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Nielsen LF, Pott F, Lohse A, Talibi MN, Olsen MH. Cerebral fat emboli in a patient with paraplegia caused by bilateral femur fractures. BMJ Case Rep 2024; 17:e257702. [PMID: 38176747 PMCID: PMC10773286 DOI: 10.1136/bcr-2023-257702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
Abstract
Cerebral fat embolism is a rare cause of stroke and therefore an overlooked diagnosis. Often it is seen as a consequence of major bone fractures or after arthroplasty, and can lead to respiratory or circulatory collapse. We present a case of a patient with a history of paraplegia after a thoracic spinal cord injury that developed cerebral fat embolism following a bilateral femur fracture. Since the patient was paraplegic and with an altered mental state upon admission, femoral bone fractures were not initially suspected. The case shows the difficulties in diagnosing this condition.
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Affiliation(s)
| | - Frank Pott
- Department of Anaesthesiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Allan Lohse
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Markus Harboe Olsen
- Department of Anaesthesiology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Neuroanaesthesiology, Rigshospitalet, Copenhagen, Denmark
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Kimura S, Yagi R, Kishi F, Ogawa D, Yamada K, Taniguchi H, Wanibuchi M. A Case of Fulminant Fat Embolism Syndrome With Very Early Onset After Femoral Neck and Sacral Fractures. Cureus 2023; 15:e35911. [PMID: 37033540 PMCID: PMC10081915 DOI: 10.7759/cureus.35911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/11/2023] Open
Abstract
Fulminant fat embolism syndrome (FES) occurring within 1 h after trauma is extremely rare. We report a case of fulminant FES that developed hyperacute nature after a traumatic injury. A 66-year-old woman was injured when she fell approximately 1.5 m down the stairs. She was rushed to our hospital. One minute after arrival, which was 49 min after the injury, her consciousness and respiratory status deteriorated. Thoracoabdominal and pelvic computed tomography revealed preexisting interstitial pneumonia, a left femoral neck fracture, and a left sacral fracture. Head magnetic resonance imaging (diffusion-weighted imaging) showed diffuse high-signal areas and susceptibility-weighted imaging showed diffuse small perivascular of perivascular hemorrhages. She was diagnosed with fulminant FES. After conservative treatment, she was transferred to a rehabilitation hospital with a Glasgow Coma Scale (GCS) of 8 and a modified Rankin Scale of 5 on Day 45. The possibility of fulminant FES should be considered a cause of early impaired consciousness after a fracture.
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Affiliation(s)
- Seigo Kimura
- Department of Neurosurgery, Kouzenkai Yagi Neurosurgical Hospital, Osaka, JPN
| | - Ryokichi Yagi
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Osaka, JPN
| | - Fumihisa Kishi
- Department of Neurosurgery, Kouzenkai Yagi Neurosurgical Hospital, Osaka, JPN
| | - Daiji Ogawa
- Department of Neurosurgery, Kouzenkai Yagi Neurosurgical Hospital, Osaka, JPN
| | - Keiichi Yamada
- Department of Neurosurgery, Kouzenkai Yagi Neurosurgical Hospital, Osaka, JPN
| | - Hirokatsu Taniguchi
- Department of Neurosurgery, Kouzenkai Yagi Neurosurgical Hospital, Osaka, JPN
| | - Masahiko Wanibuchi
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Osaka, JPN
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Cerebral fat embolism syndrome at a single trauma center. J Stroke Cerebrovasc Dis 2022; 31:106794. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/21/2022] Open
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Vetrugno L, Bignami E, Deana C, Bassi F, Vargas M, Orsaria M, Bagatto D, Intermite C, Meroi F, Saglietti F, Sartori M, Orso D, Robiony M, Bove T. Cerebral fat embolism after traumatic bone fractures: a structured literature review and analysis of published case reports. Scand J Trauma Resusc Emerg Med 2021; 29:47. [PMID: 33712051 PMCID: PMC7953582 DOI: 10.1186/s13049-021-00861-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
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. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00861-x.
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Affiliation(s)
- Luigi Vetrugno
- Department of Anesthesia and Intensive Care, Anesthesia and Intensive Care Clinic, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy. .,Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy.
| | - Elena Bignami
- Department of Medicine and Surgery, Unit of Anesthesiology, Parma University Hospital, Parma, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Anesthesia and Intensive Care Unit 1, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care, Anesthesia and Intensive Care Unit 2, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Maria Orsaria
- Department of Medicine, Surgical Pathology Section, University of Udine, Udine, Italy
| | - Daniele Bagatto
- Department of Diagnostic Imaging, Neuroradiology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Cristina Intermite
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
| | - Francesco Meroi
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
| | | | - Marco Sartori
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
| | - Daniele Orso
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
| | - Massimo Robiony
- Department of Medicine, Maxillofacial Surgery, University of Udine, Udine, Italy.,Azienda Sanitaria Universitaria Friuli Centrale, Maxillofacial Surgery, Udine, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care, Anesthesia and Intensive Care Clinic, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy.,Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
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Lundeen KM, Bhoopal JR, Simegn MA, Leatherman JW. Acute Hypoxemia and Coma in a Patient With Hemoglobin SC Disease. Chest 2019; 155:e21-e23. [PMID: 30732697 DOI: 10.1016/j.chest.2018.10.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/18/2018] [Accepted: 10/12/2018] [Indexed: 10/27/2022] Open
Affiliation(s)
- Kayla M Lundeen
- Residency Program in Internal Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Jaidev R Bhoopal
- Division of Pulmonary and Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Mengistu A Simegn
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - James W Leatherman
- Division of Pulmonary and Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN.
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Godoy DA, Di Napoli M, Rabinstein AA. Cerebral Fat Embolism: Recognition, Complications, and Prognosis. Neurocrit Care 2019; 29:358-365. [PMID: 28932982 DOI: 10.1007/s12028-017-0463-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Fat embolism syndrome (FES) is a rare syndrome caused by embolization of fat particles into multiple organs including the brain. It typically manifests with petechial rash, deteriorating mental status, and progressive respiratory insufficiency, usually occurring within 24-48 h of trauma with long-bone fractures or an orthopedic surgery. The diagnosis of FES is based on clinical and imaging findings, but requires exclusion of alternative diagnoses. Although there is no specific treatment for FES, prompt recognition is important because it can avoid unnecessary interventions and clarify prognosis. Patients with severe FES can become critically ill, but even comatose patients with respiratory failure may recover favorably. Prophylactic measures, such as early stabilization of fractures and certain intraoperative techniques, may help decrease the incidence and severity of FES.
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Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Chacabuco 675, 4700, Catamarca, Argentina.
- Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina.
| | - Mario Di Napoli
- Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy
- Neurological Section, SMDN-Center for Cardiovascular Medicine and Cerebrovascular Disease Prevention, Sulmona, L'Aquila, Italy
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Shen Y, Guan Y, Chai J, Dai T, Suo Y. Delayed cerebral microbleeds in a patient with cerebral fat embolism. Neurol Sci 2019; 40:2185-2187. [PMID: 31152260 DOI: 10.1007/s10072-019-03950-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/24/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Yaoyao Shen
- Department of Neurology, The Affiliated Hospital of Jiujiang University, No.57 Xunyang East Rode, Xunyang District, Jiujiang, 332000, Jiangxi Province, People's Republic of China.
| | - Yanqin Guan
- Department of Neurology, The Affiliated Hospital of Jiujiang University, No.57 Xunyang East Rode, Xunyang District, Jiujiang, 332000, Jiangxi Province, People's Republic of China
| | - Jingyan Chai
- Department of Neurology, The Affiliated Hospital of Jiujiang University, No.57 Xunyang East Rode, Xunyang District, Jiujiang, 332000, Jiangxi Province, People's Republic of China
| | - Tingmin Dai
- Department of Neurology, The Affiliated Hospital of Jiujiang University, No.57 Xunyang East Rode, Xunyang District, Jiujiang, 332000, Jiangxi Province, People's Republic of China
| | - Yijun Suo
- Department of Neurology, The Affiliated Hospital of Jiujiang University, No.57 Xunyang East Rode, Xunyang District, Jiujiang, 332000, Jiangxi Province, People's Republic of China
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Abstract
PURPOSE OF REVIEW Fat embolism syndrome (FES) is a rare disorder with potentially devastating neurologic complications. This article reviews the history, pathophysiology, clinical features, diagnosis, and treatment of FES with a focus on its neurologic aspects. RECENT FINDINGS The neurologic complications of FES are more commonly recognized with current diagnostic testing and increase awareness of the disorder. FES may present initially with neurologic manifestations. Prompt diagnosis of FES and of its neurologic manifestations could be lifesaving. This includes respiratory support and management of neurological complications. The classic clinical triad of pulmonary insufficiency, neurologic disturbances, and petechial skin rash typically presents 24 to 72 h following an initial insult, most commonly a traumatic long bone fracture. Early onset (< 24 h) and delayed onset (> 72 h) have been described. Neurologic manifestations may include ischemic/hemorrhagic strokes, retinal ischemia, seizures, autonomic dysfunction, and diffuse brain injury. Diagnosis remains clinical. Management consists mainly of supportive care.
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Scarpino M, Lanzo G, Lolli F, Grippo A. From the diagnosis to the therapeutic management: cerebral fat embolism, a clinical challenge. Int J Gen Med 2019; 12:39-48. [PMID: 30655686 PMCID: PMC6324602 DOI: 10.2147/ijgm.s177407] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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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Affiliation(s)
- Maenia Scarpino
- Unit of Neurophysiopathology, Neuromuscolar Department, AOU Careggi, Florence, Italy
| | - Giovanni Lanzo
- Unit of Neurophysiopathology, Neuromuscolar Department, AOU Careggi, Florence, Italy
| | - Francesco Lolli
- Neuroscience Department (NEUROFARBA), University of Florence, Florence, Italy
| | - Antonello Grippo
- Intensive Rehabilitation Unit, IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy,
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Gillow S, Dorman J. Early presentation of cerebral fat embolism. TRAUMA-ENGLAND 2018. [DOI: 10.1177/1460408616684864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cerebral fat embolism syndrome has been identified in patients with long bone trauma, and usually occurs after a symptom free interval of 12 h. Treatment includes supportive care, and outcome is variable. We describe a case with earlier than expected presentation with good outcome despite poor initial prognostic signs.
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Affiliation(s)
- Sabreena Gillow
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - James Dorman
- Department of Neurology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
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Naddaf A, Andre J, Bly SJ, Hood D, Hodgson KJ, Desai SS. Duplex ultrasound evidence of fat embolism syndrome. J Vasc Surg Cases Innov Tech 2016. [DOI: 10.1016/j.jvscit.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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12
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Bugnitz CJ, Cripe LH, Lo WD, Flanigan KM. Recurrent Fat Embolic Strokes in a Patient With Duchenne Muscular Dystrophy With Long Bone Fractures and a Patent Foramen Ovale. Pediatr Neurol 2016; 63:76-79. [PMID: 27595520 DOI: 10.1016/j.pediatrneurol.2016.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 05/21/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Individuals with Duchenne muscular dystrophy have an increased risk of long bone fractures. Such fractures are sometimes associated with brain dysfunction due to fat embolism syndrome, although this syndrome has seldom been documented in muscular dystrophy patients. PATIENT DESCRIPTION We describe a child with Duchenne muscular dystrophy who developed fat embolism syndrome with neurological dysfunction following multiple long bone fractures. He experienced recurrent cerebral infarctions that probably resulted from embolization through a patent foramen ovale. The patent foramen ovale was closed by an occluder device in the cardiac catheterization laboratory, and he did not experience further infarctions. CONCLUSIONS Fat embolism with ischemic cerebral infarction can occur in individuals with Duchenne muscular dystrophy following long bone fractures. In this setting it is important to identify and close atrial level shunts in order to prevent additional infarctions.
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Affiliation(s)
| | - Linda H Cripe
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Warren D Lo
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Kevin M Flanigan
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
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Lui JK, Banauch GI. Diagnostic Bedside Ultrasonography for Acute Respiratory Failure and Severe Hypoxemia in the Medical Intensive Care Unit: Basics and Comprehensive Approaches. J Intensive Care Med 2016; 32:355-372. [PMID: 27402396 DOI: 10.1177/0885066616658475] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Bedside goal-directed ultrasound is a powerful tool for rapid differential diagnosis and monitoring of cardiopulmonary disease in the critically ill patient population. The bedside intensivist is in a unique position to integrate ultrasound findings with the overall clinical situation. Medically critically ill patients who require urgent bedside diagnostic assessment fall into 2 categories: (1) acute respiratory failure and (2) hemodynamic derangements. The first portion of this review outlines the diagnostic role of bedside ultrasound in the medically critically ill patient population for the diagnosis and treatment of acute respiratory failure, acute respiratory distress, and severe hypoxemia. The second portion will focus on the diagnostic role of ultrasound for the evaluation and treatment of shock states, as well as describe protocolized approaches for evaluation of shock during cardiopulmonary resuscitation. Different respiratory system pathologies that result in acute respiratory failure (such as increased interstitial fluid, alveolar consolidation, pleural effusion) cause characteristic ultrasonographic findings; diaphragmatic assessment may also add information. Intracardiac shunting can cause severe hypoxemia. Protocolized approaches for the evaluation of patients with acute respiratory failure or distress are discussed.
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Affiliation(s)
- Justin K Lui
- 1 Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Gisela I Banauch
- 1 Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.,2 Division of Pulmonary Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Stump B, Weinhouse G. Fat Embolism Syndrome: Fact or Myth? CURRENT TRAUMA REPORTS 2016. [DOI: 10.1007/s40719-016-0042-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Miller AN, Deal D, Green J, Houle T, Brown W, Thore C, Stump D, Webb LX. Use of the Reamer/Irrigator/Aspirator Decreases Carotid and Cranial Embolic Events in a Canine Model. J Bone Joint Surg Am 2016; 98:658-64. [PMID: 27098324 PMCID: PMC6948809 DOI: 10.2106/jbjs.14.01176] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Approximately 2 million patients in the United States annually undergo total joint arthroplasty with reaming and placement of intramedullary nails, resulting in extravasation of bone marrow and fat into the circulatory system and potentially causing fat embolism syndrome. Acute and chronic changes in mental status documented after these procedures may be related to embolic events. The Reamer/Irrigator/Aspirator (RIA) device has been shown to decrease intramedullary pressure during reaming. We hypothesized that the use of the RIA in a canine model would reduce the number of microemboli detected in the carotid artery and brain compared with nailing either with or without reaming. METHODS Twenty-four large canines underwent unreamed nailing (UR), sequentially reamed nailing (SR), or RIA-reamed nailing (RIA) of bilateral femora (eight dogs per group). During reaming and nailing, the number and size of microemboli transiting the carotid artery were recorded. After euthanasia, the brain was harvested for immunostaining and measurement of microinfarction volumes. RESULTS Total embolic load passing through the carotid artery was 0.049 cc (UR), 0.045 cc (SR), and 0.013 cc (RIA). The number and size of microemboli in the UR and SR groups were similar; however, the RIA group had significantly fewer larger-sized (>200-μm) emboli (p = 0.03). Pathologic examination of the brain confirmed particulate emboli, and histologic analyses demonstrated upregulation of stress-related proteins in all groups, with fewer emboli and less evidence of stress for RIA reaming. CONCLUSIONS RIA reaming decreased microemboli compared with traditional reaming and unreamed nailing, suggesting that intramedullary pressure and heat are important variables. The documented embolic events and brain stress may help to explain subtle neurobehavioral symptoms commonly seen in patients after undergoing long-bone reaming procedures. CLINICAL RELEVANCE RIA reaming decreased cranial embolic events and may have an ameliorating effect on postoperative neurologic sequelae.
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Affiliation(s)
- Anna N. Miller
- Departments of Orthopaedic Surgery (A.N.M.), Cardiothoracic Surgery (D.D., T.H., and D.S.), Anesthesiology (D.S.), and Radiology (W.B. and C.T.), Wake Forest School of Medicine, Winston-Salem, North Carolina,E-mail address for A.N. Miller:
| | - Dwight Deal
- Departments of Orthopaedic Surgery (A.N.M.), Cardiothoracic Surgery (D.D., T.H., and D.S.), Anesthesiology (D.S.), and Radiology (W.B. and C.T.), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Green
- DePuy Synthes, Inc., Westchester, Pennsylvania
| | - Timothy Houle
- Departments of Orthopaedic Surgery (A.N.M.), Cardiothoracic Surgery (D.D., T.H., and D.S.), Anesthesiology (D.S.), and Radiology (W.B. and C.T.), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - William Brown
- Departments of Orthopaedic Surgery (A.N.M.), Cardiothoracic Surgery (D.D., T.H., and D.S.), Anesthesiology (D.S.), and Radiology (W.B. and C.T.), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Clara Thore
- Departments of Orthopaedic Surgery (A.N.M.), Cardiothoracic Surgery (D.D., T.H., and D.S.), Anesthesiology (D.S.), and Radiology (W.B. and C.T.), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David Stump
- Departments of Orthopaedic Surgery (A.N.M.), Cardiothoracic Surgery (D.D., T.H., and D.S.), Anesthesiology (D.S.), and Radiology (W.B. and C.T.), Wake Forest School of Medicine, Winston-Salem, North Carolina
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Whalen LD, Khot SP, Standage SW. High-dose rosuvastatin treatment for multifocal stroke in trauma-induced cerebral fat embolism syndrome: a case report. Pediatr Neurol 2014; 51:410-3. [PMID: 25011436 DOI: 10.1016/j.pediatrneurol.2014.04.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 04/18/2014] [Accepted: 04/24/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Fat embolism syndrome is a life-threatening condition with treatment centering on the provision of excellent supportive care and early fracture fixation. No pharmacologic intervention has yet shown any clear benefit. We used high-dose rosuvastatin specifically for its anti-inflammatory effects to treat a patient with severe fat embolism syndrome. We also suggest that magnetic resonance imaging and transcranial Doppler studies are helpful in establishing the diagnosis and for monitoring the patient's course. PATIENT A 17-year-old boy developed severe cerebral fat embolism syndrome with multifocal strokes after sustaining bilateral femur fractures. RESULTS In spite of profound and prolonged neurological impairment, our patient experienced dramatic recovery by the time he was discharged from inpatient rehabilitation several weeks after his initial injury. Magnetic resonance imaging revealed the classic "starfield" pattern of infarcts on diffusion-weighted sequences early in the illness. Additionally, serial transcranial Doppler studies demonstrated dramatically elevated microembolic events that resolved completely during the course of treatment. CONCLUSION We feel that the acute administration of high-dose rosuvastatin early in the development of our patient's illness may have contributed to his ultimate recovery. Therapeutic guidelines cannot be extrapolated from a single patient, but our experience suggests that statin therapy could be potentially beneficial for individuals with severe fat embolism syndrome, and this approach deserves further clinical evaluation. Additionally, the diagnosis and monitoring of cerebral involvement in fat embolism syndrome is facilitated by both magnetic resonance imaging and transcranial Doppler studies.
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Affiliation(s)
- Lesta D Whalen
- Department of Pediatric Critical Care, University of Arizona, Tucson, Arizona.
| | - Sandeep P Khot
- Department of Neurology, Harborview Medical Center, Seattle, Washington
| | - Stephen W Standage
- Department of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington
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Kontani S, Nakamura A, Tokumi H, Hirose G. [A case of cerebral fat embolism after artificial bone replacement operation for femoral head fracture]. Rinsho Shinkeigaku 2014; 54:648-52. [PMID: 25142536 DOI: 10.5692/clinicalneurol.54.648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 83 years old woman was slipped and injured with right femoral neck fracture. After three days from the fracture, she underwent an artificial head bone replacement operation. Immediately after surgery, she complained of chest discomfort, nausea and dyspnea. A few hours later, she became comatose. Brain CT showed no abnormality and clinical diagnosis of heart failure was made without pulmonary embolism on enhanced chest CT. Magnetic resonance imaging (MRI) of the brain next day showed multiple small patchy hyperintense lesion in bilateral hemispheres on diffusion-weighted images (DWI), producing a "star field pattern''. Based on Criteria of Gurd, this patient had one major criterion and four minor criteria. And according to the Criteria of Schonfeld, this patient had 5 points, consistent with clinical diagnosis of fat embolism. Because of these criteria, she was diagnosed as cerebral fat embolism syndrome. We started supported care and edaravon. Two weeks after surgery, her condition recovered and remaind to stuporous state even six month after surgery. We experienced a typical case of cerebral fat embolism, after bone surgery with diagnostic findings on MRI-DWI. Diagnosis of cerebral fat embolism syndrome requires a history of long bone fracture and/or replacing surgery with typical finding on MRI images, such as "star field pattern''.
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Lalmohamed A, Vestergaard P, Cooper C, de Boer A, Leufkens HG, van Staa TP, de Vries F. Timing of Stroke in Patients Undergoing Total Hip Replacement and Matched Controls. Stroke 2012; 43:3225-9. [DOI: 10.1161/strokeaha.112.668509] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Arief Lalmohamed
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Peter Vestergaard
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Cyrus Cooper
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Anthonius de Boer
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Hubertus G.M. Leufkens
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Tjeerd P. van Staa
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Frank de Vries
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
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Boulon C, Baud JM, Kercret G, Pichot O, Poggi JN, Saby JC, Sprynger M. [Detection of micro-embolic signals: a review of the literature]. JOURNAL DES MALADIES VASCULAIRES 2012; 37:311-319. [PMID: 23146344 DOI: 10.1016/j.jmv.2012.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 09/28/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND The detection of micro-embolic signals (MES), by transcranial Doppler sonography might be useful for risk stratification in patients with symptomatic and asymptomatic carotid or cerebral artery stenosis, dissections, aortic atheroma, interventional procedures, and right to left cardiac shunts. AIM Review of the technique and clinical situations of MES detection. METHODS PubMed search from 1990 to 2012. RESULTS MES were found in 0,19, 48% versus 0,3, and 12% of patients with symptomatic and asymptomatic inferior than 30, 30 to 69, and 70 to 99% carotid stenosis, respectively. MES were related to the risk of recurrent stroke or transient ischemic attack (TIA). In the ACES study, the absolute annual risk of stroke or TIA after 2 years was 7% with vs 3% without MES. In patients with intracranial stenosis, the risk of stroke recurrence was 48% with vs 7% without MES at 13.6 months follow-up. MES were reported in 25% of the symptomatic versus none of the asymptomatic patients with intracranial stenosis. CONCLUSION Detection of MES is feasible and reproducible for multicenter studies, using rigourous methodology and long lasting recordings. It may contribute to risk stratification, especially in patients with extra- or intracranial stenosis.
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Affiliation(s)
- C Boulon
- Service de Médecine Vasculaire, Hôpital St-André, 1, rue Jean-Burguet, 33075 Bordeaux, France.
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Right-to-left shunts and micro-embolization in migraine. Curr Opin Neurol 2012; 25:263-8. [PMID: 22449873 DOI: 10.1097/wco.0b013e3283524103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The present review covers the latest studies on right-to-left shunts (RLSs) in migraine patients and different types of emboli capable of triggering migraine. RECENT FINDINGS Although three recent studies found no increased RLS prevalence in migraine with aura patients, there remains ample evidence that the prevalence of RLS is increased in migraine with aura. Introduced emboli in the carotid artery of mice have been shown to cause cortical spreading depression, which has been considered the pathophysiological mechanism of migraine aura. In humans, iatrogenic introduced (micro)-emboli can provoke migraine attacks; available evidence, however, is limited. SUMMARY RLS and migraine with aura (but not without) are comorbid conditions, but the biological mechanism remains speculative. Specific emboli are probably able (although infrequently) to induce migraine symptoms. There is no convincing evidence that closure of a RLS alters migraine frequency; therefore, diagnosis or treatment of RLS in migraine has no place in daily clinical practice and should only take place in controlled studies.
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