As indicated in the Case Record 23-2016 (July 28 issue) published by NEJM, a 46-year-old male patient developed rapidly progressive somnolence 12-14 hours after proximal femoral replacement surgery (1). The absence of respiratory distress and petechial rash made challenging the differential diagnosis. However, as shown in Figure3 (1), the “stratified pattern” in conventional T2-weighted or diffusion weighted MRI (DWI) is useful for the early diagnosis of fat embolism syndrome (FES) (2,3). Notably, several case reports have suggested that the recovery of the neurological symptoms observed in FES patients is accompanied by the reversible disappearance of multiple nodular or punctate foci of high signal intensity mainly distributed in the white matter of both cerebral hemispheres (3-5). Thus, the evaluation of temporal MRI changes is expected to be important for the accurate prediction of FES prognosis. I wonder whether that reversibility was the case in this patient. Furthermore, as compared with the vasogenic edema associated with numerous micro-infarcts, the cytotoxic edema is likely to be involved in the pathophysiology of FES (5). That may be why whether the cytotoxic edema is transient and reversible seems to make the difference in the prognosis of this syndrome.
[References]
1. Chiappa V, Gonzalez RG, Manian FA, Deshpande V. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 23-2016. A 46-Year-Old Man with Somnolence after Orthopedic Surgery. N Engl J Med 2016;375:370-8.
2. Bodanapally UK, Shanmuganathan K, Saksobhavivat N, et al. MR imaging and differentiation of cerebral fat embolism syndrome from diffuse axonal injury: application of diffusion tensor imaging. Neuroradiology 2013;55:771-8.
3. Parizel PM, Demey HE, Veeckmans G, et al. Early diagnosis of cerebral fat embolism syndrome by diffusion-weighted MRI (starfield pattern). Stroke 2001;32:2942-4.
4. Aravapalli A, Fox J, Lazaridis C. Cerebral fat embolism and the "starfield" pattern: a case report. Cases J 2009;2:212.
5. Butteriss DJ, Mahad D, Soh C, Walls T, Weir D, Birchall D. Reversible cytotoxic cerebral edema in cerebral fat embolism. AJNR Am J Neuroradiol 2006;27:620-3.
***
This is the opinion I have after reading this case report. I am greatly appreciated if you would be kind enough to give me some comments or advice. After all, what is the difference between fat embolization and fat embolism syndrome (FES)?
Thank you in advance.
Go J. Yoshida MD, PhD.
Hello Go J Yoshida,
The term ‘fat embolism’ indicates the presence of fat globules in the peripheral circulation and lung parenchyma after fracture of long bones, pelvis or other major trauma. It occurs in approximately all patients who sustain a long bone or a pelvic fracture. In 1861, Zenker described fat droplets in the lung capillaries of a railroad worker who sustained a fatal thoracoabdominal crush injury.
‘Fat embolism syndrome’ is a serious manifestation of fat embolism phenomenon characterized clinically by triad of dyspnoea, petechiae and mental confusion.
In 1873, Bergmann was first to establish the clinical diagnosis of fat embolism syndrome.
please cgeck the resources
regards
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700578/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665122/
www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central (PMC)
emedicine.medscape.com/article/460524-overview
ceaccp.oxfordjournals.org › Oxford Journals › Medicine & Health › BJA: CEACCP
patient.info/in/doctor/fat-embolism-syndrome
www.uptodate.com/contents/fat-embolism-syndrome
I observed such a syndrome more than twenty five years back following a successful stent implantation in femoral artery occlusion in an octogenarian with lower limb ischemia. The lesion was soft and the block was cleared but after discharge he developed cerebral and pulmonary problems at home that was fortunately cleared with medical treatment. We did not have facilities for investigation to detect the lesions but decided it to be fat and debris embolization and never repeated such procedure.
Hello Go
Fat embolism can be observed in big fractures and certain other clinical events. It is characterized by a highly osmolar lipid release from adipocytes and consequently cell and platelet activation are ofeten observed. Patients are vascularly unstable. As other collegues have documented, removal of fat from arteries will also cause the described symptoms.
I hope to have clarified the question,
regards,
My pleasure Dr Gupta. It is a very important lesson to trasmit to young or non experienced doctors.
- Badges
- Science topic
- Similar topics
- Social Psychology
- Attitude