Cerebral fat embolism after intraosseous infusion

A 75-year-old male with hypertension, type 2 diabetes mellitus and a past medical history of transient ischemic attack was admitted to an out-of-hospital military emergency center in a low-income country for fever and abdominal pain. Antibiotics, analgesic drugs and fluid resuscitation were infused by intraosseous access in the left proximal tibia. The patient developed vasoplegic shock and acute respiratory failure requiring vasopressor therapy and mechanical ventilation. He was briefly hospitalized in a local intensive care unit before the transfer to our unit in France, 2 days after. Several prostatic abscesses were diagnosed and septic shock resolved after source control by transrectal drainage. The patient had a delayed awakening and confusion despite discontinuation of sedation. No petechial rash was found and echocardiography results were normal. The computed tomography scan showed discrete frontal microbleeds. Magnetic resonance imaging showed multiple bilateral low-intensity infracentimetric lesions on susceptibility-weighted imaging (SWI), distributed in supra- and subtentorial cerebellar white matter and suggesting cerebral fat embolism (Fig. 1a). Importantly, only a few of these lesions could be seen on the fluid-attenuated inversion recovery (FLAIR) sequence (Fig. 1b). The neurological impairment recovered slowly. Five months later, only a slight attention deficit persisted, but SWI abnormalities remained on control MRI. Cerebral fat embolism is a classical complication of intraosseous access, and the recent SWI is a key sequence in MRI for its diagnosis.

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