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Application of transcranial Doppler ultrasound in pediatric patients: how to verify the indications?

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Application of transcranial Doppler ultrasound in pediatric patients:

how to verify the indications?

Wykorzystanie przezczaszkowych badań naczyn mózgowych metodą Dopplera u pacjentów

pediatrycznych: jak zweryfikować wskazania?

Ilona Kopyta

1

, Ewa Emich-Widera

1

, Maciej Świat

2

, Anna Gołba

3

1 Department of Neuropediatrics, Medical University of Silesia, Katowice, 2 Department of Neurology, Medical University of Silesia, Katowice 3 Neurological Department, Upper-Silesian Medical Center, Katowice

STRESZCZENIE

Celem pracy jest identyfikacja najistotniejszych wskazań do

przeprowadzenia badań naczyń mózgowych metodą Dopplera u dzieci. Materiał, metoda. Badaniem objęto 140 pacjentów w wieku od 8 miesiąca do 18 roku życia (93 dziewczynki i 47 chłopców). Wskazaniami do hospitalizacji w Klinice Neurolo-gii Wieku Rozwojowego były: bóle głowy, omdlenia, zawroty głowy, udar niedokrwienny potwierdzony badaniami neuroobra-zowymi. U wszystkich pacjentów przeprowadzono badanie fizy-kalne i neurologiczne, a także przezczaszkowe badanie naczyń mózgowych metodą Dopplera oraz magnetyczny rezonans jądrowy mózgu (ang. Magnetic resonance imaging); w przy-padku podejrzenia malformacji naczyniowej wysuniętego na podstawie badania TCD (ang. Transcranial Doppler) dodatkowo wykonywano angiografie rezonansu magnetycznego. Wyniki. Na podstawie przeprowadzonej diagnostyki rozpoznano: napię-ciowe bóle głowy u 52 dzieci, migrenę u 14, wtórne bóle głowy u 36, udar mózgu u 38. Nieprawidłowe wyniki TCD stwierdzono u 50 dzieci: u 10 z nich wynik sugerował hypoplazję naczy-niową; w tejże grupie potwierdzono hypoplazję tętnicy kręgo-wej u 4 dzieci. U 38 dzieci z udarem niedokrwiennym mózgu obserwowano ewolucję od cech stenozy naczynia objętego patologią do częściowej lub pełnej rekanalizacji. Wnioski. Badanie przepływów naczyń mózgowych metoda Dopplera jest szczególnie przydatne do śledzenia ewolucji zmian przepływu krwi u dzieci z udarem niedokrwiennym mózgu. U większości pacjentów z bólami głowy nie stwierdzono nieprawidłowości w parametrach przepływu krwi.

Słowa kluczowe: przezczaszkowe przepływy krwi metodą

Dopplera, dzieci, bole glowy, udar niedokrwienny, wskazania

ABSTRACT

Aim. The aim of the study is to identify the most important

indications for the transcranial Doppler in pediatric patients.

Material, method. The study population consisted of 140

chil-dren aged 8 months to 18 years (93 girls, 47 boys). The indi-cations for the patients’ admittance were: headache, vertigo, syncope, stroke confirmed by the brain computed tomography. All the patients were examined physically and neurologically; the transcranial Doppler and the head MRI were performed. In the cases were cerebrovascular malformation was suspected, the magnetic resonance angiography was conducted. Results. According to the clinical examination and the neuroimaging we diagnosed: tension headache in 52 children: migraine in 14 children; the symptomatic headache in 36 children: and the ischemic stroke in 38 children. The pathological result of the TCD was found in 50 children: in t10 of them the result suggested the hypoplasia of intracranial vessels; in the same group in 4 children the vertebral artery hypoplasia was con-firmed. In 38 children with ischemic stroke the evolution of the blood flow, from stenotic signs to partial/ full recanalization, was observed. Conclusions. The TCD is extremely important in the blood flow evolution investigation of the pediatric ischemic stroke patients. In majority of children with headache no TCD pathology was found.

Key words: transcranial Doppler, children, headache, stroke,

indications

The �ra�scra��al Doppler �TCD� �s �he d�ag�os��c procedure commo�ly used �� ambula�ory a�d hosp��al prac��ce. As �he me�hod does �o� expose �he pa��e��s �o �he X-ray rad�a��o� a�d does �o� requ�re �he a�es�hes�a, �� becomes more a�d more commo�, espec�ally �� ch�ldre�. Accord��g �o �he

Amer�ca� Academy of Neurology �he value of TCD �s well es�abl�shed �� s�ckle cell d�sease for assess��g s�roke r�sk, �� mo���or��g �he vasospasm af�er subarach�o�d hemorrhage a�d �� d�ag�os��g r�gh�-�o-lef� card�ac shu��s �Ev�de�ce Type A Class I-II�. The useful�ess of TCD �� ���racra��al

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s�e�o-occlus�ve d�sease �s less ev�de�� bu� s��ll �� �s co�s�dered as useful for the detection of intracranial stenosis/occlusion or de�ec��o� of �mpa�red cerebral hemody�am�cs �� pa��e��s w��h ex�racra��al s�e�os�s/occlus�o� a�d w��h cerebral small-ar�ery d�sease �Ev�de�ce Type �, Class II-III� [1].

Al�hough �he headaches are �o� �he ��d�ca��o� for TCD bu� �� every-day prac��ce �he me�hod �s be��g commo�ly used �o prov�de ��forma��o� abou� cerebral hemody�am�cs [2]. The cl���cal appl�ca��o� of TCD rema��s �o be de�erm�-�ed. The a�m of �he s�udy was �o �de���fy �he mos� �mpor-�a�� ��d�ca��o�s for �he �ra�scra��al Doppler �� ped�a�r�c patients.

MATERIAL AND METHODS

The s�udy popula��o� co�s�s�ed of 140 ch�ldre� aged 8 mo��hs �o 18 years �93 g�rls, 47 boys�. All �he pa��e��s were hosp��al��ed �� �he Neuroped�a�r�c Depar�me�� w��h�� �he per�od of �he las� �hree years, �he s�roke pa��e��s w��h�� �he las� 8 years. The ��d�ca��o�s for �he pa��e��’s adm���a�ce were: headache, ver��go, sy�cope, �schem�c s�roke. All stroke cases were confirmed with the brain computed tomo-graphy a�d/ or mag�e��c reso�a�ce �mag��g �MRI�. The �euro�mag��g �MRI a�d/ or MRA� was performed w��h 1, 5 Tesla mach��e a�d ���erpre�ed by a� exper�e�ced ped�a-�r�c rad�olog�s�. �ome of �he ch�ldre� requ�red �he ge�eral a�es�hes�a for �he exam��a��o�. All pa��e��s were exam��ed phys�cally a�d �eurolog�cally; �he �ra�scra��al Doppler a�d �he head MRI were performed �� all of �hem. I� �he cases were cerebrovascular malforma��o� �� TCD was suspec�ed �he mag�e��c reso�a�ce a�g�ography was co�duc�ed. The TCD �� �he pa��e��s w��h headache/ ver��go a�d sy�cope was performed �� �he ���er�c�al per�od; �� �he s�roke pa��e��s- �� the acute state of disease.

The �eurolog�cal s�a�e of �he major��y of exam��ed pa��e��s was �ormal, eve� of �he �h�r�y e�gh� pa��e��s w��h s�roke. I� �he las� group hem�pares�s a�d /or fac�al �erve paresis contralateral to the brain lesion was found.

The TCD exam��a��o� was performed w��h s��gle-cha�-�el por�able u��� ��o�eer TC 2000 �EME Ede� Med�����s-che Elek�ro��k, Uberl��ge�, Germa�y� w��h a ha�d-held �ra�sducer opera�ed �� a ra�ge-ga�ed, pulse-waved mode a� 2MH�. I��racra��al ar�er�es were ��so�a�ed �hrough �he �emporal w��dow by use of s�a�dard��ed pro�ocol[3]. M�ddle cerebral ar�ery �MCA�, a��er�or cerebral ar�ery �ACA�, �erm��al segme�� of ���er�al caro��d ar�ery �ICA� a�d pos�er�or cerebral ar�ery ��CA� were exam��ed. Ar�e-r�es were d�s���gu�shed by �he pos���o� of �he probe, �he depth of insonation and the direction of the blood flow. The sample volume s��e was 8 �o 10 mm �� �he ax�al a�d 5 mm �� �he la�eral d�rec��o�. The exam��ed parame�ers of �he blood flow were: �he mea� blood flow veloc��y �MV�, �he blood flow charac�er �lam��ar or �urbule���. The �urbule�� blood flow was recog���ed whe� spec�ral broade���g was recorded. The fea�ures of �he vessel s�e�os�s were: ��crease of �he mea� blood flow veloc��y �> 0,8 m/seco�d� or �he blood flow veloc��y d�ffere�ce be�wee� �he lef� a�d r�gh� s�de �> 0,3 m/seco�d� w��h coex�s���g �urbule�� charac�er of �he blood flow. The vessel hypoplas�a was d�ag�osed whe� �here was a s�g��f�ca�� decrease �� blood flow

velo-c��y w��h coex�s���g �urbule�� charac�er of �he blood flow. To assess cerebrovascular respo�se �o CO2 cha�ges vessel reac��v��y �es� w��h hyperve���la��o� was performed. Mea� flow veloc��y be�wee� 2 measureme��s: u�der max�mal hyperve���la��o� a�d hypove���la��o� were compared.

A rela��ve d�ffere�ce h�gher �ha� 15% argues aga��s� a releva�� �mpa�rme�� of cerebrovascular respo�se [4].

All �he TCD exam��a��o�s were performed �� co�sc�ous ch�ldre�, w��hou� a�y s�g�s of ��fec��o�. The provoca��o� by hyperve���la��o� was used �� coopera��ve ch�ldre�, �o� �� �he s�roke ch�ldre�. The s�a��s��cal a�alys�s was perfor-med w��h �he exac� F�sher’s �es�.

RESULTS

The s�roke pa��e��s were a�aly�ed w��h�� �he group 1. Accord��g �o �he cl���cal da�a s�roke pa��e��s were class�f�ed as �ACI �par��al a��er�or c�rcula��o� ��farc�, 11 ch�ldre��, LACI �lacu�ar a��er�or c�rcula��o� ��farc�, 7 ch�ldre�� a�d TACI ��o�al a��er�or c�rcula��o� ��farc�, 2 ch�ldre��. Accor-d��g �o �he cl���cal a�d add���o�al exam��a��o�s a�d �he I��er-�a��o�al Headache Class�f�ca��o� �� mos� of �he exam��ed pa��e��s �he �d�opa�h�c headache was d�ag�osed �66 pa��e��s; 47, 1%�; �he group was d�v�ded ���o subgroup w��h �e�s�o� headache �52 ch�ldre�, 37, 1%, group 2� a�d m�gra��e �14 pa��e��s, 10%, group 3�. �eco�dary headache was fou�d �� abou� 1/3 of �he whole group �36 pa��e��s, 28, 5% - group 4� �Table I�. The pos���ve fam�ly h�s�ory �headaches �� pare��s a�d/or ch�ld’s s�bl��gs� was fou�d �� s�x ch�ldre� - four w��h �e�s�o� headache a�d �wo w��h m�gra��e.

The pa�holog�cal resul� of �he TCD was fou�d �� 39 ch�ldre� �28% of all groups�.

Table I. Examined groups of patients according to diagnoses

Group diagnosis Number of patients(total n=140)

1 Ischemic stroke 38

2 Tension headache 52

3 Migraine

- common 5

- classical 4

- benign paroxysmal vertigo 5 4 Symptomatic (total number 36 patients)

- Sinusitis/ tonsillitis 28

- Arachnoid cyst 4

- Instability/ hyperlordosis of cervical vertebral column 2

- Glaucoma 2

Ge�eral��ed ��crease of �he blood flow veloc��y was fou�d �� 19 pa��e��s w��h s�roke a�d 10 pa��e��s w��h m�gra��e whereas �� �o�e �� o�her groups �Table II�. Ves-sels reac��v��y �es� was pos���ve �� four pa��e��s w��h clas-s�cal m�gra��e �group 3�. Decrease of �he segme��al blood flow veloc��y w��h �urbule�� blood flow was fou�d �� 10

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pa��e��s w��h �e�s�o� headache �group 2�. I� 4 of �hem ver�ebral ar�ery hypoplas�a was co�f�rmed �� �he mag�e-��c reso�a�ce a�g�ography. Turbule�� blood flow was also fou�d �� 15 s�roke ch�ldre� �group 1�. The local��a��o� of �he blood vessel pa�hology was co��rala�eral �o �he �euro-log�cal de�er�ora��o� fou�d �� �he pa��e��. �egme��al blood flow decrease was fou�d �� 10 cases o�ly �� �he group w��h �e�s�o� headache �group 2� �Table II�.

DISCUSSION

I� �he adul� pa��e��s w��h �e�s�o� headache a�d �he heal�hy o�es �o d�ffere�ces �� TCD blood flow parame�ers were fou�d [5]. Moreover, �� �he adul�s w��h commo� m�gra��e a�d w��h class�cal m�gra��e �� �he ���er�c�al per�od �he TCD parame�ers of cerebral vessels blood flow were s�m�lar �o �he resul�s �� heal�hy o�es [6,7].

I� adolesce��s w��h m�gra��e a�d �e�s�o� headaches �he fea�ures of cerebral vessels hyperac��v��y was fou�d o�ly dur��g �he headache ��c�de��. [8] Arjo�a e� al. have exam�-�ed �he group of pa��e��s aged 16-50 years w��h m�gra��e a�d �e�s�o� headache; �he cerebral vessels hyperac��v��y was fou�d o�ly �� �he pa��e��s w��h m�gra��e[9].

I� comparably large group of 133 ch�ldre� w��h hea-dache exam��ed by May�al e� al. �52% m�gra��e, 21% �e�-s�o� headache, 19% u�class�f�ed headache� o�ly 78 �59%� u�derwe�� �he �euro�mag��g �head CT a�d/ or MRI�. O�ly �� 4 ou� of �he 78 �he pa�holog�cal cha�ges o� �euro�ma-g��g were fou�d. The au�hors d�d �o� perform �he TCD [10,11]. All �he resul�s me���o�ed above ��d�ca�e �ha� �he �euro�mag��g s�ud�es have a very l�m��ed value �� �he eva-lua���g headaches �� ped�a�r�c pa��e��s.

The huge group of 858 ch�ldre� aged from s�x mo��hs �o 18 years was exam��ed by H�rsch e� al.w��h�� �he ��me of seve� years. The pa�holog�cal f��d��gs �� TCD were fou�d �� 0, 4% �headache, or�hos�a��c deregula��o� group�, 5,4% �acu�e �eurolog�cal symp�oms� a�d 22% of d�ffere�� rea-so�s. The pos���ve pred�c��ve value of f��d��g a�y

ab�orma-l��y was very low, so �he ��d�ca��o�s for TCD performa�ce �� ch�ldre� are very spec�f�c, for example �he k�ow� o�her vascular exam��a��o�s of pa�holog�cal processes of �he bra�� vessels �s�e�oses� a�d chro��c d�seases, l�ke s�ckle cell d�sease a�d a�g����s [2]. Our resul�s, however exam�-�a��o�s �o� performed �� such large group of pa��e��s, are s�m�lar �o �he au�hors’. Moreover, �he F�ermo��e e� al fou�d �he ��crease of �he blood flow �� �he m�gra��e pa��e��s as useful �o d�ffere���a�e be�wee� �he d�ag�os�s of m�gra��e a�d �e�s�o� headache, wh�ch �s also co�s�s�e�� w��h our resul�s [12]. Gergo�� A, Ko�era G e� al. resul�s ��d�ca�e, that there are no specific features in the blood flow parame-�ers be�wee� �he ch�ldre� w��h m�gra��e a�d �e�s�o� heada-che, so �he las� a�d �he larges� group of ped�a�r�c pa��e��s w��h headache, �he �e�s�o� headache group, s��ll prese��s �he d�ag�os��c problem[13,14]. As �he pa�hophys�ology of m�gra��e a�d �e�s�o� headache �s d�ffere��, �he TCD resul�s �� �he �wo groups are d�ffere�� as well. O�e of �he fea�ures spec�f�c �o m�gra��e �s �he blood vessel hyperac��v��y, co�-firmed also in our patients.

Nes�erovsk�j e� al. exam��ed 140 ch�ldre� aged 6 – 16 years, w��h d�ffere�� �ypes of headaches; �hey fou�d �he ��crease of blood veloc��y �� all �ypes of headaches whe� compared �o �he co��rol group [15].

I� �he very small group �four ch�ldre�� w��h �he susp�-c�o� of vessel hypoplas�a o� TCD exam��a��o�, �he mag-�e��c reso�a�ce a�g�ography resul�s co�f�rmed �he �����al d�ag�os�s. I� much larger group of ch�ldre� a�aly�ed by �oj��ova V e� al. group of 205 ch�ldre� aged 3-15 years w��h d�ffere�� symp�oms - s�roke, �ra�s�e�� �schem�c a��acks, focal se��ures� �he ���racra��al vessel hypoplas�a was fou�d �� 63 of �hem, ma��ly w��h �he use of MRI [16].

I� our group of symp�oma��c headache �group 4� �o spec�f�c fea�ures of cerebral blood flow were fou�d. I� seems �o be �he cause of headache �� �he group, as �he ch�l-dre� w��h ���racra��al pressure for hydrocephalus, �umors, head trauma or neuroinfections present the cerebral blood flow d�s�urba�ces [17-20].

Table II. The statistical analysis of the TCD parameters within the examined patients

Parameter Gr. 1stroke (N=38) Gr. 2 Tension headache (N=52) Gr. 3 Migraine (N=13) Gr. 4 Symptomatic headache (N=36) Statistical significance between the examined groups of patients

(Fisher’s exact test)

Generalized increase of blood velocity 19 (50,0%) 0(0,0%) 10(76,9%) 0(0,0%) Gr.1-Gr.2: p<0,00001 Gr.1-Gr.4: p<0,00001 Gr.3-Gr.2: p<0,00001 Gr.3-Gr.4: p<0,00001 Turbulent blood flow 15(39,5%) 10(19,2%) 0(0,0%) 0(0,0%) Gr.1-Gr.2: p=0,05 Gr.1-Gr.3: p=0,006 Gr.1-Gr.4: p<0,00001 Gr.2-Gr.4: p=0,005 Segmental blood velocity decrease 0(0,0%) 10(19,2%) 0(0,0%) 0(0,0%) Gr.2-Gr.1: p=0,004Gr.2-Gr.4: p=0,005

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All �he pa��e��s of �he group 1, �he s�roke pa��e��s, adm���ed �o hosp��al w��h �he symp�oms of hem�pares�s a�d/ or fac�al �erve pares�s of �he same s�de of �he body; some of them with speech and consciousness disturbances. O� �he base of �he cl���cal course a�d �he resul�s of �eu-ro�mag��g we qual�f�ed all of �hem �o �he o�e of �he �hree s�roke �ypes: �ACI, LACI or TACI. A� �he hosp��al adm��-�a�ce TCD resul�s prese��ed �he s�e�o��c blood flow �� �he ���racra��al par� of ICA a�d/or MCA a�d/ or ACA w��h �he ��creased mea� blood flow veloc��y �� �he vessel com-pared �o �he oppos��e, heal�hy vessel, a�d �he fea�ures of �he �urbule�� blood flow spec�rum. A� �he d�scharge form hosp��al �� 9 pa��e��s of �he group 1 �he �ormal��a��o� of �he me���o�ed parame�ers was observed, bu� s��ll �� �he las� 10 of �hem �he s�e�o��c blood flow was prese��. Th�s �s �he group of pa��e��s requ�r��g spec�al care a�d �he sys�ema��c TCD exam��a��o�s.

I� �s obv�ous �ha� �he ped�a�r�c pa��e��s w��h s�ckle cell d�seases are a� r�sk of �schem�c s�roke; �ha� r�sk ��creases w��h �he ��crease of blood flow veloc��y a�d �ha� �s �he group of pa��e��s wh�ch requ�res �he regular blood �ra�s-fus�o�s [21-25]. Al�hough �� �he descr�bed group of s�roke

ch�ldre� �here are �o pa��e��s w��h s�ckle cell d�sease, bu� s��ll �he �ecess��y of �he TCD follow-up �� �ha� group seams to be clear.

We d�d �o� f��d �� �he �ol�sh l��era�ure a�y ar��cle com-par��g �he qual��y a�d �he prevale�ce of �he cerebral blood flow �� ped�a�r�c pa��e��s w��h headaches a�d/ or ver��go a�d/ or au�o�om�c deregula��o� �o �he heal�hy ch�ldre� cor-respo�d��g for �he age a�d sex. �uch projec� �s go��g �o be �he au�hors’ �ex� a�m.

CONCLUSIONS

The TCD �s valuable �o�-��vas�ve a�d ray-free �ech��que. I� �s ex�remely �mpor�a�� �� �he blood flow evolu��o� ��ves��-ga��o� �� �he �schem�c s�roke pa��e��s, as �he cha�ge �� �he blood flow parame�ers may pred�c� �he recurre�ce of s�roke. I� major��y of ch�ldre� w��h headache �o TCD pa�hology was fou�d. I� rela��vely small group of ped�a�r�c pa��e��s �he TCD resul� sugges�s �he ���racra��al vessel malforma-��o� a�d makes �he cl���c�a�s perform mag�e��c reso�a�ce a�g�ography. More �horough �r�al w��h �he group of heal�hy ch�ldre� �s �ecessary �o es�abl�sh �he po�e���al freque�cy of CN� vessel pa�hology �� ped�a�r�c popula��o�.

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[11] Kan L., Nagelberg J., Mayttal J.: Headaches in a pediatric emergencyHeadaches in a pediatric emergency department : etiology, imaging and treatment. Headache 2000; 40 (1): 25-9.

[12] Fiermonte G., Annulli A., Pierelli F.: Transcranial Doppler evaluation of cerebral hemodynamicsin migraines during prophylactic treatment with flunarizine. Cephalalgia 1999, 492.

[13] Gergont A.:The significance of cerebrovascular ultrasound in children with headaches. Problemy diagnostyczne i terapeutyczne w bólachProblemy diagnostyczne i terapeutyczne w bólach głowy u dzieci i młodzieży. Wydawnictwo BiFolium,2009, 41-54.Wydawnictwo BiFolium,2009, 41-54. [14] Kozera G., Pilarska E., Lemka M. et al: Transcranial Doppler ultrasonography

in assessment of vasomotor reactivity of Middle cerebral artery In children with migraine and tension headache. Problemy diagnostyczneProblemy diagnostyczne i terapeutyczne w bólach głowy u dzieci i młodzieży. WydawnictwoWydawnictwo BiFolium, 2009,55-66.

[15] Nesterovskij I.E., Petrukhin A.S., Goriunova A.V.:Cerebral hemodynamics in the context of differential diagnosis and management of headache in children. Zh Nevrol Psikiatr 2007; 107 (1): 11-15.

[16] Bojinova V., Dimova P., Belopitova L.: Clinical manifestations of cerebrovascular hypoplasias in childhood. J Child Neurol 2000; 15(3): 166-71.

[17] de Oliveira R.S., Machado H.R.: Transcranial Doppler sonography for evaluation the children with hydrocephalus. Neurosurg Focus 2003; 15(4):ECP3.

[18] Kuang-Lin L., Huei-Shyong W., Tai-Ngar L.: Diagnosis and follow-up of craniopharyngiomas with transcranial Doppler sonography. J Ultrasound Med 2002;21,801.

[19] Moller K., Skinhoj P., Knudsen G.M. et al.: Effect of short-termEffect of short-term hyperventilation on cerebral blood flow autoregulation in patients with acute bacterial meningitis. Stroke 2000; 31:1116-34.

[20] Lee J.H., Kelly D.F., Oertel M.:Carbon dioxide reactivity, pressure autoregulation, and metabolic suppression reactivity after head injury: a transcranial Doppler study. J Neurosurg 2001; 95: 222.

[21] Adams R.J.: Big strokes in small persons. Arch Neurol 2007; 64 (11): 1567-74.

[22] Wang W.C., Gallagher D.M., Pegelow C.H. et al.: Multicenter comparison of magnetic resonance imaging and transcranial Doppler ultrasonography in the evaluation of the central nervous stystem in children with sickle cell disease. J Pediatr Hamatol Oncol 2000; 22(4): 335-9.

[23] Adams R.J.: TCD in sickle cell disease: an important and useful test. Pediatr Radiol 2005; 35(3): 229-34.

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[24] Adams R.J., Brambilla D.J., Granger S. et al.: Stroke and conversion to high risk in children screened with transcranial Doppler ultrasound during the STOP study. Blood 2004; 103(10): 3689-94.

[25] Hankins J.S., Fortner G.L., Mc Craville M.B. et al.: The natural history of conditional transcranial Doppler flow velocities in children with sickle cell anemia. Br J Haematol 2008; 142 (1): 4-9.

The publ�ca��o� �s suppor�ed w��h gra�� of �ol�sh M���s�ry of �c�e�ce, �umber of arra�geme�� N406 047 31/0986

Correspondence:

Ilona Kopyta, Department of Neuropediatrics Medical University of Silesia, 40-752 Katowice, 16 Medykow Str., Poland, e-mail: ilonakopyta@autograf.pl

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