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1617 - Disorder of Consciousness Resulting from Fat Emboli Syndrome after Mild Complex TBI: A Case Report

Friday, February 28, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

CT

Chau Tran, DO

PGY-4 Resident in PM&R
University of New Mexico PM&R Residency
Albuquerque, New Mexico, United States

Co-Author(s)

TP

Tram J. Pham, DO

PGY-4 Resident in PM&R
University of New Mexico
Albuquerque, New Mexico, United States
AD

Austin Davis, MD

Assistant Professor, Traumatic Brain Injury
University of New Mexico
Albuquerque, New Mexico, United States
MG

Mirella Galvan-De La Cruz, MD

PGY-3 Resident in PM&R
University of New Mexico
Albuquerque, New Mexico, United States
JS

Jessica Sullivan, MD

PGY-2 Resident in PM&R
University of New Mexico
Albuquerque, New Mexico, United States

Case Diagnosis: Disorder of Consciousness Resulting from Fat Emboli Syndrome after Mild Complex TBI

Case Description: A 29-year-old man presented after motor vehicle accident with unknown loss of consciousness, Glasgow Coma Score (GCS) of 15, trace subarachnoid hemorrhage and right femur fracture. Early course included respiratory failure requiring intubation with GCS stabilizing at 4T6. Day two intramedullary nail placement was followed by neurologic decline into disorder of consciousness. Day five brain magnetic resonance imaging (MRI) demonstrated diffuse white matter susceptibility weighted imaging abnormalities. Exam demonstrated a lack of environmental awareness with flexion posturing until day eleven when he opened eyes to voice and intermittently followed simple, one-step commands. On day twelve, he consistently communicated with yes/no and participated in therapy.

Discussions: A young man who otherwise met criteria for mild complex traumatic brain injury (TBI) demonstrated rapid clinical deterioration with respiratory failure and disorder of consciousness secondary to cerebral fat emboli syndrome (CFES).

CFES classically presents as a triad of respiratory distress, petechiae, and neurological deficits in the setting of long bone fracture. In this case, the patient did not demonstrate any cutaneous findings but exhibited early respiratory failure followed by a rapid, severe neurologic decline. MRI findings mimicked diffuse axonal injury (DAI) more characteristic of severe TBI. Abrupt clinical decline in the setting of respiratory failure and long bone fracture led the PM&R consult team to suspect CFES with its associated favorable prognosis.

Conclusions: We report a classic case of CFES in which diagnosis was aided by an abrupt clinical deterioration. In moderate to severe TBI where clinical decline may be less apparent, clinicians should be aware of the degree to which CFES can mimic DAI on MRI and depress the neurologic exam in the first weeks after injury. This is especially important when discussing goals of care as CFES outcomes are generally very positive.