Forty-two-year-old female patient with resistant hypertension, bilateral renal fibromuscular dysplasia and intracranial aneurysm

We present a case of a 42-year-old woman with 1-month known history of resistant hypertension. On admission the patient’s blood pressure was 230/123 mm Hg and during the subsequent days ranged from 165/103 to 157/97 mm Hg (24 h ambulatory blood pressure values (ABPM) 151/102 mm Hg) despite taking 4 antihypertensive drugs (nebivolol 5 mg, amlodipine 10 mg, clonidine 375 µg and indapamide 1.5 mg). Physical examination revealed no abnormalities. Malignant hypertension was diagnosed based on grade III fundoscopy. Laboratory data showed normal serum potassium, creatinine and estimated glomerular filtration rate (eGFR), hemoglobin and platelet count. Urine analysis showed no abnormalities. Electrographic (ECG) and echocardiographic examinations were normal. The patient had two complicated pregnancies and one miscarriage. Doppler ultrasonography revealed bilateral, significant renal artery stenosis (RAS) with renal-aortic ratio (RAR) > 6 on the right side and RAR 4 on the left side, confirmed in computed tomography angiography (angio-CT). Invasive angiography revealed typical multifocal fibromuscular dysplasia (FMD) morphology (“string of beads” appearance) with at least 2 significant lesions of the main right renal artery trunk and also multifocal FMD lesions of left renal artery, with a significant lesion in the central region of the trunk (Figures 1 A and B). Multilevel balloon angioplasty of both arteries was performed, with good final flow, without significant residual stenosis (Figures 2 A and B).
Angio-CT of carotid and vertebral arteries showed an irregular small aneurysm (2 × 2 × 2.5 mm) of the left internal carotid artery (ICA) in the C 4 segment (Figure 1 C). Other intracranial arteries were normal.
Further evaluation of the left ICA aneurysm required angiography, which confirmed left ICA aneurysm: sac (6.07 × 1.99 mm), neck 1.79 mm (Figure 1 C). No other vascular abnormalities were found in other vascular beads on angio-CT. As an irregular aneurysm with the sac bigger than 5 mm requires treatment in a patient with hypertension, the patient was offered endovascular exclusion of an aneurysm using the stent-assisted coiling technique.
In 6-month follow-up a significant decrease in blood pressure was observed and the number of antihypertensive drugs was reduced. Twenty-four h ABPM was 119/80 mm Hg while staying on 2 antihypertensive drugs (nebivolol 5 mg, amlodipine 5 mg). On Doppler ultrasonography bilateral non-significant RAS with RAR...


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