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Published online before print June 24, 2009, doi:10.1212/WNL.0b013e3181ae2361)
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 Volume 73, Number 5, August 4, 2009
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Received June 26, 2008
Accepted May 7, 2009

Submandibular TCD approach detects post-bulb ICA stenosis in children with sickle cell anemia

Mark J. Gorman MD*, Karin Nyström APRN, Judith Carbonella APRN, and Howard Pearson MD

From the Stroke Program (M.J.G.), Department of Neurology, University of Vermont, Burlington; Stroke Program (K.N.), Yale-New Haven Hospital; and Department of Pediatrics (J.C., H.P.), Yale University School of Medicine, New Haven, CT.


* To whom correspondence should be addressed. E-mail: mgorman1{at}uvm.edu.

Background: Transcranial Doppler (TCD) ultrasound is a procedure commonly used to screen individuals with the major hemoglobin S diseases, Hb SS and Hb S-beta°, for significant stenoses in the circle of Willis. Flow velocities above 200 cm/s have been shown to identify patients at elevated risk for cerebral infarction. Among TCD's limitations is the inability to insonate the distal extracranial, petrous, and cavernous internal carotid artery (ICA) through the standard transtemporal approach.

Methods: We extended the submandibular approach to include infra-siphon portions of the ICA.

Results: Using the extended submandibular approach to evaluate these portions of the ICA, we identified stenotic lesions in 4 patients with Hb SS disease out of a population of 131 children with Hb SS. Three of the 4 patients had no history of overt stroke or stroke-like symptoms. Neuroimaging confirmed the stenotic lesions, and also revealed watershed infarction as well as discrete areas of silent infarction. All 4 children had neuropsychological impairment.

Conclusions: The submandibular approach, when added to a standard transcranial Doppler examination, may increase the sensitivity of this technique to identify important potential sources of cerebral infarction.


Related Article

Will submandibular TCD prevent stroke in children with sickle cell anemia?
Lori C. Jordan and John J. Strouse
Neurology 2009 73: 340-341. [Full Text] [PDF]



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L. C. Jordan and J. J. Strouse
Will submandibular TCD prevent stroke in children with sickle cell anemia?
Neurology, August 4, 2009; 73(5): 340 - 341.
[Full Text] [PDF]