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Fat Emboli Cerebral Infarction


KEY FACTS

Terminology

  • Acute stroke related to fat emboli

Imaging

  • Acute ischemia with appropriate clinical history

    • Long bone or pelvic fractures, cardiac surgery, joint replacement surgery

  • Often mimics thromboembolic stroke

  • Commonly affects both gray and white matter

    • May affect deep and periventricular white matter

    • May affect deep gray nuclei

  • May involve typical vascular territory

  • May mimic “watershed” infarct

  • NECT: Typically negative acutely

    • Hypodense MCA sign related to fat within MCA

  • T2WI: Multiple small, scattered hyperintense foci

  • DWI: Acute diffusion restriction

Top Differential Diagnoses

  • Acute cerebral ischemia-infarction

  • Acute hypertensive encephalopathy, PRES

  • Vasculitis

Pathology

  • Fat emboli can pass through pulmonary capillaries without shunting lesions and result in systemic embolization (brain, kidneys most commonly)

Clinical Issues

  • Fat embolism syndrome: Pulmonary, CNS, and cutaneous manifestations

    • Hypoxia, deteriorating mental status, petechiae

  • Neurological dysfunction varies from confusion to encephalopathy with coma and seizures

  • Uncommon but potentially life threatening

  • Fat embolism syndrome after fractures: Up to 2.2%

Axial DWI MR shows innumerable punctate foci of restriction
throughout the white matter and gray matter of this 68-year-old patient with mental status changes post hip surgery. Note the extensive involvement of the basal ganglia and thalami.

Axial DWI in the same patient shows the extensive foci of restriction
related to acute ischemia from the patient's fat emboli. Note the more focal involvement of the left middle carotid artery territory with frontal and temporal lobe involvement.

Axial FLAIR MR in the same patient shows minimal abnormal hyperintensities in the deep gray nuclei and periventricular white matter. Diffusion imaging is the most sensitive sequence for acute stroke imaging.

Axial DTI trace shows 2 punctate foci of restriction related to fat emboli in this 39-year-old trauma patient with bilateral acetabular fractures. DTI may be more sensitive than DWI in acute ischemia. Imaging of fat emboli often mimics a typical thromboembolic stroke.

TERMINOLOGY

Definitions

  • Acute stroke related to fat emboli

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