Makindo Medical Notes.com

Introduction

• Embolisation of the contents of an atherosclerotic plaque (primarily cholesterol crystals) from a proximal large artery
• Causes distal small to medium arteries causing mechanical plugging and an inflammatory response.
• Embolisation distal to head/neck vessel scan cause acute limb, renal, gut is ischaemia but is not covered here

Aetiology

• Causes stroke and neurological damage if lesions are proximal to head and neck vessels
• Generally characterized by a multitude of small emboli/microemboli occurring over time.
• Usually would involve ascending aorta
• Usually causes diffuse and small infarcts
• Non-specific acute inflammatory response
• Plaque damage during procedures e.g. coronary angiography but this seems rare

Pathological criteria

Clinical

• Acute ischaemic stroke may be caused often diffuse and small
• Constitutional symptoms such as fever and malaise
• These episodes may be recurrent
• Visual symptoms: cholesterol emboli may be seen by fundoscopy
• Livedo reticularis, blue toe syndrome, skin ulcers, digital gangrene
• Acute renal failure and hypertension

Differential

• Artery to arterial thromboembolism in which thrombus that forms over an atheromatous plaque in large artery which embolises. This is much commoner.
• Cardioembolic stroke

Investigations

• Raised WCC (hypereosinophilia) and elevated ESR and CRP due perhaps to IL-5 release
• U&E : may show an AKI
• Trans oesophageal echocardiography (TEE) is the most commonly used imaging technique for the detection and measurement of the aortic atherosclerotic plaque
• CT/MRI Aorta can also detect aortic plaque
• CT Brain - may show infarction(s) but MRI more sensitive showing distribution
• Carotid duplex : may show plaque
• ECG and 24 hr tape and Echo: exclude AF and cardioembolic causes
• Skin or Muscle biopsy: may be done to confirm diagnosis

Management

• No specific treatment beyond acute stroke care. Uncertainty over the use of thrombolysis.
• It is a manifestation of atherosclerosis, so management of smoking, hypertension, and serum cholesterol strongly advised
• Statin therapy may decrease the risk of cholesterol embolisation syndrome

References and further reading

• Cholesterol Embolisation Syndrome. Circulation. 2010;122:631-641