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Porras-Colon J, Scott CK, Pizano A, Driessen A, Timaran CH, Modrall JG, Tsai S, Kirkwood ML, Ramanan B. Outcomes of carotid stenting in patients with fibromuscular dysplasia. J Vasc Surg 2023; 77:829-835. [PMID: 36400362 DOI: 10.1016/j.jvs.2022.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Fibromuscular dysplasia (FMD) is a noninflammatory arterial disease that affects the extracranial carotid arteries in young patients. The ideal treatment of FMD has continued to be debated, and the role of carotid artery stenting (CAS) is controversial. The aim of the present study was to assess the feasibility and outcomes of CAS for patients with FMD. METHODS A retrospective analysis of patients who had undergone CAS was performed using the Vascular Quality Initiative database from December 2012 to May 2021. Patients who had undergone CAS for atherosclerosis and FMD were included and matched 1:1 by age, gender, and clinical presentation. The demographics, clinical parameters, and procedural data were analyzed. The end points included postoperative stroke and transient ischemic attack (TIA), and adverse events (perioperative and 1-year mortality, neurologic changes, access site complications, hematoma or bleeding, infection, congestive heart failure, arrhythmia, myocardial infarction, reperfusion symptoms), and hospital length of stay. RESULTS After matching, 55 patients had undergone CAS for FMD (mean age, 58.7 ± 14 years; 62% women; 69% White; mean body mass index, 28 ± 6 kg/m2). Most of these procedures (69%) were elective. The FMD group had had a lower rate of hypertension (55% vs 82%; P = .002), smoking (35% vs 80%; P < .001), diabetes (13% vs 45%; P < .001), and coronary artery disease (9% vs 45%; P < .001) compared with the non-FMD group. In the FMD group, prior TIA and stroke was identified in 39 (71%) and 31 (57%) patients, respectively. The mean interval from a prior stroke or TIA to the index surgery was 160 days. Additionally, 23 patients (42%) had had anatomically high lesions above the level of the second cervical vertebra. In the FMD group, the transfemoral approach was used for 43 patients (78%), with distal embolic protection used for 40 patients (93%). Flow reversal was used for nine patients (23%). Most cases were performed with local anesthesia (58%). Three patients (6%) in the FMD group had had access site complications that were managed nonoperatively. No differences were found between the FMD and non-FMD groups in perioperative stroke, TIA, or 30-day mortality. The length of stay was similar between the two groups, and the 1-year survival was 100% for both groups. All the patients in the FMD group were discharged without neurologic complications, and 50 patients (91%) were receiving dual antiplatelet therapy. The median follow-up was 328 days (interquartile range, 1-732 days) with no mortality or reinterventions during follow-up. CONCLUSIONS CAS for FMD is a feasible and safe procedure with favorable technical success, a low incidence of neurologic complications, and good clinical outcomes at 1 year of follow-up.
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Affiliation(s)
- Jesus Porras-Colon
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carla K Scott
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Alejandro Pizano
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anna Driessen
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - John G Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Shirling Tsai
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Melissa L Kirkwood
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Bala Ramanan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Division of Vascular and Endovascular Surgery, Department of Surgery, Dallas Veterans Affairs Medical Center, Dallas, TX.
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Kythreotou A, Weerakkody RA, Koysombat K, Marzouqa N, Baker DM. A Retrospective Cohort Study of Cerebrovascular Fibromuscular Dysplasia. Ann Vasc Surg 2023; 92:104-110. [PMID: 36642164 DOI: 10.1016/j.avsg.2022.12.092] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/21/2022] [Accepted: 12/26/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Fibromuscular dysplasia (FMD) is a rare vasculopathy for which limited data are available particularly from Europe. Our aim was to study the clinical characteristics of a regional cohort of carotid fibromuscular dysplasia patients to assess their clinical outcomes and the rate of vascular complications. METHODS A retrospective cohort study of all cases of carotid/cerebrovascular FMD presenting to our regional vascular service (catchment population approximately 2 million), between 1998 and 2020. Imaging reports and patient case notes were screened using the keywords "FMD", "Fibromuscular Dysplasia", and "carotid". From case-note and imaging review, all relevant clinical data were extracted and the anatomical extent of vascular disease recorded. RESULTS Eighty six patients with a diagnosis of cerebrovascular fibromuscular dysplasia were identified on imaging (31 computed tomography angiography, 46 magnetic resonance angiography, and 9 digital subtraction angiography) by a neurovascular radiologist. The mean age was 64 years, 78 (90%) patients were female, and 45/59 (75%) were Caucasian. Presenting clinical syndromes were Stroke/transient ischemic attack in 54 (63%) patients, symptomatic intracranial aneurysm in 6 (10%), and other neurological symptoms (headache/migraine, tinnitus) in 14 (16%), with 11 (13%) presenting incidentally. Six patients (7%) had a positive family history of FMD (2 patients) or other cerebrovascular event (4 patients: carotid dissection, intracerebral bleed, or stroke). Eight patients (9%) had a known or suspected hereditary connective tissue disorder (2 Ehlers-Danlos syndrome). Involved vessels were as follows: Carotid (mainly extracranial) in 79 (92%), vertebral 19 (22%), and a combination of these in 15 (17%) patients. Fifty eight (67%) patients had bilateral disease. Cerebrovascular complications were observed in 35 (41%) patients as follows: carotid dissection 11 (23%), carotid stenosis or occlusion 8 (9%), carotid aneurysm 8 (9%), cerebral aneurysm 9 (11%), vertebral aneurysm/dissection 2 (2%), and carotid-cavernous fistula 2 (2%). Of the 22 patients who had extracranial imaging, 14 (60%) had FMD affecting other beds-renal artery in 8 (36%) patients, other visceral arteries in 4 (18%), and aorta in 2 (9%). In addition, 4 (18%) patients had aneurysm or dissection affecting renal, splenic, and lower limb arteries. Overall, 67 (80%) patients had FMD affecting more than 1 vessel and 50 (58%) had multisite FMD (>/ = 2 vascular beds involved). Fifty nine (68%) patients were managed conservatively on close surveillance. Nineteen (21%) patients required carotid/cerebrovascular intervention and 9 (10%) required vascular intervention at other sites. Recurrent cerebrovascular events (stroke/transient ischemic attack, symptomatic Berry aneurysm) were seen in 20 (23%) patients. Overall mortality was 7% over a median follow-up period of 47 months. CONCLUSIONS Carotid FMD patients have a high rate of multisite involvement, extracerebral vascular complications, and evidence of hereditary vasculopathy, requiring careful screening and surveillance.
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Affiliation(s)
- Anthousa Kythreotou
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Ruwan A Weerakkody
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK; Vascular Surgery service, The National Hospital for Neurology and Neurosurgery, University College Hospitals NHS Foundation Trust, London, UK
| | - Kantida Koysombat
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Natalie Marzouqa
- Vascular Surgery service, The National Hospital for Neurology and Neurosurgery, University College Hospitals NHS Foundation Trust, London, UK
| | - Daryll M Baker
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK; Vascular Surgery service, The National Hospital for Neurology and Neurosurgery, University College Hospitals NHS Foundation Trust, London, UK; UCL Division of Medicine, Royal FreeCampus, University College London, London, UK.
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Cucchiara BL, Kasner SE. Treatment of “Other” Stroke Etiologies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kasner SE, Cucchiara BL. Treatment of “Other” Stroke Etiologies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Zerbino DD, Kuzyk YI. [Pathological deformation of the carotid arteries]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:118-123. [PMID: 25945380 DOI: 10.17116/jnevro201511511118-123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The literature on the etiology, pathogenesis, clinical manifestations and pathology, basic approaches to the treatment of congenital and acquired pathological deformation of the internal carotid artery has been analyzed. The review discusses the possible risk factors and diseases that lead to the development of pathological deformations as well as existing hypotheses of pathogenesis. Open and unresolved issues of the etiology and pathogenesis of this disease are identified. The disputable issues on the emergence and development of vascular deformations in children, young people and elderly are discussed. The authors posit a hypothesis that congenital and acquired pathological deformations are different diseases which differ by etiology, pathogenesis, clinical and pathomorphological picture, prognosis, approaches to diagnosis and treatment; the relationship between them has not been proved.
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Affiliation(s)
- D D Zerbino
- Institute of Clinical Pathology, Danylo Halytsky Lviv National Medical University, Lviv
| | - Yu I Kuzyk
- Institute of Clinical Pathology, Danylo Halytsky Lviv National Medical University, Lviv
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Intracranial fibromuscular dysplasia presenting as various ocular manifestations. J Neurol Sci 2014; 337:232-4. [DOI: 10.1016/j.jns.2013.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 12/01/2013] [Accepted: 12/04/2013] [Indexed: 11/22/2022]
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Dittrich R, Nassenstein I, Ringelstein EB, Kuhlenbaumer G, Nabavi DG. A distinctive case of fibromuscular dysplasia. Neurol Res 2013; 29:551-2. [PMID: 17535572 DOI: 10.1179/016164107x172130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Fibromuscular dysplasia (FMD) is a rare, non-inflammatory angiopathy, which can affect the brain supplying arteries. Usually, the diagnosis is based on conventional and/or MR angiography. We present a patient with multisegmental stenoses of the internal carotid artery (ICA) where the diagnosis of FMD is based on an eye-catching ultrasound finding.
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Affiliation(s)
- R Dittrich
- Department of Neurology, University Hospital of Muenster, Muenster, Germany.
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Abstract
PURPOSE OF REVIEW Pulsatile tinnitus is an uncommon otologic symptom, which often presents a diagnostic and management dilemma to the otolaryngologist. The majority of patients with pulsatile tinnitus have a treatable cause. Failure to establish correct diagnosis may have disastrous consequences, because a potentially life-threatening, underlying disorder may be present. The purpose of this review is to familiarize the otolaryngologist with the most common causes, evaluation, and management of pulsatile tinnitus. RECENT FINDINGS The pathophysiology, classification, various causes, evaluation, and management of the most common causes of pulsatile tinnitus are presented in this review. SUMMARY Pulsatile tinnitus deserves a thorough evaluation and, in the majority of cases, there is a treatable underlying cause. The possibility of a life-threatening cause needs to be ruled out in every patient with pulsatile tinnitus. The otolaryngologist should be familiar with the evaluation and management of this symptom.
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Treatment of “Other” Stroke Etiologies. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Foa-Torres G, Ganame J, Juaneda E, Peirone A, Barcudi MS, Achaval A. Systemic hypertension and transient ischemic attack in a 6-year-old girl with fibromuscular dysplasia treated with percutaneous angioplasty. Cardiovasc Intervent Radiol 2009; 33:173-6. [PMID: 19367433 DOI: 10.1007/s00270-009-9562-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 03/08/2009] [Accepted: 03/16/2009] [Indexed: 10/20/2022]
Abstract
We describe a 6-year-old girl with arterial hypertension secondary to fibromuscular dysplasia with stenoses of both renal arteries and transient ischemic attack due to extracranial right internal carotid artery subtotal occlusion as well as left internal carotid artery stenosis. She was treated with percutaneous angioplasty of both renal and both carotid arteries.
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Poppe AY, Minuk J, Glikstein R, Leventhal M. Fibromuscular dysplasia with carotid artery dissection presenting as an isolated hemianopsia. J Stroke Cerebrovasc Dis 2007; 16:130-4. [PMID: 17689408 DOI: 10.1016/j.jstrokecerebrovasdis.2006.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Accepted: 12/03/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Internal carotid artery (ICA) dissection is a well-known cause of anterior circulation stroke, but its association with posterior circulation stroke has been less commonly reported. The latter situation can arise when there is persistent fetal circulation of the posterior cerebral artery and has, to our knowledge, never been reported in the setting of fibromuscular dysplasia (FMD) involving the ICA. METHODS A 52-year-old man awoke with severe headache and noted visual loss. Examination confirmed a congruous left homonymous hemianopsia. A head computed tomography scan revealed an acute right posterior parietal infarct. Carotid ultrasonography demonstrated complete occlusion of the right ICA. Conventional angiography confirmed this and was diagnostic of FMD with dissection. A right-sided persistent fetal circulation was also noted. Magnetic resonance imaging revealed right parietal and right occipital infarctions. RESULTS The patient received ASA and clopidogrel and his visual deficit resolved within days. One year later, he remained asymptomatic and there was no suggestion of FMD in other vascular beds. CONCLUSIONS Although infrequently reported, carotid disease, including dissection, can be responsible for posterior circulation infarcts. Cervical artery dissection can be related to underlying arteriopathies such as FMD, which must be differentiated from vasculitis and vasospasm.
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Affiliation(s)
- Alexandre Y Poppe
- Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Stahlfeld KR, Means JR, Didomenico P. Carotid artery fibromuscular dysplasia. Am J Surg 2007; 193:71-2. [PMID: 17188091 DOI: 10.1016/j.amjsurg.2006.03.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Revised: 03/07/2006] [Accepted: 03/07/2006] [Indexed: 11/20/2022]
Abstract
Extracranial carotid artery fibromuscular dysplasia (FMD) is a rare finding that is frequently incidental and asymptomatic. It usually occurs in middle-age women and is secondary to medial fibrodysplasia or, less commonly, intimal fibrodysplasia. The carotid artery may be elongated or kinked and associated aneurysms have been reported. Symptoms including transient ischemic attack or stroke are uncommon and are due to low flow or embolization of platelet aggregates. Digital subtraction angiography demonstrates high-grade stenosis with the characteristic "string of beads" pattern. Antiplatelet medication with sequential imaging is the accepted therapy for asymptomatic lesions. Graduated endoluminal dilation under direct vision should be reserved for patients with documented lateralizing symptoms.
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Affiliation(s)
- Kurt R Stahlfeld
- Department of Surgery, Mercy Hospital of Pittsburgh, 400 Locust St., Pittsburgh, PA 15219, USA
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Virmani R, Burke AP, Taylor AJ. Congenital Malformations of the Vasculature. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50071-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
The most common clinical manifestations of fibromuscular dysplasia (FMD) are hypertension due to renal artery involvement and transient ischemic attack or stroke due to carotid or vertebral artery involvement. Patients with renal artery FMD and hypertension should undergo primary angioplasty with the goal of curing the hypertension. If the blood pressure fails to normalize following angioplasty, the physician should institute antihypertensive medications according to the recommendations of the Joint National Committee on the Prevention, Detection, and Treatment of High Blood Pressure VII. In patients with cerebrovascular FMD, antiplatelet agents represent the cornerstone of therapy. Percutaneous angioplasty has emerged as the preferred treatment for symptomatic cerebrovascular FMD.
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Affiliation(s)
- David P Slovut
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine,One Gustave L. Levy Place, Box 1033,New York,NY 10029-6574,USA.
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Arning C, Grzyska U. Color Doppler imaging of cervicocephalic fibromuscular dysplasia. Cardiovasc Ultrasound 2004; 2:7. [PMID: 15265239 PMCID: PMC493280 DOI: 10.1186/1476-7120-2-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2004] [Accepted: 07/20/2004] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fibromuscular dysplasia (FMD) is a possible cause of stroke, especially in middle-aged women. However, only few reports are available on ultrasonographic detection and monitoring. METHODS Among the 15,000 patients who underwent color Doppler imaging (CDI) of the cervicocephalic arteries during the study period, all cases fulfilling ultrasound criteria of FMD were included into the case series. Criteria of FMD were: 1. Segmental string-of-beads pattern, 2. Localization in the distal extracranial part of internal carotid artery (ICA) or vertebral artery (VA), and 3. (optional): Direct and/or indirect criteria of stenosis. RESULTS CDI detected FMD in 39 vessels (37 ICA and 2 VA segments) of 21 patients. 16 patients had bilateral manifestation on ICA, one of those also on VA, bilaterally. CDI disclosed 4 symptomatic high-grade ICA stenoses, 3 of them underwent endovascular treatment. 5 patients with moderate symptomatic ICA stenoses got medical treatment. In 6 patients FMD was the most likely cause of headache and in one patient FMD was diagnosed as a cause of vertigo. CONCLUSIONS CDI may be used for detection of cervicocephalic FMD. Due to the unfavourable localisation of FMD for CDI, the sensitivity of CDI is lower in comparison to angiography. However, high-grade FMD stenoses that require invasive treatment can be recognized on the basis of indirect hemodynamic criteria.
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Affiliation(s)
- Christian Arning
- Department of Neurology, Allgemeines Krankenhaus Hamburg-Wandsbek, Alphonsstr. 14, D-22043 Hamburg, Germany
| | - Ulrich Grzyska
- Department of Neuroradiology, Universitätskrankenhaus Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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Leary MC, Finley A, Caplan LR. Cerebrovascular complications of fibromuscular dysplasia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2004; 6:237-248. [PMID: 15096316 DOI: 10.1007/s11936-996-0019-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Patients with cerebral ischemia or hemorrhage due to fibromuscular dysplasia (FMD) should be admitted to a monitored hospital bed and receive supportive stroke care. Based on our personal clinical experience, we recommend antiplatelet agents for future stroke prevention in patients with symptomatic FMD. In patients with watershed stroke due to hemodynamically significant FMD, our opinion is that hypertensive, hypervolemic therapy should be initiated immediately. Additionally, we suggest that potential revascularization therapies, such as intraoperative or primary percutaneous angioplasty, should be discussed.
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Affiliation(s)
- Megan C. Leary
- Division of Stroke and Cerebrovascular Disease, Palmer 125, Department of Neurology
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Affiliation(s)
- David P Slovut
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York 10029-6574, USA
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Affiliation(s)
- Sherry D Scovell
- Department of Vascular Surgery, The Cleveland Clinic Foundation, OH 44195, USA
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