A Retrospective Cohort Study of Cerebrovascular Fibromuscular Dysplasia.

BACKGROUND: Fibromuscular dysplasia (FMD) is a rare vasculopathy for which limited data are available particularly from Europe. Our aim was to study the clinical characteristics of a regional cohort of carotid fibromuscular dysplasia patients to assess their clinical outcomes and the rate of vascular complications. METHODS: A retrospective cohort study of all cases of carotid/cerebrovascular FMD presenting to our regional vascular service (catchment population approximately 2 million), between 1998 and 2020. Imaging reports and patient case notes were screened using the keywords "FMD", "Fibromuscular Dysplasia", and "carotid". From case-note and imaging review, all relevant clinical data were extracted and the anatomical extent of vascular disease recorded. RESULTS: Eighty six patients with a diagnosis of cerebrovascular fibromuscular dysplasia were identified on imaging (31 computed tomography angiography, 46 magnetic resonance angiography, and 9 digital subtraction angiography) by a neurovascular radiologist. The mean age was 64 years, 78 (90%) patients were female, and 45/59 (75%) were Caucasian. Presenting clinical syndromes were Stroke/transient ischemic attack in 54 (63%) patients, symptomatic intracranial aneurysm in 6 (10%), and other neurological symptoms (headache/migraine, tinnitus) in 14 (16%), with 11 (13%) presenting incidentally. Six patients (7%) had a positive family history of FMD (2 patients) or other cerebrovascular event (4 patients: carotid dissection, intracerebral bleed, or stroke). Eight patients (9%) had a known or suspected hereditary connective tissue disorder (2 Ehlers-Danlos syndrome). Involved vessels were as follows: Carotid (mainly extracranial) in 79 (92%), vertebral 19 (22%), and a combination of these in 15 (17%) patients. Fifty eight (67%) patients had bilateral disease. Cerebrovascular complications were observed in 35 (41%) patients as follows: carotid dissection 11 (23%), carotid stenosis or occlusion 8 (9%), carotid aneurysm 8 (9%), cerebral aneurysm 9 (11%), vertebral aneurysm/dissection 2 (2%), and carotid-cavernous fistula 2 (2%). Of the 22 patients who had extracranial imaging, 14 (60%) had FMD affecting other beds-renal artery in 8 (36%) patients, other visceral arteries in 4 (18%), and aorta in 2 (9%). In addition, 4 (18%) patients had aneurysm or dissection affecting renal, splenic, and lower limb arteries. Overall, 67 (80%) patients had FMD affecting more than 1 vessel and 50 (58%) had multisite FMD (>/ = 2 vascular beds involved). Fifty nine (68%) patients were managed conservatively on close surveillance. Nineteen (21%) patients required carotid/cerebrovascular intervention and 9 (10%) required vascular intervention at other sites. Recurrent cerebrovascular events (stroke/transient ischemic attack, symptomatic Berry aneurysm) were seen in 20 (23%) patients. Overall mortality was 7% over a median follow-up period of 47 months. CONCLUSIONS: Carotid FMD patients have a high rate of multisite involvement, extracerebral vascular complications, and evidence of hereditary vasculopathy, requiring careful screening and surveillance.

The role of teleconsultation in the management of suspected skin malignancy in plastic surgery during COVID-19 outbreak: A single centre experience.

The COVID-19 pandemic has had a profound impact on the provision of skin cancer treatment in the UK. To preserve the service, the department transformed the outpatient skin cancer clinic into teleclinic service. This study examines the safety and efficacy of a teleclinic consultation, in comparison to a face-to-face consultation. We assessed efficacy in terms of accuracy of the clinical diagnosis in comparison to the histopathological result and whether treatment was designated the appropriate clinical priority/urgency. A total of 120 lesions in 98 patients were assessed, 55 patients in the face-to-face clinic cohort, and 43 patients in the teleclinic cohort. Diagnostic accuracy was better in face-to-face clinic compared to teleclinic; 85.0% and 63.6% respectively (χ2 (1, N = 120) = 7.35, p = 0.0067). The accuracy of listing patients on the correct pathway was slightly higher for teleclinic patients. Of the teleclinic patients listed through the urgent pathway, 45.7% justified their urgent status, compared with 37.5% of those listed urgent in face-to-face clinic (p = 0.67). For those listed as routine, 100% of teleclinic patients were listed appropriately whereas the accuracy was 96.8% for the face-to-face clinic counterpart. In conclusion, despite teleclinic having slightly reduced diagnostic accuracy, teleclinics show comparable accuracy in listing patients to urgent or routine skin cancer pathways. It offers convenience to patients in addition to reducing time to treatment and cost effectiveness. The lessons learned in the pandemic can be applied to the post-COVID healthcare environment.