Massive cerebral involvement in fat embolism syndrome and intracranial pressure management

Case report

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Fat embolism syndrome (FES) is a common clinical entity that can occasionally have significant neurological sequelae. The authors report a case of cerebral fat embolism and FES that required surgical management of intracranial pressure (ICP). They also discuss the literature as well as the potential need for neurosurgical management of this disease entity in select patients. A 58-year-old woman presented with a seizure episode and altered mental status after suffering a right femur fracture. Head CT studies demonstrated hypointense areas consistent with fat globules at the gray-white matter junction predominantly in the right hemisphere. This CT finding is unique in the literature, as other reports have not included imaging performed early enough to capture this finding. Brain MR images obtained 3 days later revealed T2-hyperintense areas with restricted diffusion within the same hemisphere, along with midline shift and subfalcine herniation. These findings steered the patient to the operating room for decompressive hemicraniectomy. A review of the literature from 1980 to 2012 disclosed 54 cases in 38 reports concerning cerebral fat embolism and FES. Analysis of all the cases revealed that 98% of the patients presented with mental status changes, whereas only 22% had focal signs and/or seizures. A good outcome was seen in 57.6% of patients with coma and/or abnormal posturing on presentation and in 90.5% of patients presenting with mild mental status changes, focal deficits, or seizure. In the majority of cases ICP was managed conservatively with no surgical intervention. One case featured the use of an ICP monitor, while none featured the use of hemicraniectomy.

Abbreviations used in this paper:DWI = diffusion-weighted imaging; FES = fat embolism syndrome; ICP = intracranial pressure; TBI = traumatic brain injury.

Article Information

Address correspondence to: Robert G. Kellogg, M.D., 1725 W. Harrison St., Ste. 855, Chicago, IL 60612. email: Robert_Kellogg@Rush.edu.

Please include this information when citing this paper: published online August 16, 2013; DOI: 10.3171/2013.7.JNS13363.

© AANS, except where prohibited by US copyright law.

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Figures

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    A and B: Axial head CTs obtained on postinjury Day 1 demonstrating hypodensities at the gray-white matter junction in multiple areas. C and D: Axial T2-weighted and FLAIR MR images obtained on postinjury Day 3 showing edema and midline shift.

  • View in gallery

    A: Operative photograph demonstrating ample frontotemporoparietal decompression and edematous, hyperemic brain parenchyma with sulcal effacement. B and C: Postoperative axial CTs demonstrating improvement in midline shift and effective decompression.

References

1

Allardyce DBMeek RNWoodruff BCassim MMEllis D: Increasing our knowledge of the pathogenesis of fat embolism: a prospective study of 43 patients with fractured femoral shafts. J Trauma 14:9559621974

2

Ammon JTKhalily CLester DK: Fatal cerebral emboli in the absence of a cardiac arterial-venous shunt: case report. J Arthroplasty 22:4774792007

3

Anegawa SHayashi TTorigoe ROgasawara THashizume T: Magnetic resonance imaging of fat embolism syndrome— case report. Neurol Med Chir (Tokyo) 31:3593611991

4

Babikian VLCaplan LR: Brain embolism is a dynamic process with variable characteristics. Neurology 54:7978012000

5

Barak MKabha MNorman DSoudry MKats YMilo S: Cerebral microemboli during hip fracture fixation: a prospective study. Anesth Analg 107:2212252008

6

Beretta LCalvi MRFrascoli CAnzalone N: Cerebral fat embolism, brain swelling, and severe intracranial hypertension. J Trauma 65:E46E482008

7

Brooks RA: A quantitative theory of the Hounsfield unit and its application to dual energy scanning. J Comput Assist Tomogr 1:4874931977

8

Bulger EMSmith DGMaier RVJurkovich GJ: Fat embolism syndrome. A 10-year review. Arch Surg 132:4354391997

9

Buskens CJGratama JWCHogervorst Mvan Leeuwen RBRommes JHSpronk PE: Encephalopathy and MRI abnormalities in fat embolism syndrome: a case report. Med Sci Monit 14:CS125CS1292008

10

Butteriss DJAMahad DSoh CWalls TWeir DBirchall D: Reversible cytotoxic cerebral edema in cerebral fat embolism. AJNR Am J Neuroradiol 27:6206232006

11

Chen JJSHa JCMirvis SE: MR imaging of the brain in fat embolism syndrome. Emerg Radiol 15:1871922008

12

Chrysikopoulos HManiatis VPappas JFilalithis PGogali CSfyras D: Case report: post-traumatic cerebral fat embolism: CT and MR findings. Report of two cases and review of the literature. Clin Radiol 51:7287321996

13

Citerio GBianchini EBeretta L: Magnetic resonance imaging of cerebral fat embolism: a case report. Intensive Care Med 21:6796811995

14

Cooper DJRosenfeld JVMurray LArabi YMDavies ARD'Urso P: Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364:149315022011

15

Cox GTzioupis CCalori GMGreen JSeligson DGiannoudis PV: Cerebral fat emboli: a trigger of post-operative delirium. Injury 42:Suppl 4S6S102011

16

Dive AMDubois PEIde CBulpa PABroka SMInstallé E: Paradoxical cerebral fat embolism: an unusual cause of persistent unconsciousness after orthopedic surgery. Anesthesiology 96:102910312002

17

Duja CMBerna CKremer SGéronimus CKopferschmitt JBilbault P: Confusion after spine injury: cerebral fat embolism after traumatic rupture of a Tarlov cyst: case report. BMC Emerg Med 10:182010

18

Eguia PMedina AGarcia-Monco JCMartin VMonton FI: The value of diffusion-weighted MRI in the diagnosis of cerebral fat embolism. J Neuroimaging 17:78802007

19

Erdem ENamer IJSaribas OAras TTan EBekdik C: Cerebral fat embolism studied with MRI and SPECT. Neuroradiology 35:1992011993

20

Fabian TC: Unravelling the fat embolism syndrome. N Engl J Med 329:9619631993

21

Findlay JMDeMajo W: Cerebral fat embolism. Can Med Assoc J 131:7557571984

22

Gombar SDey NDeva C: Pupillary signs in fat embolism syndrome. Acta Anaesthesiol Scand 49:7232005. (Letter)

23

Gossling HRPellegrini VD Jr: Fat embolism syndrome: a review of the pathophysiology and physiological basis of treatment. Clin Orthop Relat Res 16568821982

24

Gregorakos LSakayianni KHroni DHarizopoulou VMarkou NGeorgiadou F: Prolonged coma due to cerebral fat embolism: report of two cases. J Accid Emerg Med 17:1441462000

25

Guillevin RVallée JNDemeret SSonneville RBolgert FMont'alverne F: Cerebral fat embolism: usefulness of magnetic resonance spectroscopy. Ann Neurol 57:4344392005

26

Gurd ARWilson RI: The fat embolism syndrome. J Bone Joint Surg Br 56B:4084161974

27

Jacobson DMTerrence CFReinmuth OM: The neurologic manifestations of fat embolism. Neurology 36:8478511986

28

Kamano MHonda YKitaguchi MKazuki K: Cerebral fat embolism after a nondisplaced tibial fracture: case report. Clin Orthop Relat Res 3892062092001

29

Kamenar EBurger PC: Cerebral fat embolism: a neuropathological study of a microembolic state. Stroke 11:4774841980

30

Kawano YOchi MHayashi KMorikawa MKimura S: Magnetic resonance imaging of cerebral fat embolism. Neuroradiology 33:72741991

31

Kim KCHwang DSShin HD: Post-traumatic cerebral fat embolism prior to operative repair of femoral and tibial fractures. Orthopedics 31:1702008

32

Kumar SGupta VAggarwal SSingh PKhandelwal N: Fat embolism syndrome mimicker of diffuse axonal injury on magnetic resonance imaging. Neurol India 60:1001022012

33

Lee SCYoon JYNam CHKim TKJung KALee DW: Cerebral fat embolism syndrome after simultaneous bilateral total knee arthroplasty: a case series. J Arthroplasty 27:4094142012

34

Levy D: The fat embolism syndrome. A review. Clin Orthop Relat Res 2612812861990

35

Marshall GBHeale VRHerx LAbdeen AMrkonjic LPowell J: Magnetic resonance diffusion weighted imaging in cerebral fat embolism. Can J Neurol Sci 31:4174212004

36

Metting ZRödiger LARegtien JGvan der Naalt J: Delayed coma in head injury: consider cerebral fat embolism. Clin Neurol Neurosurg 111:5976002009

37

Meyer NPennington WTDewitt DSchmeling GJ: Isolated cerebral fat emboli syndrome in multiply injured patients: a review of three cases and the literature. J Trauma 63:139514022007

38

Nastanski FGordon WILekawa ME: Posttraumatic paradoxical fat embolism to the brain: a case report. J Trauma 58:3723742005

39

Parizel PMDemey HEVeeckmans GVerstreken FCras PJorens PG: Early diagnosis of cerebral fat embolism syndrome by diffusion-weighted MRI (starfield pattern). Stroke 32:294229442001

40

Pell ACChristie JKeating JFSutherland GR: The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing. A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br 75:9219251993

41

Pfeffer GHeran MKS: Restricted diffusion and poor clinical outcome in cerebral fat embolism syndrome. Can J Neurol Sci 37:1281302010

42

Rughani AIFlorman JESeder DB: Clinical and radiographic improvement following cerebral fat emboli. Neurocrit Care 15:1901932011

43

Saito AMeguro KMatsumura AKomatsu YOohashi N: Magnetic resonance imaging of a fat embolism of the brain: case report. Neurosurgery 26:8828851990

44

Sakamoto TSawada YYukioka TYoshioka TSugimoto TTaneda M: Computed tomography for diagnosis and assessment of cerebral fat embolism. Neuroradiology 24:2832851983

45

Sasano NIshida STetsu STakasu HIshikawa KSasano H: Cerebral fat embolism diagnosed by magnetic resonance imaging at one, eight, and 50 days after hip arthroplasty: a case report. Can J Anaesth 51:8758792004

46

Satoh HKurisu KOhtani MArita KOkabayashi SNakahara T: Cerebral fat embolism studied by magnetic resonance imaging, transcranial Doppler sonography, and single photon emission computed tomography: case report. J Trauma 43:3453481997

47

Schneider RC: Fat embolism; a problem in the differential diagnosis of craniocerebral trauma. J Neurosurg 9:1141952

48

Scopa MMagatti MRossitto P: Neurologic symptoms in fat embolism syndrome: case report. J Trauma 36:9069081994

49

Simon ADUlmer JLStrottmann JM: Contrast-enhanced MR imaging of cerebral fat embolism: case report and review of the literature. AJNR Am J Neuroradiol 24:971012003

50

Stienen MNGautschi OP: Cerebral fat embolism after severe road traffic accident. Am J Emerg Med 30:831.e1831.e22012

51

Takahashi MSuzuki ROsakabe YAsai JIMiyo TNagashima G: Magnetic resonance imaging findings in cerebral fat embolism: correlation with clinical manifestations. J Trauma 46:3243271999

52

Thaunat OThaler FLoirat PDecroix JPBoulin A: Cerebral fat embolism induced by facial fat injection. Plast Reconstr Surg 113:223522362004

53

Walshe CMCooper JDKossmann THayes IIles L: Cerebral fat embolism syndrome causing brain death after longbone fractures and acetazolamide therapy. Crit Care Resusc 9:1841862007

54

Yeon HBRamappa ALandzberg MJThornhill TS: Paradoxic cerebral embolism after cemented knee arthroplasty: a report of 2 cases and prophylactic option for subsequent arthroplasty. J Arthroplasty 18:1131202003

55

Yoshida AOkada YNagata YHanaguri KMorio M: Assessment of cerebral fat embolism by magnetic resonance imaging in the acute stage. J Trauma 40:4374401996

56

Zenker FA: Beiträige zur normalen und pathologischen Anatomie der Lunge DresdenG. Schonfeld1862

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