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# Arteriosclerosis: the three patterns

- Lesion

‘Hardening of the arteries’ has three forms: fatty plaques in big arteries, calcium rings in the media, and thick-walled tiny arterioles.

Updated Nov 12, 2026

## Key points

- Hyaline arteriolosclerosis: pink glassy wall from leaked plasma proteins and matrix; benign hypertension, diabetes, ageing.
- Hyperplastic arteriolosclerosis: concentric onion-skin layers of smooth muscle and basement membrane; malignant hypertension, often with fibrinoid necrosis.
- Kidney: hyaline change gives benign nephrosclerosis (finely granular small kidneys); hyperplastic change gives ‘flea-bitten’ kidneys.
- Mönckeberg: ring-like medial calcification of muscular arteries; lumen preserved; seen as ‘pipe-stem’ arteries on x-ray.
- Atherosclerosis is an intimal disease; Mönckeberg is medial; arteriolosclerosis is in the smallest arteries.

## What it is

Arteriosclerosis means thickening and loss of elasticity of arterial walls. Atherosclerosis, the commonest and most important form, affects large and medium arteries. Mönckeberg medial sclerosis is calcification of the media of muscular arteries in older people; it does not narrow the lumen. Arteriolosclerosis affects small arteries and arterioles in hypertension and diabetes: hyaline in benign disease, hyperplastic (onion-skin) in severe hypertension.

## Structure

- Hyaline arteriolosclerosis: PAS-positive homogeneous wall, small round lumen; afferent arterioles of the kidney are typical.
- Hyperplastic: smooth-muscle cells and reduplicated basement membrane arranged like an onion; lumen nearly closed.
- Mönckeberg: basophilic calcium rings in the media with a normal intima.

## The three patterns of arteriosclerosis

| Pattern | Vessels | Layer | Microscopy | Consequence |
| --- | --- | --- | --- | --- |
| Atherosclerosis | Aorta, coronary, carotid, iliac and other large and medium arteries | Intima | Fibrofatty plaque with necrotic lipid core and fibrous cap | Stenosis, thrombosis, aneurysm, embolism |
| Mönckeberg medial sclerosis | Muscular arteries (femoral, tibial, radial, uterine) | Media | Ring-like calcium deposits in the media, sometimes bone | Usually none; stiff vessels |
| Hyaline arteriolosclerosis | Arterioles | Whole wall | Homogeneous pink hyaline thickening, narrow lumen | Benign nephrosclerosis, lacunar infarcts |
| Hyperplastic arteriolosclerosis | Arterioles, small arteries | Whole wall | Concentric onion-skin layers; fibrinoid necrosis (necrotizing arteriolitis) | Malignant hypertension, acute kidney injury |

## Clinical notes

- Diabetes causes hyaline arteriolosclerosis of both afferent and efferent glomerular arterioles.
- Medial calcification can make ankle–brachial pressure readings falsely high because the arteries cannot be compressed.

## Memory aid

Glass for the slow pressure (hyaline), onions for the fast one (hyperplastic), and stone rings that leave the pipe open (Mönckeberg).

## Test yourself

Think of the answer, then tap the question to see it.

## Which arteriolar lesion is typical of malignant hypertension?

Hyperplastic (onion-skin) arteriolosclerosis, often with fibrinoid necrosis.

## Does Mönckeberg medial sclerosis narrow the lumen?

No; the calcium is in the media and the intima is normal, so the lumen is preserved.

## What two diseases are classically linked to hyaline arteriolosclerosis?

Benign (long-standing) hypertension and diabetes mellitus, plus ageing.

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## Elsewhere in DurgiPedia

- [Blood vessels: artery, vein and capillary layers](https://durgical.com/en/histology/blood-vessels-artery-vein-and-capillary-layers/)

## Connections

## Related 5

- [Hypertension: mechanisms](https://durgical.com/en/general-pathology/hypertension-mechanisms/)
- [Atherosclerotic plaque: stable vs vulnerable](https://durgical.com/en/general-pathology/atherosclerotic-plaque-stable-vs-vulnerable/)
- [Patterns of necrosis: coagulative, liquefactive, caseous, fat, fibrinoid, gangrenous](https://durgical.com/en/general-pathology/patterns-of-necrosis-coagulative-liquefactive-caseous-fat-fibrinoid-gangrenous/)
- [Pathologic calcification: dystrophic vs metastatic](https://durgical.com/en/general-pathology/pathologic-calcification-dystrophic-vs-metastatic/)
- [Thrombotic microangiopathies: TTP vs HUS](https://durgical.com/en/general-pathology/thrombotic-microangiopathies-ttp-vs-hus/)

## Related conditions 6

- [Arterial hypertension](https://durgical.com/en/conditions/arterial-hypertension/)
- [Hypertensive emergency and urgency](https://durgical.com/en/conditions/hypertensive-emergency-and-urgency/)
- [Hypertensive nephrosclerosis](https://durgical.com/en/conditions/hypertensive-nephrosclerosis/)
- [Type 2 diabetes mellitus](https://durgical.com/en/conditions/type-2-diabetes-mellitus/)
- [Atherosclerosis and dyslipidaemia](https://durgical.com/en/conditions/atherosclerosis-and-dyslipidaemia/)
- [Chronic kidney disease](https://durgical.com/en/conditions/chronic-kidney-disease/)

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Educational content on the mechanisms of disease; not a diagnostic or treatment guide and no substitute for a health professional's advice. No doses are given.

Sources: [Atherosclerosis | Arteriosclerosis | MedlinePlus](https://medlineplus.gov/atherosclerosis.html) (MedlinePlus, US National Library of Medicine, 2025).

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Representative model, for educational purposes only.

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