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Cholesterol embolism as a cause of transient ischemic attacks and cerebral infarction

Although cerebral cholesterol embolism is a well-known process, the range of clinical manifestations has not been established. In the present case, the occurrence of transient ischemic attacks in association with cerebral cholesterol embolism is described for the first time. A 69-year-old man experienced multiple 5- to 8-minute spells of numbness or weakness involving one or the other hand in 3 years. The attacks continued despite warfarin therapy. When the left arm became permanently paralyzed, an ulcerative plaque was removed from the right internal carotid artery, but the neurologic deficits increased. Progressive renal failure developed, and he died 5 months after the initial medical evaluation. Neuropathologic examination disclosed multiple small infarcts in both cerebral hemispheres, predominantly in the border-zone territory on the right side. Many small cerebral arteries were occluded by cholesterol emboli. Anticoagulant therapy appeared to exert an adverse affect.