Cerebral fat embolism after traumatic bone fractures: a structured literature review and analysis of published case reports

Abstract Background The incidence of cerebral fat embolism (CFE) ranges from 0.9–11%, with a mean mortality rate of around 10%. Although no univocal explanation has been identified for the resulting fat embolism syndrome (FES), two hypotheses are widely thought: the ‘mechanical theory’, and the ‘chemical theory’. The present article provides a systematic review of published case reports of FES following a bone fracture. Methods We searched MEDLINE, Web of Science and Scopus to find any article related to FES. Inclusion criteria were: trauma patients; age ≥ 18 years; and the clinical diagnosis of CFE or FES. Studies were excluded if the bone fracture site was not specified. Results One hundred and seventy studies were included (268 cases). The male gender was most prominent (81.6% vs. 18.4%). The average age was 33 years (±18). The mean age for males (29 ± 14) was significantly lower than for females (51 ± 26) (p < 0.001). The femur was the most common fracture site (71% of cases). PFO was found in 12% of all cases. Univariate and multivariate regression analyses showed the male gender to be a risk factor for FES: RR 1.87 and 1.41, respectively (95%CI 1.27–2.48, p < 0.001; 95%CI 0.48–2.34, p < 0.001). Conclusions FES is most frequent in young men in the third decades of life following multiple leg fractures. FES may be more frequent after a burst fracture. The presence of PFO may be responsible for the acute presentation of cerebral embolisms, whereas FES is mostly delayed by 48–72 h.

Download Full-text

Cerebral fat embolism in the absence of a long bone fracture: A rare case report

Surgical Neurology International ◽

10.25259/sni_946_2020 ◽

2021 ◽

Vol 12 ◽

pp. 78

Author(s):

James B. Fowler ◽

Brian Fiani ◽

Kasra Sarhadi ◽

Vladimir Cortez

Keyword(s):

Bone Fracture ◽

Case Reports ◽

Small Diameter ◽

Fat Embolism ◽

Long Bone ◽

Pathology Report ◽

Fat Embolism Syndrome ◽

Embolism Syndrome ◽

Long Bone Fracture ◽

Tandem Lesions

Background: The classic triad of fat embolism syndrome consists of pulmonary distress, mental status change, and petechial rash. Typically, symptoms manifest 24–48 hours after a long bone fracture, but case reports have demonstrated fat embolism syndrome without long bone fracture. These cases are initiated by a stress response, mobilizing free fatty acids into the circulation. Case Description: Herein, we present the case of a 70-year-old male who presented with the left-sided hemiparesis and was subsequently found to have tandem lesions of the right internal carotid artery (ICA) and right middle cerebral artery (MCA) warranting emergent mechanical thrombectomy (MT). The ensuing pathology report determined the source of ischemic stroke to be caused by fat embolism, a rare and intriguing case of cryptogenic large vessel occlusion (LVO) with unique features distinguishing it from other reports in the literature. Conclusion: According to the biochemical theory, a catecholamine surge can precipitate fat globules forming in the circulatory system, leading to tissue hypoxia, injury, and ischemia. While the majority of cerebral fat emboli cause reversible ischemia of small diameter vessels, our case presents with LVO and tandem lesions in both the ICA and MCA resulting in infarct and residual hemiparesis.

Download Full-text

Can the rate of mortality and neurological recovery be predicted from the time of onset of symptoms and MRI grade in patients with cerebral fat embolism?

The Bone & Joint Journal ◽

10.1302/0301-620x.104b1.bjj-2021-0420.r1 ◽

2022 ◽

Vol 104-B (1) ◽

pp. 142-149

Author(s):

B. Roy W. Armstrong ◽

Agraharam Devendra ◽

Shweta Pokale ◽

Bala Subramani ◽

Velmurugan Rajesh Babu ◽

...

Keyword(s):

Early Onset ◽

Fat Embolism ◽

Clinical Severity ◽

Neurological Recovery ◽

Embolism Syndrome ◽

The Mean ◽

Cerebral Fat Embolism Syndrome ◽

Late Recovery ◽

State Examination

Aims The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated. Methods The study included 34 patients who were diagnosed with CFES following trauma between 2012 and 2018. The clinical diagnosis was confirmed and the severity graded by MRI. We investigated the rate of mortality, the time and extent of neurological recovery, the time between the injury and the onset of symptoms, the clinical severity of the condition, and the MRI grade. All patients were male with a mean age of 29.7 years (18 to 70). The mean follow-up was 4.15 years (2 to 8), with neurological recovery being assessed by the Glasgow Outcome Scale and the Mini-Mental State Examination. Results In all, seven who had early-onset CFES (< 24 hours), and a severe Takahashi grade on MRI, died. There was a significant association between the time of onset of neurological signs and mortality (p = 0.035). Mortality was also significantly associated with a severe Takahashi grade (p < 0.001). Among the 27 surviving patients, 26 (96.3%) recovered completely. One (3.7%) had a cognitive deficit. The mean time to recovery was 4.7 weeks (2 to 13), with late recovery aftereight eight weeks being recorded in three patients. Conclusion There was a significantly increased rate of mortality in patients with CFES who had an early onset of symptoms and a severe grade on MRI. Complete neurological recovery can be expected in most patients with CFES who survive. Cite this article: Bone Joint J 2022;104-B(1):142–149.

Download Full-text

Fat Embolism Syndrome with Bone Fractures

Tuberculosis and Respiratory Diseases ◽

10.4046/trd.1990.37.2.167 ◽

1990 ◽

Vol 37 (2) ◽

pp. 167-174

Author(s):

Byung Il Kim ◽

Se Kyu Kim ◽

Joon Chang ◽

Hyung Gil Kim ◽

Sung Kyu Kim ◽

...

Keyword(s):

Bone Fractures ◽

Fat Embolism ◽

Fat Embolism Syndrome ◽

Embolism Syndrome

Download Full-text

Correlation between Pelvic Bone Fracture Site and Arterial Embolization in Severe Trauma Patients: A Retrospective Study in a Single Korean Institute

Trauma Monthly ◽

10.5812/traumamon.33461 ◽

2016 ◽

Vol inpress (inpress) ◽

Author(s):

Yong Han Cha ◽

Joong Suck Kim ◽

Yeong Cheol Kim ◽

Young Hoon Sul ◽

Ha Yong Kim ◽

...

Keyword(s):

Retrospective Study ◽

Bone Fracture ◽

Arterial Embolization ◽

Severe Trauma ◽

Fracture Site ◽

Pelvic Bone ◽

Trauma Patients

Download Full-text

Fat Embolism Syndrome

Mayo Clinic Challenging Images for Pulmonary Board Review ◽

10.1093/med/9780199756926.003.0007 ◽

2010 ◽

pp. 34-46

Author(s):

Edward C. Rosenow

Keyword(s):

Aortic Arch ◽

Bone Fracture ◽

Fat Embolism ◽

Long Bone ◽

Fat Embolism Syndrome ◽

Fat Globules ◽

Direct Trauma ◽

Embolism Syndrome ◽

Long Bone Fracture

Biopsy of these petechiae would show fat globules in the small arterioles. Such petechiae are theorized to occur only above the level of the diaphragm because the fat floats and is spun off in the aortic arch into the subclavian and innominate vessels • Within 48 hours of a long-bone fracture, the following develop (unrelated to direct trauma):...

Download Full-text

Hemostasis and Thrombosis in Trauma Patients

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0034-1398378 ◽

2015 ◽

Vol 41 (01) ◽

pp. 026-034 ◽

Cited By ~ 14

Author(s):

Satoshi Gando

Keyword(s):

Wound Healing ◽

Protein C ◽

Activated Protein C ◽

Fat Embolism ◽

Whole Body ◽

Severe Bleeding ◽

Trauma Patients ◽

Embolism Syndrome ◽

Acute Coagulopathy Of Trauma ◽

Pathological Reaction

Hemostasis and thrombosis in trauma patients consist of physiological hemostasis for wound healing and the pathological reaction of disseminated intravascular coagulation (DIC). Whole body trauma, isolated brain injury, and fat embolism syndrome, if extremely severe, can cause DIC and affect a patient's prognosis. Shock-induced hyperfibrinolysis causes DIC with the fibrinolytic phenotype, contributing to oozing-type severe bleeding. If uncontrolled, this phenotype progresses to thrombotic phenotype at the late stage of trauma, followed by microvascular thrombosis, leading to organ dysfunction. Another type of pathological hemostatic change is acute coagulopathy of trauma shock (ACOTS), which gives rise to activated protein C–mediated systemic hypocoagulation, resulting in bleeding. ACOTS occurs only in trauma associated with shock-induced hypoperfusion and there is nothing to suggest DIC in this phenomenon. This review will provide information about the recent advances in hemostasis and thrombosis in trauma and will clarify the pathogeneses of the pathological processes observed in trauma patients.

Download Full-text

Complications of fractures

10.1093/med/9780199550647.003.012002 ◽

2011 ◽

Author(s):

James Wilson-MacDonald ◽

Andrew James

Keyword(s):

Bone Fractures ◽

Fat Embolism ◽

Gas Gangrene ◽

Long Bone ◽

Vein Thrombosis ◽

Embolism Syndrome ◽

Tissue Removal ◽

Trophic Changes ◽

Prolonged Pain ◽

Deep Vein

♦ Fat embolism syndrome is defined as the presence of globules of fat in the lungs and in other tissues and occurs occasionally in long bone fractures♦ Reflex sympathetic dystrophy is characterized by intense prolonged pain, vasomotor disturbance, delayed functional recovery, and trophic changes♦ Avascular necrosis typically affects intra-articular bone after fracture and can occur in up to 70% of displaced talar neck fractures♦ Immobility associated with recovery from fracture is associated with deep vein thrombosis, which carries a risk of pulmonary embolism, and should be treated with anti-coagulants♦ Gas gangrene is a rapidly-spreading infection of devitalized tissue, removal of the affected area and treatment with penicillin is required♦ Compartment syndrome within a closed compartment can result in tissue ischaemia and necrosis followed by fibrosis and muscle contracture

Download Full-text