When the fat hits the brain—salvage STA–MCA bypass for an intracranial ICA occlusion due to a fat embolus

Abstract

BackgroundLarge fat embolus is a rare but potential reversible cause of ischaemic stroke.Methods and resultsWe describe the neurosurgical management of a complete right internal carotid artery occlusion due to a large fat embolus, caused by a mitral valve replacement.ConclusionKnowledge of acute cerebral ischaemia due to large fat embolism and its hallmark ‘hypodense artery’ is mandatory. Extracranial to intracranial bypass is a feasible rescue treatment after failure of endovascular embolectomy.

Cerebral Large Vessel Occlusion Caused by Fat Embolism—A Case Series and Review of the Literature

“…Nine patients were female, seven were male, and two did not have gender reported. Eight of the reported patients had undergone cardiac surgery, most commonly mitral valve replacement (6 patients) (11,(14)(15)(16)(17)(18)(19)(20). Six patients had orthopaedic procedures or preceding trauma, and three patients were deemed spontaneous (2,10,(21)(22)(23)(24)(25)(26)(27).…”

“…Distal contact aspiration alone (ADAPT) OR used in combination with stent retrievers would be a favoured first line approach. Of the 7 reported patients who underwent reperfusion therapy (ECR or STA-MCA bypass, excluding the patient who had unsuccessful ECR), 5 survived with reasonable function (modified Rankin scale 3 or better from case descriptions), one patient died due lack of clinical improvement, and another died due to intracranial haemorrhage shortly after ECR (2,14,(22)(23)(24)(25)(26). In comparison, of the patients who did not receive reperfusion therapy or received unsuccessful reperfusion therapy, five patients died, and two were functionally disabled (mRS 4) (10,15,17,18,21,27,28).…”

“…One patient had LVO 9 days after Caesarean section, with multiple other embolic complications ( 28 ). Eleven of the 15 patients who did not have spontaneous LVO had onset of symptoms within 6 h of the presumed mechanism of injury ( 10 , 11 , 14 , 15 , 19 – 21 , 23 – 25 , 27 ). Four of the five patients who underwent PFO assessment were found to have a PFO ( 23 – 25 , 27 , 28 ).…”

“…With regards to treatment where it was available, one patient was treated with intravenous thrombolysis, eight patients underwent ECR or attempted ECR and three patients underwent decompressive hemicraniectomy. One patient also underwent (superficial temporal artery to middle cerebral artery) STA-MCA bypass in an attempt to bypass a right internal carotid artery occlusion ( 14 ). Of the patients with reported outcomes, 7 patients died within 3 months, 3 had mild persistent symptoms, and 3 had significant functional disability.…”

“…In contrast, cases of LVO from fat emboli appear more neurologically severe compared to FES, with previous patient reports requiring decompressive hemicraniectomy for diffuse cerebral oedema ( 10 , 15 , 28 , 34 ). Endovascular clot retrieval is also emerging as a treatment option for these cases ( 2 , 14 , 22 – 26 , 28 , 35 ). Successful endovascular clot retrieval has also been performed in large vessel occlusions due to fat embolism during liposuction ( 35 ).…”