Further Outpatient Care
Neurorehabilitation generally helps to recover function if any residual neurologic deficits are present.
Further Inpatient Care
Physical and occupational therapy and speech therapy may be important aspects of patient care should neurologic deficits exist.
Inpatient & Outpatient Medications
See the list below:
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As mentioned above, life-long antiplatelet agents are generally suggested if a stroke occurred because of their benefit in reducing stroke and their relatively low morbidity.
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Given the potential pro-coagulant effects of estrogen, especially in smokers, oral contraceptives and hormonal replacement therapy is often avoided. No data exists to support or refute this strategy.
Deterrence/Prevention
See the list below:
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Lifestyle changes that minimize the risk of vascular disease should be stressed.
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These changes include quitting smoking, weight control, doing exercise, and eating a healthy diet.
Complications
See the list below:
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The complications of FMD can be diverse, notably because it is a systemic vascular disease. Fortunately, most patients have relatively isolated disease, and invasive measures during follow-up are not required.
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Blood pressure should be monitored carefully throughout the patient's lifetime because of the possibility of renovascular hypertension.
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Any symptoms compatible with ischemia and angiographic findings should prompt consideration of FMD as the underlying etiology. Symptoms include neurologic deficits, angina pectoris, limb claudication, and abdominal pain.
Prognosis
See the list below:
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Statistics on the natural course of cerebrovascular FMD are not available, especially because most cases are symptomatic and relatively benign.
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Case series tend to present a relatively favorable picture of long-term stroke-free survival, both in medically and in surgically managed patients. For example, in a 1981 report, Collins et al monitored 18 patients after surgical dilatation for a mean of just over 4 years, and none had strokes. [34] They monitored 5 patients with global symptoms (eg, hypoperfusion and not embolic events) and conservative therapy for a mean of 42 months, and none had strokes.
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Saccular aneurysm rupture has such a high mortality that autopsy series may be biased in their detection of FMD. The presence of saccular aneurysms likely poses the greatest morbidity and mortality threat, especially if blood pressure is not controlled.
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In a prospective series of patients with carotid artery dissection observed for an average of 4 years, of those with recurrence (5 of 103), 80% had FMD. [23]
Patient Education
See the list below:
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Patients with FMD who have experienced strokes should receive proper education in this regard. Further education regarding FMD should help patients recognize further symptoms that may indicate disease progression or complications.
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Education regarding other risk factors for stroke should be provided where applicable. Topics should include abstinence from smoking, the benefits of a healthy diet, and good glycemic control.
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Patients should be informed about the risk of dissection and cautioned to avoid neck trauma and rigorous neck manipulations.
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For patient education resources, see the Brain and Nervous System, as well as Aneurysm, Brain and Stroke.
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Digital subtraction angiogram of the right internal carotid artery demonstrates an irregular extracranial portion that is consistent with FMD.
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Conventional angiogram of the left carotid artery demonstrates a 1.5-cm, long, smooth, severe stenosis of the extracranial internal carotid artery. Note that the artery is not completely occluded and a thin continuous string of contrast is present along the length of the stenosis. This smooth tubular stenosis is suggestive of the intimal fibroplasia form of FMD but can be observed with any of the subtypes.
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Cerebral angiogram of the left carotid artery territory demonstrates a long, irregular stenosis with a string-of-beads appearance along the entire extracranial length of the internal carotid artery (ICA). This is consistent with the most common medial dysplasia form of fibromuscular dysplasia. Also note similar involvement of the first 3 cm of the external carotid artery (ECA). Such extensive ICA involvement, as well as ECA involvement, is atypical. Note sparing of the carotid bulb.
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Lateral view of a right carotid angiogram demonstrates multiple stenoses of FMD of the internal carotid artery. The string of beads appearance is suggestive of the medial dysplasia form of FMD.
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Anteroposterior view of a right carotid angiogram demonstrates FMD of the extracranial portion of the right internal carotid artery.
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Angiogram of the descending aorta demonstrates the stenoses of FMD in the renal arteries bilaterally.
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Angiogram of the right vertebral artery demonstrating irregular stenoses of fibromuscular dysplasia at the level of C2-3.
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Illustration of the operative approach of graduated dilatation of the internal carotid artery (ICA). The common carotid and external carotid arteries are cross-clamped, and the superior thyroid artery is clipped while the ICA is isolated, opened, and dilated with progressively larger dilators. This technique has been shown to be successful in the management of medically refractive FMD stenoses.
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Illustration depicts the intraluminal appearance of graduated dilatation of the stenoses of FMD. The dilator is passed into the vessel and opens the bandlike narrowings.
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Illustration depicts the locations of FMD lesions, which differentiate regions with typical and atypical angiographic appearances of this disease.
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Digital subtraction angiography of the left internal carotid artery distribution demonstrates a large 1.5-cm-diameter aneurysm of the right anterior communicating artery. Aneurysms may be associated with systemic vasculopathies such as FMD.
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Small infarct in woman with fibromuscular dysplasia from dissected vertebral artery. An incidental aneurysm, or ovoid diverticula, is noted in the supraclinoid left internal carotid artery.
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Small infarct in woman with fibromuscular dysplasia from dissected vertebral artery. An incidental aneurysm, or ovoid diverticula, is noted in the supraclinoid left internal carotid artery. Dissected vertebral artery.
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Small infarct in woman with fibromuscular dysplasia from dissected vertebral artery. An incidental aneurysm, or ovoid diverticula, is noted in the supraclinoid left internal carotid artery. Internal carotid angiogram.
