion therapy in children with sickle cell disease (SCD) identified as high risk with transcranial Doppler ultrasonography (TCD) screening.

Methods: We studied the utilization of TCD screening in a retrospective cohort of all children with SCD within a large managed care plan from January 1993 to December 2005. Rates of first TCD screening were estimated using life table methods; predictors of TCD were evaluated using Cox proportional hazards regression. Stroke incidence rates were estimated in person-time before (pre-TCD) and after (post-TCD) first TCD.

Results: The average annual rate of TCD screening in 157 children with SCD was 1.8 per 100 person-years pre-1998, 5.0 from January 1, 1998, to December 31, 1999, and 11.4 after 1999. The only independent predictor of TCD screening was proximity to the vascular laboratory. The annualized stroke rate pre-TCD was 0.44 per 100 person-years, compared to 0.19 post-TCD.

Conclusions: Since the Stroke Prevention Trial in Sickle Cell Anemia, the rate of transcranial Doppler ultrasonography (TCD) screening in sickle cell disease (SCD) has increased sixfold within a large health care plan. Children living farther from a vascular laboratory are less likely to be screened. Increased availability of TCD screening could improve the utilization of this effective primary stroke prevention strategy.

Abbreviations: CI = confidence interval; HR = hazard ratio; KPMCP = Kaiser Permanente Medical Care Program; MRA = magnetic resonance angiography; SCD = sickle cell disease; STOP = Stroke Prevention Trial in Sickle Cell Anemia; TCD = transcranial Doppler ultrasonography.

Supported by a research grant from the Thrasher Research Fund to H.J.F.

Disclosure: J.A.-W., B.G., S.S., D.K., S.C.S., and H.J.F. have no competing financial interests. R.J.A. has received modest honoraria/speakers’ bureau income from Bristol-Myers Squibb (BMS), Novartis, Sanofi-Synthelabo, and Wyeth; significant honoraria/speakers’ bureau income from Boehringer Ingelheim; modest consultant/advisory board income from BMS, Boehringer Ingelheim, Sanofi-Synthelabo, and Wyeth; and modest other income from Acuson, ATL, BMS, Boehringer Ingelheim, and Nicolet.

Received September 22, 2008. Accepted in final form January 15, 2009.

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				Transcranial Doppler Ultrasound for Primary Stroke Prevention in Sickle Cell Disease Journal Watch Neurology, August 4, 2009; 2009(804): 1 - 1. [Full Text]