Late recovery in cerebral fat embolism
A 20-year-old male presented 7 h following a Road Traffic Accident (RTA) with closed fracture of mid-shaft tibia and fibula involving both his legs. On arrival patient was conscious and oriented with a Glasgow Coma Scale (GCS) - 15/15. He was hemodynamically stable with oxygen saturation of 100% on room air. Blood investigations were normal except for raised serum lactate (5.7 mmol/L). Urine microscopy was negative for fat globules. Fractures in the legs were splinted by above knee slab application.\nTwo hours after admission (9 h since injury), patient became drowsy with a blood pressure of 116/74 mmHg, oxygen saturation – 84% at room air and pulse rate of 138/min. Oxygen supplementation through the face mask was given. Further 4 h later patient became lethargic and comatose with the GCS falling to 8/15. Electrolyte and metabolic imbalance was ruled out. Computed tomography (CT) brain was carried out which showed no abnormality. Patient was intubated and ventilated and was on supportive treatment with neuro-monitoring. Magnetic resonance imaging (MRI) of the brain revealed multiple well defined tiny hyperintense lesions on T2 and fluid-attenuated inversion-recovery sequences with restricted diffusion bilaterally scattered in the subcortical white matter, centrum semiovale, basal ganglia, thalami and cerebellum suggestive of multiple tiny infarcts due to fat embolism []. Chest X-ray which was initially clear, revealed minimal bilateral diffuse haziness only after 3 days []. Fractures of both bones of both legs were stabilized by external fixation on 4th day after injury. Patient regained consciousness only after 2 weeks, but had poor higher mental functions such as slurred speech, poor cognition and disturbed memory. GCS had improved to 13/15 and ventilator support was gradually weaned and withdrawn at 3 weeks. Later at 4 weeks (since injury), external fixator removal and interlocking nailing was carried out for fractures of both the tibiae. At 10 weeks postinjury, patient was conscious and oriented, but with poor cognition. At 5 months, patient had regained full neurological recovery and fractures of both bones of both the legs united []. Neurological recovery was evaluated by Glasgow outcome scale (GOS) and mini-mental state examination (MMSE), which showed good recovery and normal cognition respectively. MRI of the brain repeated at 10 months postinjury revealed resolution of previously visualized hyperintense lesions except in the periventricular region without any diffusion restriction pattern [].