Cerebral fat embolism syndrome following revision of right total hip arthroplasty.

To cite: Carmona R, Tuan A, Hughes TH, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2014-204955 DESCRIPTION A 74-year-old man underwent an uncomplicated right total hip arthroplasty revision. Postoperatively, the patient had no focal neurological deficits. Twelve hours later, his mental status declined and he was subsequently intubated. He had roving eyes, decerebrate posturing and minor grimacing to noxious stimuli. He never developed a petechial rash. EEG was unremarkable for seizure activity, transoesophageal echocardiography was negative for cardioembolic sources or interatrial septal defects, and neck CTangiography demonstrated no vascular abnormalities. Head CT was unremarkable and diffusion-weighted images (DWI) of the brain showed multiple foci of restricted diffusion, compatible with acute/subacute infarcts (figure 1A–C). The initial T2*-weighted gradient echo MRI (GRE) was normal (figure 1D); however, 3 days later the same sequence showed areas of susceptibility, compatible with diffuse microhaemorrhages (figure 1E). The patient’s clinical course and imaging findings were consistent with cerebral fat embolism (CFE) and the diagnosis was made. CFE occurs in 0.5–3.5% of long bone fractures. Fortunately, some patients recover completely with supportive care. Hyperintensities on DWI reflect areas of cytotoxic oedema from microinfarcts. DWI findings have been reported in patients following emergency surgery due to hip fracture and in the absence of intracardiac shunts, but rarely after