Fat Embolism and Nonconvulsive Status Epilepticus

Abstract

Fat embolism syndrome (FES) typically occurs following orthopedic trauma and may present with altered mental status and even coma. Nonconvulsive status epilepticus is an electroclinical state associated with an altered level of consciousness but lacking convulsive motor activity and has been reported in fat embolism. The diagnosis is clinical and is treated with supportive care, antiepileptic therapy, and sedation. A 56-year-old male presented with altered mental status following internal fixation for an acute right femur fracture due to a motor vehicle accident 24 hours earlier. Continued neuromonitoring revealed nonconvulsive status epilepticus. Magnetic resonance imaging of the brain showed multiple bilateral acute cerebral infarcts with a specific pattern favoring the diagnosis of fat embolism syndrome. He was found to have a significant right to left intracardiac shunt on a transesophageal echocardiogram. He improved substantially over time with supportive therapy, was successfully extubated on day 6, and discharged to inpatient rehabilitation on postoperative day 15. Fat embolisms can result in a wide range of neurologic manifestations. Nonrefractory nonconvulsive status epilepticus that responds to antiepileptic drugs, sedation, and supportive therapy can have a favorable outcome. A high index of suspicion and early recognition reduces the chances of unnecessary interventions and may improve survival.

Fat Embolism Syndrome With Cerebral Involvement: An Underrecognized Complication of Long Bone Fractures

“…Damage to the retina, kidney, liver, and heart has been reported, although the triad of petechial hemorrhages, respiratory distress, and altered mental status is the most common clinical presentation [ 1 - 2 ]. Cutaneous manifestations take on the form of a petechial vest-like structure in the axillary or trunk region and occur in up to 50-60% of cases but can be transient [ 1 , 7 - 8 ]. Pulmonary complications occur in up to 75% of cases, and 39% of patients develop severe hypoxemic respiratory failure that can be indistinguishable from acute respiratory distress syndrome [ 1 , 7 ].…”

“…The clinical presentation and ultimate prognosis of CFE are variable and depend on the disease burden. Patients with acute respiratory distress syndrome generally have the worst prognosis, as most deaths are attributed to respiratory failure [ 1 , 7 ]. This was evident in the presented case, as the patient’s worsening respiratory failure contributed to mortality despite an early diagnosis of CFE.…”

“…Cutaneous manifestations take on the form of a petechial vest-like structure in the axillary or trunk region and occur in up to 50-60% of cases but can be transient [ 1 , 7 - 8 ]. Pulmonary complications occur in up to 75% of cases, and 39% of patients develop severe hypoxemic respiratory failure that can be indistinguishable from acute respiratory distress syndrome [ 1 , 7 ]. Neurologic symptoms are the most common and occur in 85% of cases [ 1 , 7 ].…”

“…Pulmonary complications occur in up to 75% of cases, and 39% of patients develop severe hypoxemic respiratory failure that can be indistinguishable from acute respiratory distress syndrome [ 1 , 7 ]. Neurologic symptoms are the most common and occur in 85% of cases [ 1 , 7 ]. CFE is a sequela of FES and is diagnosed when neurological involvement is either seen on imaging or is the main symptomatic manifestation of the disease [ 3 , 6 ].…”

<p>Extremely Acute-Onset Cerebral Fat Embolism</p>

“…Studies have reported nonconvulsive status epilepticus (NCSE) secondary to FES. 14,20,21 NCSE shows only the presence of an altered consciousness but lacks convulsive motor activity; thus, EEG should be diagnosed. Our patient had been in coma without focal motor or generalized tonic-clonic seizure; however, EEG showed no epileptiform discharges even without the use of any sedative or antiepileptic drugs.…”