PMC10436317_01
(A) Non-contrast computed tomography shows multiple low-density shadows along the blood vessels. (B) Diffusion-weighted imaging shows high-signal intensities in the left cerebral hemisphere. (C) Fluid attenuated inversion recovery. (D) T2-weighted sequences show much smaller lesions. (E) Magnetic resonance angiography shows occlusion of the left internal carotid artery, anterior cerebral artery, and middle cerebral artery. (F) Susceptibility-weighted imaging shows hypointensity along the cerebral vessels, indicating slowed blood flow caused by the fat emboli.
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F1
CT signs such as the "blizzard sign," ruling out pulmonary fat embolism. Cranial non-contrast computed tomography (CT) revealed multiple low-density shadows along the blood vessels (Figure 1A). Diffusion-weighted imaging (DWI) confirmed fresh infarctions in the left frontal, parietal, and temporal lobes (Figure 1B). The lesions appeared much smaller on fluid-attenuated inversion recovery (FLAIR) and T2-weighted sequences (Figures 1C, D). Magnetic resonance angiography demonstrated the occlusion of the left internal carotid artery (ICA), left anterior cerebral artery, and left middle cerebral artery (Figure 1E). No obvious hemorrhage was observed on susceptibility-weighted imaging, and the hypointense lesions along the cerebral vessels indicated slowed blood flow caused by fat emboli (Figure 1F).
(A) Digital subtraction angiography confirms occlusion of the left internal and external carotid arteries. (B) Mechanical thrombectomy fails to achieve complete recanalization. (C) Pathological examination of the emboli confirms the presence of adipocytes. (D) Postoperative computed tomography demonstrates a large cerebral infarction with extravasation of the contrast agent in the left cerebral hemisphere and a slight rightward shift of the midline.
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F2
Owing to the mismatch between the FLAIR and DWI findings, we performed digital subtraction angiography, which confirmed the occlusion of the left ICA and external carotid artery (Figure 2A). After obtaining consent from the patient's family, we immediately performed mechanical thrombectomy (MT) using the ADAPT (a direct aspiration first pass technology) and SWIM (Solitaire FR/stent with intracranial support catheter for mechanical thrombectomy) techniques but failed to achieve complete recanalization (Figure 2B). Pathological examination of the emboli confirmed the presence of adipocytes (Figure 2C). Immediate cranial non-contrast CT showed a large cerebral infarction in the left cerebral hemisphere and a slight rightward shift of the midline (Figure 2D).
Timeline of symptoms, physical signs, and treatment. FAFG, facial autologous fat graft; HR, heart rate; SAS, symptoms and signs; MT, mechanical thrombectomy.
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F3
Decompressive craniectomy was promptly performed (Figure 3).