Cholesterol crystal embolism-related cerebral infarction: Magnetic resonance imaging and clinical characteristics

Yuko Kondo; Mami Kanzaki; Daisuke Ishima; Ryo Usui; Ayato Kimura; Kotaro Usui; Yasuyuki Amoh; Yasuo Takeuchi; Toshihiro Kumabe; Junya Ako; Kagami Miyaji; Kazutoshi Nishiyama; Tsugio Akutsu

doi:10.1016/j.ensci.2021.100388

Cholesterol crystal embolism-related cerebral infarction: Magnetic resonance imaging and clinical characteristics

eNeurologicalSci. 2021 Dec 8:25:100388. doi: 10.1016/j.ensci.2021.100388. eCollection 2021 Dec.

Authors

Yuko Kondo¹, Mami Kanzaki^{1

2}, Daisuke Ishima^{1

2}, Ryo Usui^{1

2}, Ayato Kimura^{1

2}, Kotaro Usui^{1

2}, Yasuyuki Amoh³, Yasuo Takeuchi⁴, Toshihiro Kumabe⁵, Junya Ako⁶, Kagami Miyaji⁷, Kazutoshi Nishiyama^{1

2}, Tsugio Akutsu^{1

2}

Affiliations

¹ Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan.
² Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan.
³ Department of Dermatology, Kitasato University School of Medicine, Kanagawa, Japan.
⁴ Department of Nephrology, Kitasato University School of Medicine, Kanagawa, Japan.
⁵ Department of Neurosurgery, Kitasato University School of Medicine, Kanagawa, Japan.
⁶ Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan.
⁷ Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan.

Abstract

Background and aims: Cholesterol crystal embolism-related cerebral infarction (CCE-CI) is frequently misdiagnosed due to the lack of specific symptoms. To aid in differential diagnosis, this study comprehensively characterized the magnetic resonance imaging (MRI) and clinical manifestations of CCE-CI and compared these features to those of atherothrombotic cerebral infarction (ACI).

Methods: This single-center, retrospective, observational study was conducted at Kitasato University Hospital, Kanagawa, Japan. We identified 37 clinically or histopathologically confirmed CCE-CI cases and 110 ACI cases treated from January 2006 to May 2020. Groups were compared for mean age, sex ratio, clinical presentations, imaging manifestations, precipitating factors, comorbid conditions, medications, and smoking history.

Results: Of 37 eligible patients with CCE-CI, 10 (27.0%) received brain MRI, of which 8 (21.6%) exhibited high-intensity signals indicative of brain lesions on diffusion-weighted imaging (DWI). However, two patients with DWI lesions exhibited no detectable neurological abnormalities. Patients with CCE-CI frequently demonstrated bilateral DWI lesions involving the bilateral anterior and posterior circulation, a pattern absent in ACI (50% vs. 0%, p < 0.001). Compared to patients with ACI, CCE-CI patients also demonstrated significantly lower estimated glomerular filtration rate (p < 0.001) as well as more frequent eosinophilia (p = 0.006), atherosclerotic plaques ≥4-mm thick in the ascending aorta or proximal arch (p = 0.001), and aortic aneurysm (p < 0.001).

Conclusions: Patients with CCE-CI develop multiple DWI lesions across several vascular territories, even in the absence of neurological symptoms. Comorbid aortic aneurysm may increase CCE-CI risk. These findings could help in the differential diagnosis of CCE-CI.

Keywords: ACI, Atherothrombotic cerebral infarction; Atheroembolism; Atherothrombotic cerebral infarction; CAS, Carotid artery stenting; CCE, Cholesterol crystal embolism; CI, Confidence intervals; CRP, C-reactive protein; CTA, Computed tomography angiography; Cerebral infarction; Cholesterol crystal embolism; Cholesterol crystal embolism-related cerebral infarction; DWI, Diffusion-weighted imaging; Diffusion-weighted imaging; IRB, Institutional review board; LDL, Low-density lipoprotein; MRA, Magnetic resonance angiography; MRI, Magnetic resonance imaging; OR, Odds ratios; PCI, Percutaneous coronary intervention; TIA, Transient ischemic attack.