Cerebral Embolism as a Result of Facial Filler Injections: A Literature Review

Abstract

Background With the popularity of facial filler injections, increased severe adverse events, such as cerebral embolism, have been reported. Objectives This article aims to summarize the clinical manifestations, and proposed mechanism of the filler-induced cerebral embolism (FICE) cases. Methods A literature review was performed with the search keywords including “filler injection, hyaluronic acid, fat graft, cerebral infarction/embolism, stroke, cerebrovascular infarction, disorders of consciousness, and hemiplegia”. Results Among the 43 cases of FICE from 35 articles enrolled, 37 patients were female, and 6 were male. Twenty-nine of these patients received fat grafting, followed by 12 who received HA injection. Most of the injection sites of FICE patients were at the glabella, followed by temporal, forehead, and nasal areas. Among 30 patients receiving injection under local anesthesia, 43.33% presented with neurological symptoms during the procedure. The main symptoms were consciousness disorders and hemiplegia. Most of the embolization sites were in the middle cerebral artery, followed by frontal lobe infarction and anterior cerebral artery infarction. Three patients developed cerebral hemorrhage after embolism. Twenty-six patients presented with newly acquired vision loss, and 17 patients did not have newly acquired vision loss. The management for FICE cases included embolectomy, thrombolysis, decompressive craniectomy, antiplatelet/anticoagulant therapy and symptomatic and nutritional treatment. Nearly half of the patients recovered or improved in neurological manifestations but not the visual loss. Five patients died. Conclusions FICE is a severe complication following facial filler injection. Careful prevention, timely identification and treatment are crucial to decrease the morbidity and mortality of FICE.

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

“…Patients were excluded from our review where they underwent a recent procedure involving injection or removal of fat, including autologous fat filler procedures, and liposuction. The entity of filler induced cerebral embolism (FICE) has been well-reported and has been recently reviewed by Wang et al FICE generally involves areas of extensive arterial supply and are known “danger zones” for intracranial emboli ( 13 ).…”

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)—Implications for Therapeutic Interventions

“…The most commonly employed modalities included pharmacotherapy (steroids, antiplatelet agents, mannitol, and thrombolytics), HBOT, decompressive craniectomy, and intra-arterial mechanical/thrombolytic interventions. Despite treatment, the majority of patients with FICE suffered persistent functional deficits and 10% succumbed to injuries [ 26 ]. The early recognition and prompt initiation of therapy are critical to the successful management of CRI.…”

“… Increasing incidence in the number of published cases of filler-induced complications between 2001 and 2020: ( a ) skin necrosis, data from Soares et al [ 25 ]; ( b ) cerebral embolism, data from Wang et al [ 26 ]. …”

“…Beleznay et al reported nearly 50 cases of filler-induced blindness within a period of approximately 3 years between 2015 and 2018, standing in sharp contrast to the 98 published instances of such occurrences in the preceding century [ 23 , 24 ]. Similarly, the incidence of filler-induced ischemic skin injuries has shown a 30-fold increase between 2000 and 2020, while that of filler-induced stroke has risen by 300% ( Figure 2 ) [ 25 , 26 ]. In 2015, in response to this well-documented hazard, the FDA ordered the re-labelling of all filler products to include a warning statement on the risk of vascular occlusion [ 27 ].…”

Commentary on: Three-Dimensional Arterial Distribution Over the Midline of the Nasal Bone

“…Skin necrosis, blindness, strokes, and even deaths are the dire modern-day consequences of inadvertent facial filler embolism into the branches of the ophthalmic arteries, which have only been documented in the last 30 years. Over 200 cases of blindness 8-10 and 43 cases of cerebral strokes 11 have been officially recorded during this period, a large majority of them from Asia.…”