Cholesterol Crystal Embolism Following Mechanical Thrombectomy for Acute Ischemic Stroke

Overview

Journal Cureus

Specialty Biomedical Engineering

Date 2024 Nov 21

PMID 39569281

Authors

May Pyae Kyaw

Tatsuya Tanaka

Jun Ito

Ryosuke Matsuoka

Mina Komuta

Akira Matsuno

Affiliations

Soon will be listed here.

Abstract

Cholesterol crystal embolism (CCE) is a rare but serious complication of atherosclerotic plaque rupture, often occurring after endovascular interventions. We report the case of a 73-year-old man who developed CCE following mechanical thrombectomy (MT) for an acute ischemic stroke (AIS) due to left internal carotid artery occlusion. The patient, with a history of hypertension and hyperlipidemia, underwent successful MT with complete recanalization. However, four weeks after the procedure, he presented with blue toe syndrome and acute kidney injury. Histopathological analysis of a skin biopsy confirmed the diagnosis of CCE. The patient's renal function partially improved with corticosteroid therapy. Clinicians should maintain a high level of suspicion for CCE in patients who develop renal dysfunction or peripheral ischemia after MT, particularly in those with significant atherosclerotic risk factors. Early detection and timely intervention are critical for improving outcomes. Further research is warranted to clarify the incidence and optimal management of CCE in the context of MT for AIS.

References

Fine M, Kapoor W, Falanga V . Cholesterol crystal embolization: a review of 221 cases in the English literature. Angiology. 1987; 38(10):769-84. DOI: 10.1177/000331978703801007. View

Tanaka H, Yamana H, Matsui H, Fushimi K, Yasunaga H . Proportion and risk factors of cholesterol crystal embolization after cardiovascular procedures: a retrospective national database study. Heart Vessels. 2020; 35(9):1250-1255. DOI: 10.1007/s00380-020-01593-1. View

Servais A, Meredith D, Gravereaux E, Belkin M . Hydrophilic polymer embolization after intravascular lithotripsy. J Vasc Surg. 2023; 78(2):539. DOI: 10.1016/j.jvs.2022.11.054. View

Miyachi S, Taki W, Sakai N, Nakahara I . Historical perspective of carotid artery stenting in Japan: analysis of 8,092 cases in The Japanese CAS survey. Acta Neurochir (Wien). 2012; 154(12):2127-37. DOI: 10.1007/s00701-012-1508-9. View

Pandit A, Ohshima T, Kawaguchi R, Srivastava M, Miyachi S . Cholesterol Embolization Syndrome After Carotid Artery Stenting Associated with Delayed Cerebral Hyperperfusion Intracerebral Hemorrhage. World Neurosurg. 2020; 142:274-282. DOI: 10.1016/j.wneu.2020.07.021. View

Sugiyama N, Hasegawa H, Kudo K, Miyahara R, Saito R, Maruki C . Cholesterol Crystals in the Retrieved Thrombus by Mechanical Thrombectomy for Cerebral Embolism: A Case Report and Literature Review. NMC Case Rep J. 2022; 9:225-230. PMC: 9398466. DOI: 10.2176/jns-nmc.2022-0095. View

Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A . The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol. 2003; 42(2):211-6. DOI: 10.1016/s0735-1097(03)00579-5. View

Scolari F, Tardanico R, Zani R, Pola A, Viola B, Movilli E . Cholesterol crystal embolism: A recognizable cause of renal disease. Am J Kidney Dis. 2000; 36(6):1089-109. DOI: 10.1053/ajkd.2000.19809. View

Usui G, Hashimoto H, Sugiura Y, Nishi Y, Kusakabe M, Horiuchi H . Aortogenic Embolic Stroke Diagnosed by a Pathological Examination of Endovascularly Removed Thrombus: An Autopsy Report. Intern Med. 2019; 58(19):2851-2855. PMC: 6815896. DOI: 10.2169/internalmedicine.2857-19. View

10.

Scolari F, Ravani P, Gaggi R, Santostefano M, Rollino C, Stabellini N . The challenge of diagnosing atheroembolic renal disease clinical features and prognostic factors. Circulation 116: 298-304, 2007. Clin J Am Soc Nephrol. 2023; 3(2):317-323. DOI: 10.2215/01.CJN.0000926960.01383.34. View

11.

Agrawal A, Ziccardi M, Witzke C, Palacios I, Rangaswami J . Cholesterol embolization syndrome: An under-recognized entity in cardiovascular interventions. J Interv Cardiol. 2017; 31(3):407-415. DOI: 10.1111/joic.12483. View

12.

Tunick P, Kronzon I . Atheromas of the thoracic aorta: clinical and therapeutic update. J Am Coll Cardiol. 2000; 35(3):545-54. DOI: 10.1016/s0735-1097(99)00604-x. View

13.

Goyal M, Menon B, van Zwam W, Dippel D, Mitchell P, Demchuk A . Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016; 387(10029):1723-31. DOI: 10.1016/S0140-6736(16)00163-X. View

14.

Matsumoto N, Takahashi M, Katano T, Kutsuna A, Kanamaru T, Sakamoto Y . Cholesterol Crystal in Thrombus Removed by Mechanical Thrombectomy Should be a Strong Marker for Aortogenic Embolic Stroke. J Stroke Cerebrovasc Dis. 2020; 29(10):105178. DOI: 10.1016/j.jstrokecerebrovasdis.2020.105178. View