Case ReportCholesterol Embolization Syndrome After Carotid Artery Stenting Associated with Delayed Cerebral Hyperperfusion Intracerebral Hemorrhage
Introduction
The cholesterol embolization syndrome (CES) results from the distal embolization of cholesterol crystals from atheromatous plaques in large vessels such as the aorta and causes multiorgan damage.1 It can occur after the use of endovascular catheters that results in direct vascular injury, anticoagulant use, and thrombolytic therapy.2 The onset of CES has usually ranged from 1 day to 3 months after the precipitating event.3 CES can result in very high mortality of 58%–90%, and significant morbidity subsequent to renal dysfunction, with some patients requiring long-term hemodialysis, limb amputation, and other treatment.4 It can affect multiple systems, including the skin, kidneys, gastrointestinal tract, brain, and so forth. We have reported an interesting case of definite CES with multiorgan involvement and intracerebral hemorrhage.
Section snippets
Patient History and Clinical Findings
A 75-year-old man had presented with cognitive impairment and slurred speech to an outpatient clinic. He had no history of any other systemic symptoms such as fever, weight loss, arthropathy, ulcers, dry mouth, or dry eyes. He had a history of smoking and had hypertension for ~16 years, which was properly controlled and he had been receiving regular treatment. He had no medical history of diabetes mellitus, stroke, transient ischemic attack, or chronic infections. On evaluation, cerebral
Discussion
To the best of our knowledge, we have described the first case of CES with renal, cutaneous, and neurological involvement and with intracerebral hemorrhage after the patient had undergone carotid artery stenting for symptomatic critical left carotid artery stenosis.
CES, in a recent review of 23 studies, had developed in 648 of 905 patients after a vascular procedure.3 The risk factors reported in 19 studies were hypertension (78%), diabetes mellitus (18%), smoking (58%), hyperlipidemia (31%),
Conclusions
CES can involve multiple organs and can result in renal dysfunction, heart failure, gastrointestinal ischemia, cutaneous involvement, and neurological involvement. The organs affected have most often been the skin, kidneys, and brain. Our patient with CES had cutaneous involvement affecting the lower limbs, as well as renal and neurological involvement, all of which had developed 3 weeks after the endovascular intervention. CES can be mild to catastrophic. An increased CRP level can identify
Acknowledgments
We are thankful to our patient for allowing us to report his case.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.