Introduction: Isolated cerebral fat embolism syndrome (FES) is a rare complication that occurs within the first 3 days of the initial insult. We report a case of multiple long bone fractures with isolated cerebral FES, despite undergoing early total care with definitive fixation.
Case presentation: A 22-year-old female presented with type IIIA open femur shaft fracture on the right side (AO 32B2), closed femur shaft fracture (AO 32B2), comminuted patella fracture on the left side (AO 34C3), and undisplaced mandible fracture. She had a normal sensorium with a Glasgow Coma Scale (GCS) of E4V5M6. A whole body computed tomography (CT) scan was done to rule out other injuries. All initial scans were normal. After about 6 h in the ICU, she was noticed to have disconjugate gaze and was answering in monosyllables. A repeat CT scan of the brain was normal. The early total care and definitive fixation with titanium intramedullary nails for femur fractures and tension band wiring for patella was done under general anesthesia. On 1st post-operative day (POD), her GCS dropped to E1VTM1. On the 3rd POD, she developed decerebrate rigidity and generalized tonic clonic seizures. Fundoscopic examination showed multiple fat globules along the vessel in the entire field of both eyes. Since there were no other signs of FES in the lungs or on the skin, an MRI brain was done which revealed a hyperintensive starfield pattern on diffusion-weighted images, suggestive of cerebral fat embolism (CFE). At 4 weeks, her upper limb and lower limb muscle power improved. By 2 months, she was mobilized with support. Her Mini-Mental State Examination showed no cognitive impairment. At the latest follow-up at 1 year, her fractures are completely healed and she has no neurological or functional impairment.
Conclusion: We must always suspect isolated cerebral FES as a diagnosis in polytrauma patients even when the classical findings are not present. MRI compatible implants have to be used as far as possible as MRI may be required to confirm the diagnosis of CFE. The early total care with definitive fixation and supportive treatment helped us in this patient's complete recovery without cognitive impairment.
Keywords: Cerebral fat embolism; bilateral femur fracture; fat embolism syndrome; polytrauma.
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