🧩 Cholesterol Embolisation Syndrome (CES) occurs when fragments of an atherosclerotic plaque (mainly cholesterol crystals) break off and embolize from a proximal large artery.
🔒 This causes both mechanical plugging and an inflammatory response in distal small–medium arteries.
🩸 Embolisation from head/neck vessels can cause acute limb, renal, gut, or brain ischaemia — here we focus on neurological effects.

🦠 Aetiology

🧠 Causes stroke when proximal to cerebral vessels.
⚡ Typically multiple small microemboli over time (not a single large clot).
🫀 Most often from the ascending aorta → multiple small infarcts.
🔥 Triggers a non-specific acute inflammatory response.
💉 Can occur after procedures (e.g. coronary angiography, vascular surgery), though relatively rare.

🔬 Pathological Criteria

6 Key Elements for CES Development:
🫀 Plaque in a large proximal artery (aorta, carotid, iliac). 💥 Plaque rupture (spontaneous, traumatic, or iatrogenic). 🧊 Embolisation of debris (cholesterol crystals, platelets, fibrin, calcium). 🚧 Lodging in small/medium arteries (100–200 µm) → obstruction. 🛡️ Foreign-body inflammatory reaction. ⚠️ End-organ damage via occlusion + inflammation.

🧾 Clinical Features

🧠 Acute ischaemic stroke → often multiple, small, diffuse infarcts.
🤒 Systemic: fever, malaise.
♻️ Recurrent episodes common.
👁️ Visual: Hollenhorst plaques (cholesterol emboli on fundoscopy).
🦶 Skin: livedo reticularis, blue toe syndrome, ulcers, gangrene.
💧 Renal: acute renal failure, hypertension.

🩺 Differential Diagnosis

🫀 Artery-to-artery thromboembolism: clot forms on a plaque → embolises (more common than CES).
❤️ Cardioembolic stroke: atrial fibrillation, mural thrombus, valvular disease.

🔎 Investigations

🧪 Bloods: ↑WBC, eosinophilia, ESR, CRP (IL-5 mediated).
🧮 U&E: AKI from renal involvement.
🔊 TEE: detects aortic plaque.
🖼️ CT/MRI aorta: visualize plaque burden.
🧠 Brain imaging: CT/MRI shows multiple small infarcts (MRI more sensitive).
🩻 Carotid duplex: detect carotid plaques.
📈 ECG / Holter / echo: exclude AF or cardiac source.
🧴 Skin/muscle biopsy: diagnostic (cholesterol clefts).

💊 Management

🚑 No specific therapy beyond standard acute stroke care. Thrombolysis use is uncertain.
🌍 Treat systemic atherosclerosis: stop smoking, control BP, lipids, diabetes.
💊 Statins: may stabilise plaque & reduce recurrence.
🤝 Supportive: renal support, wound care for skin lesions.

📚 References & Further Reading

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

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Cholesterol Embolisation Syndrome

📖 Introduction