ALBERT

Description: Background: The Stroke Prevention Trial in Sickle Cell Anemia (STOP) and Optimizing Primary Stroke Prevention in Sickle Cell Anemia (STOP 2) established routine transcranial Doppler ultrasound (TCD) screening with indefinite chronic red cell transfusions (CRCT) for children with abnormal TCD as standard of care. To identify children at high-risk of stroke, annual TCD screening is recommended from ages 2 to 16 years, with more frequent monitoring if the result is not normal. A reduction in stroke incidence in children with SCD has been reported in several clinical series and analyses utilizing large hospital databases when comparing rates before and after the publication of the STOP study in 1998. We sought to determine the rate of first ischemic stroke in a multicenter cohort of children who had previously participated in the STOP and/or STOP 2 trials and to determine whether these strokes were screening or treatment failures. Subjects and Methods: Between 1995 and 2005, STOP and STOP 2 (STOP/2) were conducted at 26 sites in the US and Canada. These studies included 3,835 children, ages 2 to 16 y with SCD type SS or S-beta-0-thalassemia. Participation in STOP/2 ranged from a single screening TCD to randomization. STOP 2 also had an observational arm for children on CRCT for abnormal TCD whose TCD had not reverted to normal. The Post-STOP study was designed to follow-up the outcomes of children who participated in one or both trials. 19 of the 26 original study sites participated in Post-STOP, contributing a total of 3,539 (92%) of the STOP/2 subjects. After exit from STOP/2, these children received TCD screening and treatment according to local practices. Data abstractors visited each clinical site and obtained retrospective data from STOP/2 study exit to 2012-2014 (depending on site) including follow-up TCD and brain imaging results, clinical information, and laboratory results. Two vascular neurologists, blinded to STOP/2 status and prior TCD and neuroimaging results, reviewed source records to confirm all ischemic strokes, defined as a symptomatic cerebral infarction; discordant opinions were resolved through discussion. For the first Post-STOP ischemic stroke, prior TCD result and treatment history subsequently were analyzed. Results: Of the 3,539 subjects, follow-up data were available for 2,850 (81%). Twelve children who had a stroke during STOP or STOP2 were excluded from these analyses resulting in data on 2,838 subjects. The mean age at the start of Post-STOP was 10.5 y and mean duration of follow-up after exiting STOP/2 was 9.1 y. A total of 69 first ischemic strokes occurred in the Post-STOP observation period (incidence 0.27 per 100 pt years). The mean age at time of stroke was 14.4±6.2 (median 13.8, range 3.5-28.9) y. Twenty-five of the 69 patients (36%) had documented abnormal TCD (STOP/2 or Post-STOP) prior to the stroke; 15 (60%) were receiving CRCT and 9 (36%) were not (treatment data not available for 1 subject). Among the 44 subjects without documented abnormal TCD, 29 (66%) had not had TCD re-screen in the Post-STOP period prior to the event; 7 of these 29 (24%) were 16 y or older at the start of Post-STOP, which is beyond the recommended screening age. Four of the 44 (9%) patients had inadequate TCD in Post-STOP (1 to 10.7 y prior to event). Six (14%) had normal TCD more than a year before the event (1.2 - 4 y); all but one of these children were younger than 16 y at the time of that TCD. Only 5 (11%) had a documented normal TCD less than 1 year prior to the event. Conclusions: In the Post-STOP era, the rate of first ischemic stroke was substantially lower than that reported in the Cooperative Study of Sickle Cell Disease, prior to implementation of TCD screening. Many (39%) of the Post-STOP ischemic strokes were associated with a failure to re-screen according to current guidelines, while only 11% occurred in children who had had recent low-risk TCD. Among those known to be at high risk prior to stroke, treatment refusal or inadequate treatment may have contributed. While TCD screening and treatment are effective at reducing ischemic stroke in clinical practice, significant gaps in screening and treatment, even at sites experienced in the STOP protocol, remain to be addressed. Closing these gaps should provide yet further reduction of ischemic stroke in SCD. Disclosures No relevant conflicts of interest to declare.

Description: Background: Primary hemorrhagic stroke is a rare complication of sickle cell disease (SCD) that usually occurs in adults. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) and Optimizing Primary Stroke Prevention in Sickle Cell Anemia (STOP 2) established routine transcranial Doppler ultrasound (TCD) screening with indefinite chronic red cell transfusions (CRCT) for patients with abnormal TCD as standard of care. Despite a notable improvement in the incidence of infarctive stroke in children with SCD after the introduction of TCD screening protocols, it is unclear how this protocol will affect the rate of hemorrhagic stroke. Presumably, early TCD screening and subsequent initiation of CRCT in high risk patients will prevent the progression of cerebral vasculopathy, which should decrease the risk of hemorrhagic stroke; however this has not been proven. Using the large multicenter cohort of children who participated in STOP and/or STOP 2 trials, we sought to assess whether the rate of hemorrhagic stroke was impacted by the use of TCD screening and/or CRCT. Subjects and Methods: Between 1995 and 2005, STOP and STOP 2 (STOP/2) were conducted at 26 sites in the US and Canada. These studies included 3835 children, ages 2 to 16 y with SCD type SS or S-beta-0-thalassemia. Participation in STOP/2 required at least a single screening TCD for randomization. Patients on STOP 2 also had an observational arm for children started on CRCT who had an abnormal TCD. The Post-STOP study was designed to follow-up the outcomes of children who participated in one or both of trials. For all participants the date of their last encounter in STOP/2 was defined as the start of their Post-STOP period. 19 of the 26 original study sites participated in Post-STOP, contributing a total of 3539 (92%) of the STOP/2 subjects. After exit from STOP/2, these children received TCD screening and treatment according to local practices. Data abstractors visited each clinical site and obtained retrospective data from STOP/2 study exit to 2012-2014 including follow-up TCD and brain imaging results, clinical information, and laboratory results. Two separate neurologists, blinded to STOP/2 status and prior TCD and neuroimaging results adjudicated all suspected strokes. Results: Follow-up data were available for 2850 of the 3539 subjects (81%). Twelve children who had a stroke during the STOP study period were further excluded from this analysis resulting 2838 subjects. The mean age at the start of Post-STOP was 10.5 years and mean duration of follow-up after exiting STOP/2 until time of last medical encounter was 9.1 years. A total of 31 patients had a primary hemorrhagic stroke during the Post-STOP observation period (incidence 0.12 per 100 pt years). The mean age at time of stroke was 16.2+5.6 (median 15.3 range (4.8-30.2) years of age. Of those 31 patients, only 52% had a TCD during Post-STOP prior to the event. Seven of those children who underwent screening had documentation of an abnormal TCD prior to the event (5 during STOP era and/or 3 Post-STOP). However, only 1/7 patients (14%) were documented on CRCT at the time of the stroke (4 patients were receiving HU and 2 patients had unknown treatment). Discussion: Although less common than infarctive stroke, patients with SCD are at increased risk for hemorrhagic stroke. There is an increased risk of mortality for patients who suffer from hemorrhagic stroke (up to 26% in some reports in the 2 weeks after the event). It is unclear if TCD screening and subsequent initiation of CRCT will impact the rate of hemorrhagic stroke in the long term. In our results, a similar incidence of primary hemorrhagic stroke was noted although the patients were overall younger than previously reported (16.5+/- 5.5 years versus 20-29 years in Cooperative Study of Sickle Cell Disease). Many patients who had a hemorrhagic stroke (48%) had not undergone TCD screening during the Post-Stop period. Additionally, although a safe stopping point for CRCT has not been established in patients who have had an abnormal TCD, only 1 patient was documented on CRCT at the time of the event (14%). Thus, it is unclear at this time whether TCD screening and subsequent, lifelong continuation of CRCT could have prevented these other events. Clearly, these results demonstrate that improved implementation of STOP protocol is needed as well as further evaluation of the impact of this protocol on the incidence of hemorrhagic stroke. Disclosures No relevant conflicts of interest to declare.

Description: Abstract 244 Stroke is a major cause of morbidity and mortality among children with sickle cell anemia (SCA). Children with SCA at risk for stroke can be identified by transcranial Doppler (TCD) ultrasound screening for abnormally high cerebral artery blood flow velocity and strokes can be prevented by chronic packed red blood cell (RBC) transfusion. However, the mechanisms that lead to cerebral vasculopathy and stroke in SCA and that explain the beneficial effects of chronic RBC transfusions in stroke prevention are poorly understood. We have previously shown that pre-treatment serum levels of brain derived neurotropic factor (BDNF) and platelet derived growth factor (PDGF) subtypes, biomarkers of cerebral ischemia and arterial remodeling, were associated with both high TCD velocity and development of stroke. We hypothesized that frequency of RBC transfusion would be associated with altered serum levels of neurodegenerative, inflammatory and angiogenic markers in SCA children with high TCD velocity and tested this hypothesis by assaying levels of these markers in post-STOP serum samples. Frozen serum samples drawn one year after subject's exit from the STOP clinical trial phase were utilized. Given the positive trial results, all but 9 subjects had been on chronic transfusion regimen for at least one year at the time of sample collection. Eighty samples were assayed using multiplex antibody immobilized beads (Millipore Corp, Billerica, MA). The mean fluorescent intensity was measured using the Milliplex xMAP system powered by Luminex (Bio-Rad, Hercules, CA). Ten biologically related neurodegenerative, inflammatory and angiogenic biomarkers were tested. The total number (frequency) of RBC transfusions recorded over the study period (4 years) for each participant was categorized into High (≥ 40), Moderate (20 – 39) or Low (〈 20) frequency of transfusion. Median distribution with 10 – 90th percentile of the levels of biomarkers and TCD velocity were expressed using box-plots and the differences in median distribution between groups based on frequency of transfusion was estimated using Kruskal-Wallis test. A principal component analysis (PCA) loading plot was used to demonstrate the biological relationships between the biomarkers, taking into consideration linear correlations and spatial relationships between them. There were no significant differences in the hematological and anthropometric measures between groups. Overall, our result showed that low transfusion frequency was associated with high serum levels of biomarkers and vice versa, despite no significant difference in hemoglobin level between groups. The high frequency transfusion group had lower serum levels of BDNF (p = 0.02), sVCAM-1 (p 〈 0.001), PDGF-AA (p 〈 0.001), CCL5 (p 〈 0.01), tPAI-1 (p 〈 0.01) and NCAM (p 〈 0.01) levels compared with the low frequency transfusion group (figure 1 a – e). Although not shown in the figures, the same pattern was observed with TCD velocity which was lower (160, 115.7 – 204.9 cm/s) in the low compared with the high (195, 154 – 272 cm/s) frequency transfusion group. In addition, the medium frequency transfusion group had significantly lower serum sVCAM-1 (p 〈 0.01) compared with the low frequency transfusion group and higher PDGF-AA (p 〈 0.01) compared with the high frequency transfusion group. A PCA loading plot (figure 2) shows clustering of the biomarkers that are most closely biologically related, these are also the biomarkers that were significantly affected by the frequency of transfusion. Red blood cell transfusions in the STOP study were associated with reduced serum levels of biomarkers of angiogenesis (PDGF-AA and sVCAM-1), cerebral ischemia/neuronal survival adaptation (BDNF and NCAM) and inflammation (RANTES/CCL5), and this effect was most pronounced in the group with the highest frequency of transfusions (equivalent to most chronic transfusion regimen). This suggests that the protective effects of chronic RBC transfusions on stroke development in children with SCA may be attributable to improved cerebral perfusion, reduced inflammation and down-regulation of hypoxia-induced angiogenic responses that promote arterial remodeling. One or more in this group of biologically-related and relevant markers may be useful for monitoring children with SCA receiving stroke prevention therapies and for designing treatment targets. Disclosures: No relevant conflicts of interest to declare.