Cerebral embolization presenting as delayed, severe obtundation in the postanesthesia care unit after total hip arthroplasty

Bilateral lower limb ischaemia following acetabular reconstruction and arthroplasty

The incidence of acetabular fractures has increased markedly in patients over 60 in the last quarter of a century, with open reduction and internal fixation being regarded to be the treatment of choice in most patients with displaced acetabular fractures. Lower limb ischaemia following acetabular fixation or arthroplasty is rare. However, such complications can be limb or life threatening, and therefore, it is important to recognise them as early as possible. We present the case of a 70-year-old man with no significant medical history who underwent acetabular fixation with simultaneous arthroplasty complicated with bilateral lower limb ischaemia. We highlight the importance of having a high degree of suspicion which allows early diagnosis and corrective measures to be implemented which can ultimately lead to excellent outcome.

Cerebral fat embolism following hip hemiarthroplasty in the absence of a patent foramen ovale with almost complete resolution

We describe the first case of clinically significant neurological manifestations of the fat embolism syndrome in the absence of both patent foramen ovale and cardiopulmonary resuscitation during hip hemiarthroplasty. This is an important differential diagnosis in postoperative neurological dysfunction requiring high index of suspicion. Management is supportive.

Dynamic MR imaging patterns of cerebral fat embolism: a systematic review with illustrative cases

Different MR imaging patterns of cerebral fat embolism have been reported in the literature without a systematic review. Our goal was to describe the patterns, explore the relationship between disease course and the imaging patterns, and discuss the underlying mechanism. We reveal 5 distinctive MR imaging patterns: 1) scattered embolic ischemia occurring dominantly at the acute stage; 2) confluent symmetric cytotoxic edema located at the cerebral white matter, which mainly occurs at the subacute stage; 3) vasogenic edematous lesions also occurring at the subacute stage; 4) petechial hemorrhage, which persists from the acute to the chronic stage; and 5) chronic sequelae, occurring at late stage, including cerebral atrophy, demyelinating change, and sequelae of infarction or necrosis. Underlying mechanisms of these imaging patterns are further discussed. Recognition of the 5 evolving MR imaging patterns of cerebral fat embolism may result in adjustment of the appropriate management and improve the outcome.

Bone cement implantation syndrome

Bone cement implantation syndrome (BCIS) is poorly understood. It is an important cause of intraoperative mortality and morbidity in patients undergoing cemented hip arthroplasty and may also be seen in the postoperative period in a milder form causing hypoxia and confusion. Hip arthroplasty is becoming more common in an ageing population. The older patient may have co-existing pathologies which can increase the likelihood of developing BCIS. This article reviews the definition, incidence, clinical features, risk factors, aetiology, pathophysiology, risk reduction, and management of BCIS. It is possible to identify high risk groups of patients in which avoidable morbidity and mortality may be minimized by surgical selection for uncemented arthroplasty. Invasive anaesthetic monitoring should be considered during cemented arthroplasty in high risk patients.

Crisis management during anaesthesia: embolism

BACKGROUND

Embolism with gas, thrombus, fat, amniotic fluid, or particulate matter may occur suddenly and unexpectedly during anaesthesia, posing a diagnostic and management problem for the anaesthetist.

OBJECTIVES

To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK" supplemented by a specific sub-algorithm for embolism, in the management of embolism occurring in association with anaesthesia.

METHODS

The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.

RESULTS

Among the first 4000 incidents reported to AIMS, 38 reports of embolism were found. A sudden fall in end-tidal carbon dioxide and oxygen saturation were the cardinal signs of embolism, each occurring in about two thirds of cases, with hypotension and electrocardiographic changes each occurring in about one third of cases.

CONCLUSION

The potential value of an explicit structured approach to the diagnosis and management of embolism was assessed in the light of AIMS reports. It was considered that, correctly applied, it potentially would have led to earlier recognition of the problem and/or better management in over 40% of cases.

[Fatal course after osteosynthesis in a 18-year-old male]

A previously healthy patient became comatose 8 h after osteosynthesis of a fractured femur and humerus. After an initially normal cranial computed tomography, extended lesions were found 10 h later in the control scan as an indication of an embolization in the basilar artery. After neurosurgeons assessed the situation to be unfavorable, no other interventions were conducted and 6 days later brain death was confirmed. During the subsequent heart transplantation the suspicion of a patent foramen ovale as the reason for the paradoxical cerebral embolization was confirmed. This tragic course raises the question whether a patent foramen ovale should be excluded or closed by interventional measures in similar situations.