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DISPLACE study shows poor quality of transcranial doppler ultrasound for stroke risk screening in sickle cell anemia
Kimberly A Davidow1, Robin E Miller1, Shannon M Phillips2
1Department of Pediatrics, Lisa Dean Moseley Foundation Institute for Cancer and Blood Disorders, Nemours Children's Hospital, Delaware, Wilmington, DE.
Insights
Standardizing transcranial Doppler (TCD) reporting is crucial for accurately screening children with sickle cell anemia (SCA) for stroke risk. Inconsistent TCD measurements hinder effective stroke prevention, necessitating improved quality assurance and training.
Area of Science:
- Neurology
- Pediatrics
- Medical Imaging
Background:
- Children with sickle cell anemia (SCA) face a heightened risk of stroke compared to their peers.
- The Stroke Prevention Trial in Sickle Cell Anemia (STOP) established that transcranial Doppler (TCD) screening and red blood cell transfusions significantly reduce stroke risk by over 90%.
- Accurate measurement of time-averaged mean maximum velocity (TAMMV) is critical for TCD screening, but adherence to STOP criteria has been challenging.
Purpose of the Study:
- To evaluate the quality and accuracy of transcranial Doppler (TCD) and transcranial Doppler imaging (TCDi) reports in the context of sickle cell anemia (SCA) stroke risk assessment.
- To identify inconsistencies in TCD/TCDi reporting practices across different institutions.
Main Methods:
- A subanalysis of the DISPLACE study involving over 12,000 TCD/TCDi reports from 28 institutions.
- Detailed review of 391 TCD reports to assess reporting quality and adherence to established criteria.
- Analysis of variations in assessed vessels, velocity thresholds for abnormal results, and interpreter qualifications.
Main Results:
- Significant variability was observed in the cerebral vessels assessed and the velocities used to define abnormal TCD/TCDi results.
- In 52% of reviewed reports, it was unclear if the time-averaged mean maximum velocity (TAMMV) was the measured parameter.
- Only 42% of reports clearly indicated that TAMMV was used for the interpretation of the examination as normal or abnormal.
Conclusions:
- There are substantial inconsistencies in TCD/TCDi reporting for sickle cell anemia (SCA) stroke screening.
- Standardization of TCD/TCDi reporting, specialized training for personnel, and robust quality assurance measures are urgently recommended.
- Implementing these improvements is essential to ensure the appropriate and effective use of TCD/TCDi for potentially life-saving stroke prevention in SCA patients.
Abstract:
Children with sickle cell anemia (SCA) are at increased risk of stroke when compared with their age-based counterparts. The Stroke Prevention Trial in Sickle Cell Anemia (STOP) previously demonstrated that with the use of transcranial Doppler ultrasound (TCD; Sickle Stroke Screen) and chronic red cell transfusion, the risk of stroke is reduced by over 90%. The STOP criteria detailed the type and method of measurement required; the time-averaged mean maximum velocity (TAMMV). Unfortunately, it has been difficult to adhere to the appropriate TAMMV measurements. The objectives of this study were to assess the quality of TCD and transcranial Doppler imaging (TCDi) reports to determine the report quality and accuracy. This is a subanalysis of the DISPLACE (Dissemination and Implementation of Stroke Prevention Looking at the Care Environment) study. Over 12 000 TCD/TCDi reports were collected during this study from 28 institutions; 391 TCDs were reviewed for this subanalysis. There were significant variations in the vessels being assessed, the velocities used to define abnormal results, and who was interpreting the scans. In 52% of reports, it was impossible to identify whether the TAMMV was what was measured. Similarly, it was only clear in 42% of reports that the TAMMV was used to interpret the examination as normal/abnormal. Given this inconsistency, we strongly recommend standardization of TCD/TCDi reporting, specialized training for those performing and interpreting the scans in the use of TCD/TCDi in patients with SCA, internal quality assurance, and institutional quality improvement work to ensure appropriate use of this potentially lifesaving technology.
