BackgroundWe present a case of a patient with a femoral neck fracture that shows neurological impairment and respiratory distress 1 day after trauma, caused by the Fat Embolism Syndrome with the presence of Cerebral Fat Embolisms.Case summaryA 75 year old female remained unresponsive after a hemi arthroplasty was performed because of a 1 day old femoral neck fracture. She rapidly developed respiratory insufficiency and an obstructive shock with right ventricle dilatation on transthoracic echocardiography. The diffusion-weighted MRI brain images showed the “Starfield” pattern, a radiologic phenomenon typical for FES. During 3 weeks of ICU admission the neurologic state slowly ameliorated.ConclusionThe rare FES is a clinical diagnosis with mainly respiratory, neurologic and dermatologic symptoms in the setting of a trauma patient. Fat embolisms are able to reach the brain without the presence of a patent foramen ovale to cause neurological symptoms. Diagnosing FES remains challenging but the distinctive “Starfield” pattern on MRI scans is promising.