Susceptibility-Weighted Imaging Diagnosis of Cerebral Fat Embolism

Burns, Joseph D.; Noujaim, Daniel L.; Scott, Brian J.

doi:10.1177/1941874416669284

Cited by 3 publications

(2 citation statements)

References 2 publications

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“…SWI sequences make it possible to detect the presence of petechial hemorrhage , another characteristic pattern of CFE that is observed in all stages, because they can evaluate vascular structures, blood products, and changes in iron content 52,58–61. These tiny lesions, localized in the perivascular space at both the white and deep gray matter level in the cerebellum, brainstem, and corpus callosum, need to be distinguished from the petechial hemorrhage lesions present in diffuse axonal injury (DAI), another condition that, like CFE, can be observed after a traumatic event.…”

Section: Introductionmentioning

confidence: 99%

From the diagnosis to the therapeutic management: cerebral fat embolism, a clinical challenge

Scarpino¹,

Lanzo²,

Lolli³

et al. 2019

IJGM

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Cerebral fat embolism (CFE) is an uncommon incomplete type of fat embolism syndrome (FES), characterized by purely cerebral involvement. It usually occurs 12–72 hours after the initial trigger, mainly represented by closed, long-bone multiple fractures of the lower extremities. Neurological manifestations are mainly characterized by headache, confusion, seizures, focal deficit, and alteration of the consciousness state up to coma onset. It represents a diagnostic challenge, above all when secondary to uncommon nontraumatic causes, because neurological signs and symptoms are variable and nonspecific, not satisfying the Gurd and Wilson’s criteria, the diagnostic features most widely used today for FES diagnosis. Neuroimaging (mainly MRI, but in some cases, brain computed tomography too) can hasten the diagnosis, avoiding other unnecessary investigations and treatment. Usually self-limiting, CFE may sometimes be fatal. Treatment is to date mainly supportive and prophylactic strategies are considered an important tool to decrease the development of fat embolism and, consequently, the rate of CFE.

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Section: Introductionmentioning

confidence: 99%

From the diagnosis to the therapeutic management: cerebral fat embolism, a clinical challenge

Scarpino¹,

Lanzo²,

Lolli³

et al. 2019

IJGM

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“…Diagnosing fat embolism syndrome is challenging, with uncertain accuracy of clinical scoring systems 1,17 based on inflammation, neurological symptoms, petechiae, and respiratory failure. Cerebral magnetic resonance imaging (MRI) with susceptibility- and diffusion-weighted images is definitive for diagnosing cerebral bone marrow emboli 4,18-20 , while computed tomography (CT) is insufficient for diagnosing cerebral and pulmonary emboli 21,22 . Perioperative transesophageal echocardiography (TEE) can detect emboli 23-26 but is rarely used during orthopaedic surgery.…”

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confidence: 99%

Femoral Nailing in a Porcine Model Causes Bone Marrow Emboli in the Lungs and Systemic Emboli in the Heart and Brain

Kristiansen,

Jarmund,

Hilmo

et al. 2024

JBJS Open Access

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Background: Shaft fractures of the femur are commonly treated with intramedullary nailing, which can release bone marrow emboli into the bloodstream. Emboli can travel to the lungs, impairing gas exchange and causing inflammation. Occasionally, emboli traverse from the pulmonary to the systemic circulation, hindering perfusion and resulting in injuries such as heart and brain infarctions, known as fat embolism syndrome. We studied the extent of systemic bone marrow embolization in a pig model. Methods: Twelve anesthetized pigs underwent bilateral intramedullary nailing of the femur, while 3 animals served as sham controls. Monitoring included transesophageal echocardiography (TEE), pulse oximetry, electrocardiography, arterial blood pressure measurement, and blood gas and troponin-I analysis. After surgery, animals were monitored for 240 minutes before euthanasia. Post mortem, the heart, lungs, and brain were biopsied. Results: Bone marrow emboli were found in the heart and lungs of all 12 of the pigs that underwent intramedullary nailing and in the brains of 11 of them. No emboli were found in the sham group. The pigs subjected to intramedullary nailing exhibited significant hypoxia (PaO2/FiO2 ratio, 410 mm Hg [95% confidence interval (CI), 310 to 510) compared with the sham group (594 mm Hg [95% CI, 528 to 660]). The nailing group exhibited ST-segment alterations consistent with myocardial ischemia and a significant increase in the troponin-I level compared with the sham group (1,580 ng/L [95% CI, 0 to 3,456] versus 241 ng/L [95% CI, 0 to 625] at the 240-minute time point; p = 0.005). TEE detected emboli in the right ventricular outflow tract, but not systemically, in the nailing group. Conclusions: Bilateral intramedullary nailing caused bone marrow emboli in the lungs and systemic emboli in the heart and brain in this pig model. The observed clinical manifestations were consistent with coronary and pulmonary emboli. TEE detected pulmonary but not systemic embolization. Clinical Relevance: Femoral intramedullary nailing in humans is likely to result in embolization as described in our pig model. Focused monitoring is necessary for detection of fat embolism syndrome. Absence of visual emboli in the left ventricle on TEE does not exclude the occurrence of systemic bone marrow emboli.

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Microbleeds show a characteristic distribution in cerebral fat embolism

et al. 2021

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This systematic review aims to test the hypothesis that microbleeds detected by MRI are common and show a characteristic pattern in cerebral fat embolism (CFE). Eighty-four papers involving 140 CFE patients were eligible for this review based on a systematic literature search up to 31 January 2020. An additional case was added from hospital records. Patient data were individually scrutinised to extract epidemiological, clinical and imaging variables. Characteristic CFE microbleed pattern resembling a “walnut kernel” was defined as punctuate hypointensities of monotonous size, diffusely located in the subcortical white matter, the internal capsule and the corpus callosum, with mostly spared corona radiata and non-subcortical centrum semiovale, detected by susceptibility- or T2* weighted imaging. The presence rate of this pattern and other, previously described MRI markers of CFE such as the starfield pattern and further diffusion abnormalities were recorded and statistically compared. The presence rate of microbleeds of any pattern, the “walnut kernel microbleed pattern”, diffusion abnormality of any pattern, the starfield pattern, and cytotoxic edema in the corpus callosum was found to be 98.11%, 89.74%, 97.64%, 68.5%, and 77.27% respectively. The presence rate between the walnut kernel and the starfield pattern was significantly (p < 0.05) different. Microbleeds are common and mostly occur in a characteristic pattern resembling a “walnut kernel” in the CFE MRI literature. Microbleeds of this pattern in SWI or T2* MRI, along with the starfield pattern in diffusion imaging appear to be the most important imaging markers of CFE and may aid the diagnosis in clinically equivocal cases.

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Susceptibility-Weighted Imaging Diagnosis of Cerebral Fat Embolism

Cited by 3 publications

References 2 publications

From the diagnosis to the therapeutic management: cerebral fat embolism, a clinical challenge

From the diagnosis to the therapeutic management: cerebral fat embolism, a clinical challenge

Femoral Nailing in a Porcine Model Causes Bone Marrow Emboli in the Lungs and Systemic Emboli in the Heart and Brain

Microbleeds show a characteristic distribution in cerebral fat embolism

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