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Título

Recurrence of stroke in a patient with fibromuscular dysplasia

RESUMO

CLINICAL CASE: A 64-year-old woman, previously hypertensive, woke up with a sudden loss of strength on the right and dysmetria on the left. She was rescued, but with a time longer than 4.5 hours, which contraindicated the use of thrombolytics for stroke. Basic investigation was performed with cranial tomography at admission and after 24 hours, transthoracic echo, carotid and vertebral Doppler. After normal findings in all exams, the investigation continued with cranial magnetic resonance, which showed T2/FLAIR hypersignal in bridge and left cerebellum with restriction of water molecule to diffusion. Patient progressed using secondary prophylaxis with dual antiplatelet therapy. However, 17 days later, she was hospitalized again, with a worsening of the same symptoms. A new CT scan 1 day after the new condition showed subacute hypodensity in a capsule on the left. Cerebral angiography showed occlusion of vertebral arteries and a pattern of multiple parietal irregularities, extending throughout its course in the“string of beads” appearance. Secondary prophylaxis was changed to anticoagulation with apixaban, in addition to motor rehabilitation and outpatient follow-up. DISCUSSION: Fibromuscular dysplasia (FMD) is a non-inflammatory and non-atherosclerotic disease that courses with arterial stenosis, occlusion, aneurysm, dissection and arterial tortuosity, more frequent in young adult women, the internal carotid artery is more frequently affected, histological form more common is fibroelastic dysplasia with thickening of the media and muscular layer with destruction of the elastic lamina. Diagnosis is by vessel study. Genetic predisposition, chronic trauma, stretching of the involved vessel and hormonal factors are believed to have been suggested as etiologic agents. The clinical presentations are determined by the affected artery. In this case, the patient presented a recurrent and relapsing symptoms in a short period of time, in two different territories, first in the anterior inferior cerebellar artery territory, and later in the lenticostriate artery territory. FINAL REMARKS: FMD associated with neurovascular events can be treated with antiplatelet therapy, blood pressure control, or treatment with angioplasty with or without stent implantation. However, in this case, antiplatelet therapy was not enough for prevention in a short period of time, opting for anticoagulation with apixaban, which kept the patient stable without new neurovascular events.

Palavras Chave

fibromuscular dysplasia; stroke; secondary prevention; apixaban

Área

Doença Cerebrovascular