Cath Lab Digest - September 2007 - (Page 39)

SEPTEMBER 2007 PERSONAL ESSAY 39 My Experience with Fibromuscular Dysplasia and Stroke Pam Mace, RN President, The Fibromuscular Dysplasia Society of America worsening. The ER was backed up with trauma cases, so I approached the triage nurse to ask how long the wait would be. I explained that I was a registered nurse and that my headache was getting worse. I asked her to just look at my pupils. She started explaining that they were backed up because of all of the traumas and as I again told her I was a nurse (which wasn’t getting me anywhere), my face started to go numb. The numbness started at my left temple and slowly moved all the way down my face. I was scared to death. The nurse then took me right back. My blood pressure was 210/130. I had never had high blood pressure. After being sent for a CT scan that came out negative, a young resident presented me with discharge papers and a diagnosis of unequal pupils. Mind you, my blood pressure was still elevated and my pupils were unequal and I just had a TIA (small stroke). A Brief Review of Fibromuscular Dysplasia Jeffrey W. Olin, DO Professor of Medicine, Mount Sinai School of Medicine New York, New York What is Fibromuscular Dysplasia? Fibromuscular dysplasia (FMD) is a disease that causes one or more arteries in the body to have abnormal cell development in the artery wall. The disease typically occurs in young women and most commonly presents with hypertension, transient ischemic attack, stroke, or an asymptomatic cervical bruit. In 60% to 75% of cases, the renal artery is affected. The carotid and vertebral arteries are affected in about 25% to 30% of cases. Although renal, carotid and vertebral arteries are most affected, FMD can be present in any arterial bed. FMD is a nonatherosclerotic and noninflammatory disease. There are several different types of FMD, but medial fibroplasia, producing the appearance of a “string of beads,” is the most common type encountered. Many physicians consider fibromuscular dysplasia to be rare, but it is not that uncommon; it is often simply overlooked or misdiagnosed.1 M y name is Pam Mace and at the age of 37, I had a transient ischemic attack (TIA). It started with a headache. I woke one morning with a dull headache. Over the course of the day, my head became tender to touch. I thought I might feel better after going for a run. As I went to leave, my granddaughter, Ashley, asked if she could ride her bike alongside, and although I knew it would slow me down, I agreed. Thank God, I did! Since Ashley was with me, I had to stop at every intersection, gas station and fast food restaurant we came upon to help her with her bike. After returning home and showering, I noticed my pupils were unequal. My headache wasn’t any worse but my left pupil was very tiny and my right was huge. Being an emergency room nurse, I concluded that these were neurological symptoms. If someone arrived at the ER looking as I did, I would think something bad was going on, like a stroke or brain tumor. I called a close friend of mine, an ER physician with whom I’ve worked, and described what was happening to me. She urged me to get to the ER right away. I felt really stupid. I wouldn’t describe it as the worst headache of my life… at least not yet. After arriving at the emergency room, the pressure in my head was Possible Causes of FMD The cause of fibromuscular dysplasia remains unknown. A variety of genetic, mechanical and hormonal factors have been proposed, but further study is required to better understand the cause of this condition. Diagnosing FMD The most important aspect is recognition of the signs and symptoms that may occur with fibromuscular dysplasia. The most common presentations are hypertension or an asymptomatic carotid bruit in a young person, usually a woman. Other not uncommon presentations include neck pain, Horner’s syndrome, transient ischemic attack, stroke, headache, pulsitile tinnitus, claudication, mesenteric ischemia and renal insufficiency. Patients with FMD are more likely to experience a dissection of an artery. While the gold standard for diagnosis remains catheter-based angiography, duplex ultrasound, CT angiography and MR angiography have all been used with some success. The “string of beads” appearance as visualized on the angiogram and MR angiogram (in the accompanying article by Pam Mace, RN) is characteristic of the medial type of FMD. Intimal disease, perimedial disease and other less common types have a different angiographic appearance. Patients with carotid artery FMD should undergo a MRA of the intracranial circulation because about 7-12% of such patients have an associated intracranial aneurysm. Treatment of FMD Treatment depends on the artery affected and the associated signs or symptoms. In a young person with FMD of the renal arteries and hypertension, the treatment of choice is percutaneous balloon angioplasty. Stent implantation is not necessary as the results with angioplasty alone are excellent. FMD of the carotid arteries likewise responds very well to angioplasty. Angioplasty should be reserved for patients with symptoms (TIA or stroke). Asymptomatic carotid FMD (detected by hearing a bruit) should be treated with aspirin 81 mg daily. No intervention is required or recommended. If a dissection occurs, the patient should initially be treated with anticoagulation. If that fails, or blood supply is seriously compromised, a stent should be placed. References 1. Olin JW. Recognizing and Managing Fibromuscular Dysplasia. Cleve Clinic J Med 2007;74:273-282. 2. Slovut DP, Olin JW. Fibromuscular Dysplasia. N Engl J Med 2004;350:1862-1871. More information is also available at www.fmdsa.org. http://www.fmdsa.org

Table of Contents Feed for the Digital Edition of Cath Lab Digest - September 2007

St. Dominic Hospital The Genous Bio-engineered R Stent Percutaneous Treatment of Peripheral Arterial Chronic Total Occlusions: Device Options and Clinical Outcomes Contents Clinical Editor’s Corner Percutaneous Revascularization of Peripheral Chronic Total Occlusion — Which Patients, Why, and How? Myocardial Infarction and Syncope: A Manifestation of the “Raynaud-Prinzmetal Syndrome”? Essential Technical Components of the Transradial Approach If You Build It, Will They Come? Evidence-Based Medicine with Drug-Eluting Stents Back to School: The Value of Education in Cardiovascular Services The ACVP Standards and Competencies: Are You Using Them Effectively? What Do You Think? My Experience with Fibromuscular Dysplasia and Stroke A Brief Review of Fibromuscular Dysplasia Letter to the Editor A Look at On-the-Job Training: Perceptions, Reality and Our Profession Doing the Wave: Inventory Management with RFID The Ten-Minute Interview with… Paul Pinsker, RCIS CLD’s Annual Salary Survey Harrisburg Area Community College Volunteer Survey CEU Education Center SICP* Section Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Clinical & Industry News

Cath Lab Digest - September 2007

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.