Cerebral Fat Embolism Syndrome With Early Pulmonary Findings on Computed Tomography: A Case Report

Introduction: Cerebral fat embolism syndrome (CFES) is a rare, life-threatening condition where fat emboli cause predominantly neurologic dysfunction, most commonly due to polytrauma and multiple long-bone fractures. Diagnosing CFES is challenging due to its non-specific symptoms, with most patients having early mental status changes. We present a case of CFES with early-onset pulmonary involvement in the setting of orthopaedic trauma and explore the role of pulmonary computed tomography (CT) imaging in CFES evaluation.


Description: A 63-year-old previously healthy woman presented as a pedestrian struck by motor vehicle; injuries included bilateral tibial and unilateral fibular fractures. Approximately 24 hours post-injury, she underwent open reduction with internal fixation and intramedullary nailing with the orthopaedic trauma service. Post-operatively, she was intermittently mildly hypoxemic and chest CT angiogram showed possible pulmonary thromboembolism (PTE). Her neurologic status declined, though non-contrast CT head showed no acute findings. She was started on intravenous heparin for suspected PTE in the intensive care unit (ICU). Her symptoms progressed to isolated neurologic involvement, with magnetic resonance imaging on post-op day 5 revealing a “starfield” pattern leading to the diagnosis of CFES. Echocardiogram with bubble study was consistent with a patent foramen ovale. The initial diagnosis of PTE was most likely fat emboli, and heparin was discontinued with no indication for long-term anticoagulation. Her symptoms improved, and she was discharged 13 days post-injury.


Discussion: Fat embolism syndrome is reported to manifest on pulmonary CT scans as intraparenchymal lesions, including ground glass opacities, nodular opacities, and septal thickening. Our patient’s chest CT angiogram included these findings, though it was not recognized as possible signs of fat embolism or CFES at the time. Thus, in the appropriate clinical context, pulmonary CT imaging or angiography may raise concern for CFES before neurologic symptoms present. Early CFES diagnosis may initiate supportive care and prevent unnecessary interventions, such as prolonged anticoagulation. Further studies should evaluate the role of early pulmonary imaging in CFES.