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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 538-539

The Devastating Starfield Pattern of Cerebral Fat Embolism

1 Department of Pulmonary and Critical Care – MetroHealth Medical Center, Cleveland, OH USA 44109, USA
2 Department of Pulmonary and Critical Care - East Tennessee State University, Johnson City, TN, USA 37614, USA

Date of Submission24-Apr-2017
Date of Decision24-Jun-2019
Date of Acceptance26-Aug-2019
Date of Web Publication24-Apr-2021

Correspondence Address:
Dr. Enambir S Josan
2500 Metrohealth Drive, Dept. of Pulmonary and Critical Care, Cleveland, OH
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.314561

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How to cite this article:
Josan ES, Zaietta GA, Hoskere GV. The Devastating Starfield Pattern of Cerebral Fat Embolism. Neurol India 2021;69:538-9

How to cite this URL:
Josan ES, Zaietta GA, Hoskere GV. The Devastating Starfield Pattern of Cerebral Fat Embolism. Neurol India [serial online] 2021 [cited 2021 May 15];69:538-9. Available from:

A 22-year-old male presented with bilateral femur fractures after a 20-feet fall and underwent rapid external fixation of long bones. He was Glasgow coma scale of 15 on presentation but deteriorated shortly after procedure, developed respiratory failure, and was intubated. Diffusion-weighted imaging (DWI) on Magnetic Resonance Imaging (MRI) brain showed multiple, tiny, slightly hyperintense areas of punctate signal abnormality involving bilateral cerebral hemispheres [Figure 1], corpus callosum, cerebellar hemispheres, and brainstem that were also seen in T2 and FLAIR (Fluid attenuated inversion recovery). The pattern was consistent with starfield like presentation of diffuse fat emboli. The T2 star/gradient echo sequences did not show any areas of dark signal intensity to indicate associated hemorrhagic component. Overt parenchymal edema wasn't noted and craniocervical junction was grossly unremarkable.
Figure 1: Bilateral cerebral hemispheres showing multiple, tiny, slightly hyperintense areas of punctate signal abnormality consistent with starfield pattern on Diffusion weighted MRI of brain

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Cerebral fat embolism syndrome (CFES) is a devastating complication of fat embolization syndrome which is almost exclusively due to long bone fracture.[1] It clinically presents as sudden onset of hypoxia, altered mental status, and petechial rash in setting of long bone fracture.[1] Neurological deficits are often transient and reversible although permanent morbidity has been noted as well.[2],[3] MRI brain is diagnostic in the appropriate clinical setting with a starfield like pattern on T2 and DWI.[4] The multiple, non-confluent, small foci of punctate white matter hyperintensity (starfield pattern of white spots on dark background) is representative of micro-embolic infarcts and toxic effects of free fatty acids.[3],[4] It usually involves subcortical cerebral white matter, basal ganglia, thalami, and centrum semiovale.[2] The degree of involvement can be graded and correlates with severity of neurological decompensation, while the resolution of lesions is noted to match clinical recovery.[3] Other etiologies of disseminated T2-hyperintense lesions include demyelinating diseases, diffuse axonal injury, vasogenic edema due to microinfarcts, and glotic foci. Diffusion restriction can differentiate the chronic pathologies.[5] Vascular parkinsonian syndromes and Wilson disease may also show subcortical involvement, but with more confluent T2 hyperintensities.[6]

Early clinical suspicion with rapid fixation of fracture is targeted for prevention.[1] In patients who develop CFES, management is mainly supportive with early resuscitation, ventilator support for hypoxia, stroke prophylaxis with aspirin, and seizure prophylaxis with antiepileptics.[7]

Our patient was young and would have been a candidate for long-term ventilator support with tracheostomy and nutritional support with percutaneous gastrostomy. However, given the poor prognosis secondary to traumatic injuries, the family chose to withdraw care leading to demise.


Dr. Mudher Al Shathir and Dr. Amanda Vanlandingham for care provided for this patient.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gurd AR, Wilson RI. The fat embolism syndrome. J Bone Joint Surg Br 1974;56:408-16.  Back to cited text no. 1
Kumar S, Gupta V, Aggarwal S, Singh P, Khandelwal N. Fat embolism syndrome mimicker of diffuse axonal injury on magnetic resonance imaging. Neurol India 2012;60:100-2.  Back to cited text no. 2
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Takahashi M, Suzuki R, Osakabe Y, Asai JI, Miyo T, Nagashima G, et al. Magnetic resonance imaging findings in cerebral fat embolism: Correlation with clinical manifestations. J Trauma Acute Care Surg 1999;46:324-7.  Back to cited text no. 3
Kuo KH, Pan YJ, Lai YJ, Cheung WK, Chang FC, Jarosz J. Dynamic MR imaging patterns of cerebral fat embolism: A systematic review with illustrative cases. Am J Neuroradiol 2014;35:1052-7.  Back to cited text no. 4
Ghuman MS, Kaur S, Sahoo SK, Saggar K, Ahluwalia A, Singh G. Brain studded with bright spots: The unusual cause. Neurol India 2016;64:174-5.  Back to cited text no. 5
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Srivanitchapoom P, Pitakpatapee Y, Suengtaworn A. Parkinsonian syndromes: A review. Neurol India 2018;66:S15-25.  Back to cited text no. 6
DeFroda SF, Klinge SA. Fat embolism syndrome with cerebral fat embolism associated with long-bone fracture. Am J Orthoped 2016;45:E515-21.  Back to cited text no. 7


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