Pathophysiology

  • sickle cell disease (SCD) is an autosomal recessive (AR) inherited disorder of the group of hemoglobinopathies, which is manifested by a change in the shape of erythrocytes into elongated sickles
    • HbS is caused by the substitution of glutamic acid for valine at the 6th amino acid of the β-globin chain (β6 Glu→Val), caused by a point mutation in the β-globin gene
    • if a person carries one healthy gene and one HbS gene (heterozygote), he is a carrier who usually has no health problems
      • HbS makes up < 50% of the hemoglobin in erythrocyte hemoglobin S (about 40%). The rest is normal hemoglobin, mainly HbA, which protects the individual against sickle cell disease
    • a person with two HbS genes (HbSS) is called a homozygote, cannot produce normal hemoglobin, and develops clinical manifestations of sickle cell anemia
      • SCD can also occur in people who have one gene for sickle cell anemia and one gene for one of the other types of hemoglobinopathies
  • the homozygote´s hemoglobin has different properties ⇒ unoxygenated hemoglobin aggregates, which leads to erythrocytes deformation
  • the disease manifestations usually start in childhood (from about one year of age), especially in people from tropical and subtropical areas, where malaria is also common
Sickle cell disease

blood stagnation ⇒ hypoxia

aggregation of blood cells in blood vessels ⇒ ischemia and infarcts

increased destruction of blood cells in the spleen ⇒ anemia

  • human hemoglobin is a tetramer comprising 2 pairs of polypeptide (globin) chains – 2 dimers
  • the dimers are formed in definitive erythropoiesis by the combination of one α and one non-α chain (β, γ, or δ)
  • each chain encircles a heme located in a heme pocket
  • the heme is a protoporphyrin formed by four pyrrole nuclei – tetrapyrrole. In the center of the tetrapyrrole nucleus is a hexavalent and divalent iron ion, which can reversibly bind an oxygen molecule. This allows hemoglobin to perform its primary function – the transfer of oxygen from the lungs to the tissues
Hemoglobin
  • hemoglobinopathies are congenital diseases caused by a defect in the formation of one or more globin chains
  • caused by mutations or deletions in the genes encoding globin chains
  • diseases with a defect in the structure of the globin chain
    • sickle cell disease (SCD)
    • methemoglobinemia
  • diseases with defects in globin chain synthesis
    • thalassemia

Pathogenesis of stroke in SCD

  • large-artery vasculopathy affecting the intracranial segments of internal carotid arteries (ICA) and proximal middle cerebral arteries (MCA) due to intimal hyperplasia caused by repeated traumatic injury, inflammation, and hypercoagulable state
  • progressive involvement of the arteries of the circle of Willis leads to an image of moyamoya syndrome, which predisposes to both ischemic stroke and bleeding
  • silent strokes typically occur in the territory of penetrating arteries

Clinical presentation

  • babies usually show no particular symptoms after the birth
  • the first symptoms rarely appear until around the first year of life, when hemoglobin S forms in their bodies
  • the first symptoms include pain and swelling in the arms and legs
  • the manifestations of sickle cell anemia are variable
    • from mild discomfort to severe complications
    • homozygotes tend to have worse symptoms, while heterozygotes are perfectly fine until their oxygen levels drop, which can be caused, for example, by dehydration, intense physical exertion, or staying at high altitudes
  • symptoms (both acute and chronic) resulting from ischemia – sickle-shaped erythrocytes block the arterioles
    • ischemic stroke (typically in children, the radiological appearance of moyamoya syndrome with possible secondary hemorrhages)
    • pulmonary micro-infarcts
    • muscle pain
    • bone necrosis
    • papillary renal necrosis with hematuria, microalbuminuria, and proteinuria worsening with age and often ending in uremia
    • skin ulceration, etc.
  • hemolytic anemia with increased reticulocytes levels
  • vaso-occlusive sickle cell crises
    • sudden attacks of severe, prolonged bone and muscle pain provoked by, e.g., high altitude stay, impaired lung function, increased metabolic activity, and dehydration
    • individual crises usually resolve within a few days or even weeks; frequency varies (once a year to daily)
  • dysfunctional spleen (autosplenectomy) – consequence of infarcts and infections   → more here
  • acute worsening of anemia (pallor, fatigue, dizziness)
  • infectious diseases (especially pneumonia, etc.)
  • painful enlargement of the spleen
  • liver enlargement and icterus
  • gall bladder stones
  • tibial ulcers
  • retinopathy
  • priapism
  • development of bone deformities
  • pulmonary hypertension
  • heart failure

Diagnostic evaluation

Content available only for logged-in subscribers (registration will be available soon)

Management

Specific therapy

Content available only for logged-in subscribers (registration will be available soon)

Secondary stroke prevention

  • no data from randomized trials on antithrombotic therapy in secondary prevention
    • caution is required because of the increased risk of bleeding
  • antithrombotic drugs are recommended in the presence of concomitant disease (e.g., atherosclerosis, dissection, etc.)
icon-angle icon-bars icon-times