Cerebral fat embolism syndrome at a single trauma center



      Based on a 16-year case series, we sought lessons about diagnosis and treatment of cerebral fat embolism syndrome.

      Materials and methods

      Using discharge codes at a Level 1 Trauma Center, we performed a retrospective chart review of clinical characteristics, diagnostic studies, treatments, and outcome in cerebral fat embolism syndrome.


      Thirty-nine (40%) of 97 patients with fat embolism syndrome were diagnosed with cerebral fat embolism syndrome, with 29 (74%) presenting with coma. All had abnormal brain magnetic resonance imaging, with scattered cytotoxic edema (starfield pattern) in 29 (74%). All but two of the 21 patients with dilated fundoscopy showed retinal embolism. Among 29 patients with transcranial Doppler, the presence of microembolic signals in 15 (52%) was associated with fever (p = 0.039), right-to-left intracardiac shunting (p = 0.046) and a trend towards initial coma. In 11 patients with serial transcranial Dopplers and treatment with high-intensity statin therapy, the frequency of microembolic signals tended to decrease after therapy was initiated. Of the 28 (72%) of the 39 patients discharged, 16 (57%) had mild to moderate disability at last follow up.


      The recognition of cerebral fat embolism syndrome may be improved with routine inclusion of brain magnetic resonance imaging, dilated fundoscopy, and transcranial Doppler. We share our empiric management algorithm for cerebral fat embolism syndrome using these studies and with consideration of experimental therapies in select patients to prevent ongoing cerebral injury.



      CFES (cerebral fat emboli syndrome), TCD (transcranial Doppler), MES (microembolic signals), TBI (traumatic brain injury)
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        • Godoy D.A.
        • Di Napoli M.
        • Rabinstein AA.
        Cerebral fat embolism: recognition, complications, and prognosis.
        Neurocrit Care. 2018; 29: 358-365
        • Lee S.C.
        • Yoon J.Y.
        • Nam C.H.
        • Kim T.K.
        • Jung K.A.
        • Lee DW.
        Cerebral fat embolism syndrome after simultaneous bilateral total knee arthroplasty: a case series.
        J Arthroplasty. 2012; 27: 409-414
        • Kuo K.H.
        • Pan Y.J.
        • Lai Y.J.
        • Cheung W.K.
        • Chang F.C.
        • Jarosz J.
        Dynamic MR imaging patterns of cerebral fat embolism: a systematic review with illustrative cases.
        AJNR Am J Neuroradiol. 2014; 35: 1052-1057
        • Bonow R.H.
        • Young C.C.
        • Bass D.I.
        • Moore A.
        • Levitt MR.
        Transcranial doppler ultrasonography in neurological surgery and neurocritical care.
        Neurosurg Focus. 2019; 47: E2
        • Ringelstein E.B.
        • Droste D.W.
        • Babikian V.L.
        • Evans D.H.
        • Grosset D.G.
        • Kaps M.
        • Markus H.S.
        • Russell D.
        • Siebler M.
        Consensus on microembolus detection by TCD. International consensus group on microembolus detection.
        Stroke. 1998; 29: 725-729
        • Markus H.S.
        • Brown MM.
        Differentiation between different pathological cerebral embolic materials using transcranial Doppler in an in vitro model.
        Stroke. 1993; 24: 1-5
        • Parizel P.M.
        • Demey H.E.
        • Veeckmans G.
        • Verstreken F.
        • Cras P.
        • Jorens P.G.
        • De Schepper AM.
        Early diagnosis of cerebral fat embolism syndrome by diffusion-weighted MRI (starfield pattern).
        Stroke. 2001; 32: 2942-2944
        • Takahashi M.
        • Suzuki R.
        • Osakabe Y.
        • Asai J.I.
        • Miyo T.
        • Nagashima G.
        • Fujimoto T.
        • Takahashi Y.
        Magnetic resonance imaging findings in cerebral fat embolism: correlation with clinical manifestations.
        J Trauma. 1999; 46: 324-327
        • Forteza A.M.
        • Koch S.
        • Campo-Bustillo I.
        • Gutierrez J.
        • Haussen D.C.
        • Rabinstein A.A.
        • Romano J.
        • Zych G.A.
        • Duncan R.
        Transcranial doppler detection of cerebral fat emboli and relation to paradoxical embolism: a pilot study.
        Circulation. 2011; 123: 1947-1952
        • Markus H.S.
        • King A.
        • Shipley M.
        • et al.
        Asymptomatic embolisation for prediction of stroke in the asymptomatic carotid emboli study (ACES): a prospective observational study.
        Lancet Neurol. 2010; 9: 663-671
        • Molloy J.
        • Markus HS.
        Asymptomatic embolization predicts stroke and TIA risk in patients with carotid artery stenosis.
        Stroke. 1999; 30: 1440-1443
        • Dunkel J.
        • Roth C.
        • Erbguth F.
        • Dietrich W.
        • Hugens-Penzel M.
        • Ferbert A.
        Cerebral fat embolism: clinical presentation, diagnostic steps and long-term follow-up.
        Eur Neurol. 2017; 78: 181-187
        • Whalen L.D.
        • Khot S.P.
        • Standage SW.
        High-dose rosuvastatin treatment for multifocal stroke in trauma-induced cerebral fat embolism syndrome: a case report.
        Pediatr Neurol. 2014; 51: 410-413
        • Tunick P.A.
        • Nayar A.C.
        • Goodkin G.M.
        • Mirchandani S.
        • Francescone S.
        • Rosenzweig B.P.
        • Freedberg R.S.
        • Katz E.S.
        • Applebaum R.M.
        • Kronzon I.
        • et al.
        Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque.
        Am J Cardiol. 2002; 90: 1320-1325