Cholesterol Management in Neurology: Time for Revised Strategies?

Abstract

Statin therapy has been extensively evaluated and shown to reduce the incidence of new or recurrent vascular events, ischemic stroke included. As a consequence, each published guideline pushes for lower low-density cholesterol levels in the population at large, recommending increased statin doses and/or adding new cholesterol-lowering molecules. Neurologists find it sometimes difficult to apply these guidelines, having to confront situations such as (1) ischemic strokes, mainly cardioembolic ones, in patients with already low LDL-cholesterol levels; (2) myasthenic patients, whose lifespan has been extended by available treatment, and whose age and cholesterol levels put them at risk for ischemic stroke; (3) patients with myotonic dystrophy, whose disease often associates diabetes mellitus and heart conduction defects, and in whom blood cholesterol management is also not settled. As such, further trials are needed to address these issues.

Keywords: cholesterol; cognitive impairment; lipid rafts; muscular dystrophies; myasthenia gravis; myotoxicity; statins.

Figure 1

A simplified model of lipid rafts in cell membranes. Cholesterol is abundant in the lipid raft microdomain, where the acyl chains of lipids are generally longer and saturated, as opposed to the acyl chains of non-raft phospholipids, which are unsaturated and shorter.

Figure 2

The mevalonate pathway. Statins act by inhibiting hydroxy-3-methylglutaryl-Coenzyme A reductase (HMG-CoAR), as depicted with the blue arrow.