Learning objectives
- Learning
- Understand
- Integrate
- Reflect
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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
| The following 6 key elements are required for the development
of cholesterol embolisation syndrome: |
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- Presence of a plaque in a proximal, large-calibre artery (such as the internal carotid artery, the iliac arteries, or the aorta)
- Plaque rupture (spontaneous, traumatic, or iatrogenic)
- Embolization of plaque debris (containing cholesterol crystals, platelets, fibrin, and calcified detritus)
- Lodging of the emboli in small to medium arteries with a diameter of 100 to 200 micrometres, leading to mechanical occlusion
- Foreign-body inflammatory response to cholesterol emboli
- End-organ damage due to a combined effect of mechanical plugging and inflammation
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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
- Transoesophageal 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