Presentation
Involved in a motor vehicle accident and presented with multiple bony fractures of both lower limbs, then admitted to ICU with an altered conscious state.
Patient Data
A scout view and 3D reconstructed CT images revealed multiple bilateral fractures involving both femurs and leg bones with external fixation of both leg bones.
- normal both cerebral and cerebellar hemispheres with preserved gray/white matter differentiation.
- there is an average ventricular system, basal cistern, Sylvian fissures, and convexity sulci.
- no evidence of hemorrhage, infarction, mass, or midline shift.
- the visualized parts of the skull base and sinuses are unremarkable.
Opinion:
No acute traumatic injuries or acute brain insult could be detected.
Plain radiograph series revealed post internal fixations, and intramedullary nailing was performed for both femurs fractures.
Evidence of multiple bilateral focal hyperintense signals on FLAIR /T2 WI distributed in both centrum semiovale and show evidence of restricted diffusion on DWI and corresponding ADC map. Innumerable tiny foci of hypointense signals are seen throughout the brain parenchyma on the SWAN sequence with no preference to specific regions, denoting cerebral microhemorrhage. No evidence of post-contrast enhancement.
Average ventricular system, basal cistern, Sylvian fissures, and convexity sulci.
No evidence of mass or midline shift.
There is evidence of left maxillary sinusitis; otherwise, the visualized parts of the skull base and sinuses are unremarkable.
IMPRESSION:
MRI findings of bilateral multiple focal restricted diffusion suggestive of deep watershed infarctions likely embolic infarctions with innumerable tiny microhemorrhage in this clinical context suggestive of cerebral fat embolism; however, diffuse axonal injury cannot be excluded.
Case courtesy Dr. Safwat Al Moghazi MD.
Case Discussion
This young male presented with multiple lower limb fractures, including femurs, leg bones, and right scapular fractures.
Initially, he was admitted to ER fully conscious and had a GCS of 15. Taken to OR for external fixation of the leg fractures, and internal fixation with intramedullary nailing was performed for both femoral fractures. About two days later, he developed a deteriorating conscious level.
CT was initially negative. On brain MRI, the findings of the innumerable tiny foci of susceptibility artifacts and diffusion restriction in a patient with multiple long bone fractures are highly suggestive of cerebral fat embolism syndrome rather than diffuse axonal injuries.
The clinical history of multiple bony fractures and latent interval (a few days in our case) is most consistent with cerebral fat embolism. The main differential for cerebral fat embolism in a trauma patient is diffuse axonal injury (DAI).
Case courtesy Dr. Safwat Al Moghazi MD.