Association Between Periodic Limb Movements in Sleep and Cerebrovascular Changes in Children With Sickle Cell Disease

Abstract

Study objectives: Periodic limb movements (PLMs) have been associated with increased risk of stroke, but there is currently scarce research exploring this relationship in the setting of sickle cell disease (SCD). The aim of this study was to explore whether increased PLMs in children with SCD are associated with increased risk of cerebrovascular disease and to determine if there are any clinical or laboratory differences between children with SCD with elevated periodic limb movement index (PLMI) versus those with normal PLMI.

Methods: This study is a comprehensive review of medical records of 129 children with SCD (aged ≤ 18 years) who had undergone polysomnography for evaluation of sleep-disordered breathing.

Results: Elevated PLMI (PLMI > 5 events/h) was present in 42% (54/129) of children with SCD. Children with elevated PLMI were found to have higher percentage of hemoglobin S, lower total iron, higher arousal index and tendency toward elevated transcranial Doppler velocity (P = .063, odds ratio = 3.9, 95% CI 0.93-16.22). While association between elevated PLMI and isolated cerebrovascular stenosis (P = .050, odds ratio 5.6, 95% CI 1.0-31.10) trended toward significance, there was significantly greater proportion of children with elevated PLMI who had cerebrovascular stenosis with Moyamoya disease (P = .046) as demonstrated by magnetic resonance imaging (MRI).

Conclusions: The prevalence of elevated PLMI in children with SCD was higher than in previously published data. Elevated PLMI was significantly associated with greater rates of cerebrovascular disease as detected by MRI.

Keywords: cerebrovascular disease; children; magnetic resonance imaging; periodic limb movements in sleep; polysomnography; sickle cell disease; transcranial doppler.

Figure 1. Flowchart of study design.

Of the 145 children with SCD who underwent PSG, 129 participants met inclusion criteria and were subdivided into 2 groups: children with PLMI ≤ 5 events/h and those with PLMI > 5 events/h. MRA = magnetic resonance imaging of arteries, MRI = magnetic resonance imaging, PLMI = periodic limb movement index, SCD = sickle cell disease, TCD = transcranial Doppler.

Figure 2. Brain imaging.

Axial T2 brain magnetic resonance imaging (A) and intracranial magnetic resonance imaging of arteries (B,C) show decreased flow in A1 segment of anterior cerebral artery (arrowhead) and a collateral network of medial lenticulostriate arteries (known as basal Moyamoya seen with arrows).