A 69 year-old female presented with bilateral amaurosis, headache, fever (38oC) and dyspnea two days after a liposuction and abdominoplasty. A bilateral papilledema was observed in the clinical examination, without other neurological changes. Her ESR was 60mm/h and her platelet count was low (55.000mm3). Brain MRI revealed restriction of diffusion sequence in the right globus pallidus and both retinas (Figure 1). At spinal tap opening pressure was 16cmH2O. CSF examination was normal. Angio-MRI of the head and neck were also normal. Both transthoracic and transesophagic ecoDoppler examinations of the heart, the latter tailored to exclude left-to-right shunt were normal. The whole investigation of coagulopathy, vasculitis and idiopathic intracranial hypertension were negative. The retinal angiofluoresceinography demonstrated papilledema with venous congestion and retinal hemorrhages and no change in the arterial bed (Figure 2). Patient was submitted to anticoagulation with enoxaparine 1mg/kg subcutaneous bid without reversal of amaurosis.
Sign of restriction on the diffusion in both retinas (A) and the globus pallidus to the right (B).
Papilledema with venous congestion (A) and retinal hemorrhage with no change in arterial bed (B).
Papilledema leading may be seen in increased intracranial pressure, inflammatory optic neuropathy, infiltrative optic neuropathy, optic nerve tumours, compressive optic neuropathy, vasculopathies, intra-ocular disease venous obstruction; conditions associated with a massive increase in the protein content of CSF.
There are several mechanisms described for papilledema, such as a stasis of venous and lymphatic drainage secondary to increased pressure in the subarachnoid space, to an inflammatory condition, to venous obstruction by cloths or to mechanic obstruction. Optic nerve ischemia and impaired axoplasmic flow are also mentioned as determinates of a choked disk. In the case described above the sudden onset of the amaurosis, time-locked to the surgical procedure (liposuction) suggests a vascular phenomenon. Liposuction may determine small vessel rupture and adipocyte damage. Fat microfragments are drained by the venous circulation and surpass the pulmonary capillary bed, reaching the arterial system. Criteria for fat embolism were described by Gurd and Wilson (Table)11. Gurd AR, Wilson RI. The fat embolism syndrome. J Bone Joint Surg Br. 1974;56B(3):408-16..
We hypothesized that in this case papilledema was caused bilateral cilliary arteries obstruction by fat embolism. Similar cases of cerebral fat embolism were described. Surgeons, ophtalmologists, physicians, and neurologist should be aware of this condition22. Wang HD, Zheng JH, Deng CL, Liu QY, Yang SL. Fat embolism syndromes following liposuction. Aesthetic Plast Surg. 2008;32(5):731-6. doi:10.1007/s00266-008-9183-1.
References
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1Gurd AR, Wilson RI. The fat embolism syndrome. J Bone Joint Surg Br. 1974;56B(3):408-16.
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2Wang HD, Zheng JH, Deng CL, Liu QY, Yang SL. Fat embolism syndromes following liposuction. Aesthetic Plast Surg. 2008;32(5):731-6. doi:10.1007/s00266-008-9183-1
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Erratum
Fat embolism showing restriction on diffusion sequence in brain magnetic resonance imaging.Arq Neuropsiquiatr 2016;74(7):597-598. DOI: http://dx.doi.org/10.1590/0004-282X20160052The authors:Henry Koiti Sato1, Pedro André Kowacs1, Josep Dalmau2, Paulo Sergio Faro Santos2Should be:Henry Koiti Sato1, Pedro André Kowacs1, Paulo Sergio Faro Santos1The afiliation “2Universitat de Barcelona, Institut D’Investigacions Biomédiques August Pi I Sunyer, Hospital Clínic, Barcelona, Spain.” must be ignored.
Publication Dates
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Publication in this collection
20 May 2016 -
Date of issue
July 2016
History
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Received
20 Aug 2015 -
Reviewed
22 Dec 2015 -
Accepted
1 Mar 2016