Stroke & Vascular Disorders
Cerebellar infarction and cerebellar hemorrhage
Oct. 26, 2023
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Fibromuscular dysplasia is a nonatherosclerotic vasculopathy affecting various circulatory beds, including the cerebral circulation. Cerebrovascular lesions may include arterial dissection and aneurysms. Neurologic manifestations typically result from ischemic events associated with these lesions. Management considerations are highlighted in this overview of cerebrovascular fibromuscular dysplasia.
• Although the histologic correlates of fibromuscular dysplasia have been delineated, diagnosis is typically established based on angiographic appearance.
• Associated intracranial aneurysms may occur with this disorder.
• Stroke is a relatively rare complication of fibromuscular dysplasia.
Fibromuscular dysplasia, also known as fibromuscular hyperplasia, medial hyperplasia, or arterial dysplasia, is a relatively uncommon multifocal arterial disease of unknown cause, characterized by nonatherosclerotic abnormalities involving the smooth muscle, fibrous and elastic tissue, of small- to medium-sized arterial walls (75). The first clinical and pathological description was by Leadbetter and Burkland in 1938 (44). They reported a 5-year-old boy with renal hypertension who underwent a unilateral nephrectomy. The affected renal artery was noted to harbor "an intraarterial mass of smooth muscle." For many years it was assumed that fibromuscular dysplasia damaged only renal vessels. However, in 1964, Palubinskas and Ripley published a case of fibromuscular dysplasia involving the celiac artery in a 36-year-old woman; this was the first indication that the disease may be generalized (61). Subsequent reports followed that described involvement of the visceral arteries, iliac artery, femoral artery, axillary artery, subclavian artery, coronary artery, aorta, and cephalic arteries (35; 59; 48). Involvement of the internal carotid artery was radiologically and histologically proven in 1965 (13). Cephalic vessels are involved in 25% to 30% of reported cases of fibromuscular dysplasia (06). The cephalic vessels are the second most common location, after renal arteries. Fibromuscular dysplasia predominantly involves the cervical and distal internal carotid artery (the location of the disease in 90% of cases). However, similar vascular abnormalities are observed in the middle cerebral arteries, the anterior cerebral arteries, the posterior cerebral arteries, the vertebral arteries, and the basilar artery (19; 59; 34; 85; 04; 15; 30; 84; 66). Moyamoya syndrome has also been described in association with fibromuscular dysplasia (60; 79). Vertebral artery involvement is less common and typically coexists with carotid involvement. Although cephalic fibromuscular dysplasia is often an incidental finding on autopsy or angiography, it could be complicated by cerebral infarction secondary to thromboemboli arising from irregularities of the arterial wall, spontaneous arterial dissection, formation of a carotid artery cavernous sinus fistula, or development of an aneurysm (35; 59; 76; 07). It was noted that classic fibromuscular dysplasia features are uncommonly associated with carotid webs (74). Sethi and colleagues have described a characteristic “S-curve” in the mid-distal carotid that is suggestive of the underlying disorder (73; 31). Multiple vessels may be involved with dissecting pathology in such cases (28; 25). Subarachnoid hemorrhage may result from saccular aneurysmal rupture or extension of a dissecting aneurysm.
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