ISCHEMIC STROKE / ETIOLOGY AND CLASSIFICATION
Cholesterol Embolization Syndrome
Created 13/05/2023, last revision 06/11/2023
Definition
- cholesterol embolization occurs when small pieces of cholesterol plaque break off from the arterial walls and block small and medium-sized arteries, which can lead to tissue damage
- large arteries, especially the aorta and its branches, are the usual source of emboli in elderly patients with advanced atherosclerosis
- embolization is often associated with intravascular procedures, cardiac surgery, and vascular surgery
- it differs from the more common artery-to-artery thromboembolism, in which thrombi formed on the surface of an atherosclerotic plaque embolize into the peripheral circulation
- symptoms may include skin discoloration, pain, and organ dysfunction

Etiopathogenesis
- atherosclerotic plaques in large arteries (aorta, CCA, ICA, pelvic arteries) → atherosclerotic plaques classification
- plaque formation is the result of a long-term process of lipid particle deposition in the vessel wall, accompanied by a cellular and inflammatory response
- complex plaques are characterized by a thickness ≥ 4 mm and an irregular, often exulcerated surface. Blood clots (thrombi) occur on the surface of these lesions to varying degrees and extents ⇒ frequently associated with atheroembolism and thromboembolism
- plaque rupture with the release of atheroma masses and cholesterol crystals (spontaneous, traumatic, iatrogenic) and embolization to peripheral segments
- iatrogenic – during cardiac catheterization, cardiac surgery, angioplasty
- with the development of catheterization techniques, the incidence of cholesterol embolization is decreasing
- the incidence of cholesterol embolization during renal artery catheterization procedures is reported to be as high as 30%. The course is usually asymptomatic, or there is a transient increase in urea and creatinine levels
- embolization in small and medium-sized vessels, resulting in their occlusion
- systemic inflammatory response to cholesterol emboli
- local endothelial proliferation with intimal fibrosis leading to narrowing or permanent occlusion of the affected artery
- organ damage caused by artery occlusion with hypoperfusion and inflammatory response
Clinical presentation
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Diagnostic evaluation
- the clinical manifestation of cholesterol embolization syndrome is non-specific and is a combination of end-organ lesions and a systemic inflammatory response
- cholesterol crystals trigger an inflammatory response (fever, fatigue, anorexia)
- leukocytosis, anemia, and thrombocytopenia
- ↑ ESR and CRP
- the syndrome should be considered in elderly patients with documented organ manifestations of advanced atherosclerosis, acute renal injury/hepatitis, hypereosinophilia, and skin manifestations such as livedo reticularis or “blue toe syndrome”. Particularly if they have undergone interventional or surgical procedures on large vessels before clinical presentation
- imaging – enables visualization, quantification, and characterization of atherosclerotic lesions
- CT+CTA / MRI+MRA
- neurosonology
- detection of atherosclerotic changes in extra- and intracranial arteries
- monitoring of spontaneous and provoked embolizations during interventional procedures; the limitation is the inability to distinguish cholesterol microemboli from thrombi
- detection of atherosclerotic changes in extra- and intracranial arteries
- TEE (assess aortic arch atherosclerosis)
- direct confirmation of atheroma embolization
Management
Pharmacotherapy
- no specific treatment
- manage vascular risk factors (smoking, dyslipidemia, hypertension, diabetes)
- administer antiplatelets, statins, ACE inhibitors
- the benefit of thrombolysis in acute stroke is questionable
Surgical procedures
- endarterectomy
- endovascular procedures
- bypass surgery