Cerebral Fat Embolism: Clinical Presentation, Diagnostic Steps and Long-Term Follow-Up

Abstract

Objective: Symptomatic cerebral fat embolism (CFE) is a rare complication that occurs after a traumatic injury or orthopaedic surgery and is diagnostically challenging. No data is currently available concerning long-term follow-up. Methods: We identified from medical records 9 patients with CFE and revised the clinical signs and the diagnostic process. We then analysed long-term follow-up data, targeting clinical course after discharge, neurological impairment, and current quality of life, using the Barthel index and the modified Rankin Scale. Results: All 9 patients initially showed severe neurological deficits, including disturbance of consciousness ranging from somnolence to coma. During the follow-up period for 3–58 months after the insult 2 patients had died. The 7 patients who remained alive had either recovered completely or showed only minor neurological deficits after rehabilitation. They were nearly independent in daily life and needed only minimal assistance. We performed the first brain biopsy in a patient with CFE. Conclusion: Most patients had a good outcome after long-term follow-up. In patients with an unexplained altered state of consciousness after a traumatic injury or an orthopaedic surgery, an MRI with diffusion-weighted imaging must be performed to uncover the characteristic pattern of disseminated hyperintense lesions in the white matter that are associated with CFE.

Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time—A Systematic Review

“…The findings of our literature search were clear-cut for all four questions addressed initially as follows: Regarding diagnostic standards, most authors appeared to mainly rely on the Gurd’s criteria to diagnose the clinical syndrome. Magnetic resonance imaging (T2) has been routinely used as an adjunct tool in the radiologic literature [ 43 ], but the studies looked over in our review did not routinely use it. The incidence of FES has decreased from almost 8% to close to 2% since its clinical description.…”

Microbleeds show a characteristic distribution in cerebral fat embolism

“…CT scans performed are typically without any specific finding, however may show widespread interval low density changes which should raise the suspicion of CFE [ 11 ]. Compared to CT, imaging findings in MRI are much more common in CFE [ 17 ].…”

“…The “starfield pattern” has been widely used in literature for describing the reversible imaging pattern of multifocal punctate lesions showing diffusion restriction. Other reported features include confluent cytotoxic edema in the white matter, and vasogenic lesions that may enhance [ 1 , 11 , 17 ]. Additional features of CFE that has been increasingly reported more recently are cerebral and cerebellar microbleeds depicted by susceptibility weighted imaging (SWI) or T2* MRI [ 18 ].…”

“…Cerebral fat embolism syndrome (CFES) occurs in up to 60% of patients with FES and is usually considered to be a self-limiting entity, but recent studies have also shown possible links to long term neurocognitive impairment [8][9][10]. The clinical presentation of CFES may vary considerably, symptoms typically appear between 12 to 72 h after the injury and may range from mild neurological impairment to alarming symptoms like coma or even death in the most severe cases [11].…”

Intraparenchymal Neuromonitoring of Cerebral Fat Embolism Syndrome

“…Further, at time points ranging from 10 to 15 days postischemic injury, pseudonormalization of the diffusion-weighted imaging signal must be considered when interpreting these neuroimaging results. Other investigations have observed incomplete resolution of cerebral lesions (e.g., Fluid Attenuation Inverted Recovery hyperintensities) as well as long-term neurologic deficits ( 6 ).…”