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]
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}
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||||
@@ -0,0 +1,539 @@
|
||||
---
|
||||
title: "Brain"
|
||||
docid: "080771c2-02f3-408d-ad70-04a80d849500"
|
||||
authors:
|
||||
- key: "961f3a7f-ad62-43bc-98f4-5116b17ab812"
|
||||
value: "Paula J. Woodward, MD, FSRU"
|
||||
breadcrumbs:
|
||||
-
|
||||
name: "Ultrasound"
|
||||
slug: "ultrasound"
|
||||
treeNodeId: "517432cb-177e-4b78-bd9f-4c2e751d132e"
|
||||
-
|
||||
name: "Anatomy"
|
||||
slug: "anatomy"
|
||||
treeNodeId: "43bd9326-ab1c-493e-8d96-8ad0aa58c66a"
|
||||
-
|
||||
name: "Brain and Spine"
|
||||
slug: "brain-and-spine"
|
||||
treeNodeId: "615c6d75-0c7c-43e3-87a7-df4e7ac2304b"
|
||||
-
|
||||
name: "Brain"
|
||||
slug: "brain"
|
||||
treeNodeId: null
|
||||
category: "Ultrasound"
|
||||
documentVersionId: "22ef60d5-14ee-4367-99df-09df85fb9f88"
|
||||
imageCount: 77
|
||||
lastUpdated: "12/20/17"
|
||||
pageDescription: "Brain"
|
||||
pageKeywords: "Ultrasound, Anatomy, Brain and Spine, Brain"
|
||||
pageTitle: "Brain | STATdx"
|
||||
enhancedTitle: "Brain"
|
||||
type: "ANATOMY"
|
||||
breadcrumbs:
|
||||
- "Ultrasound"
|
||||
- "Anatomy"
|
||||
- "Brain and Spine"
|
||||
- "Brain"
|
||||
---
|
||||
## GROSS ANATOMY
|
||||
|
||||
- ### Supratentorial Structures
|
||||
|
||||
|
||||
- **Gyri**: Complex convolutions of brain cortex; hypoechoic on ultrasound (US)
|
||||
- **Sulci**(fissure): CSF-filled grooves or clefts that separate gyri; echogenic on US
|
||||
- Sulci separate gyri, **fissures** separate hemispheres/lobes
|
||||
- **Frontal lobe**
|
||||
- **Central sulcus separates frontal, parietal lobes**
|
||||
- Precentral gyrus contains primary motor cortex
|
||||
- Detailed topographically-organized map ("motor homunculus") of contralateral body
|
||||
- Head/face lateral, legs/feet along medial surface
|
||||
- Premotor cortex: Within gyrus just anterior to precentral gyrus (motor cortex)
|
||||
- 3 additional major gyri: Superior frontal gyrus, middle frontal gyrus, & inferior frontal gyrus
|
||||
- Superior sulcus separates superior & middle gyri
|
||||
- Inferior sulcus separates middle & inferior gyri
|
||||
- Orbital gyri cover base of frontal lobe; gyrus rectus medially
|
||||
- **Parietal lobe**
|
||||
- **Posterior to central sulcus**
|
||||
- Separated from occipital lobe by parietooccipital sulcus (medial surface)
|
||||
- Postcentral gyrus: Primary somatosensory cortex
|
||||
- Contains topographical map of contralateral body
|
||||
- Face, tongue, lips are inferior; trunk, upper limb superolateral; lower limb on medial aspect
|
||||
- Superior & inferior parietal lobules lie posterior to postcentral gyrus
|
||||
- Supramarginal gyrus lies at end of sylvian fissure
|
||||
- Angular gyrus lies ventral to supramarginal gyrus
|
||||
- Medial surface of parietal lobe is precuneus, in front of parietooccipital sulcus
|
||||
- **Occipital lobe**
|
||||
- **Posterior to parietooccipital sulcus**
|
||||
- Primary visual cortex on medial occipital lobe
|
||||
- Cuneus on medial surface
|
||||
- **Temporal lobe**
|
||||
- **Inferior to sylvian fissure**
|
||||
- Superior temporal gyrus: Primary auditory cortex
|
||||
- Middle temporal gyrus: Connects with auditory, somatosensory, visual association pathways
|
||||
- Inferior temporal gyrus: Higher visual association area
|
||||
- Includes major subdivisions of limbic system
|
||||
- Parahippocampal gyrus on medial surface, merges into uncus
|
||||
- **Insula**
|
||||
- Lies deep in floor of sylvian fissure, overlapped by frontal, temporal, parietal opercula
|
||||
- **Limbic****system**
|
||||
- Includes amygdala, hippocampus, thalamus, hypothalamus, basal ganglia, & cingulate gyrus
|
||||
- Cingulate gyrus extends around corpus callosum
|
||||
- Tapers rostrally (anteriorly) into paraterminal gyrus, subcallosal area
|
||||
- Hippocampus including dentate gyrus, Ammon horn (cornu ammonis)
|
||||
- Important role in emotion, behavior, & long-term memory
|
||||
- **White matter tracts**: 3 major types of fibers
|
||||
- Association fibers: Interconnect different cortical regions in same hemisphere
|
||||
- Cingulum is long association fiber, which lies beneath cingulate gyrus
|
||||
- Commissural fibers: Interconnect similar cortical regions of opposite hemispheres
|
||||
- **Corpus callosum** is largest commissural fiber, links cerebral hemispheres
|
||||
- Projection fibers: Connect cerebral cortex with deep nuclei, brainstem, cerebellum, spinal cord
|
||||
- Internal capsule is major projection fiber
|
||||
- **Basal ganglia**
|
||||
- Paired deep gray matter nuclei
|
||||
- Caudate nucleus, lentiform nucleus (including putamen, globus pallidus)
|
||||
- **Thalamus**
|
||||
- Paired nuclear complexes, serve as relay station for most sensory pathways
|
||||
- ### Anatomy Relationships
|
||||
- ### Posterior Fossa (Infratentorial) Structures
|
||||
|
||||
|
||||
- Protected space surrounded by calvarium & bounded by tentorium cerebelli superiorly & foramen magnum inferiorly
|
||||
- Posterior fossa contents
|
||||
- Brainstem (midbrain, pons, & medulla oblongata) anteriorly, cerebellum posteriorly
|
||||
- Cerebral aqueduct & 4th ventricle
|
||||
- CSF cisterns containing cranial nerves, vertebrobasilar arterial system & veins
|
||||
- CSF cisterns suspend & cushion brainstem & cerebellum
|
||||
- **Cerebellum**
|
||||
- Integrates coordination & fine-tuning of movement, & regulation of muscle tone
|
||||
- 3 surfaces: Superior (tentorial), inferior (suboccipital), anterior (petrosal)
|
||||
- **2 hemispheres & midline vermis**
|
||||
- Divided into lobes & lobules by transverse fissures
|
||||
- Major fissures: Primary (tentorial), horizontal (petrosal), prebiventral/prepyramidal (suboccipital) cerebellar fissures
|
||||
- Connected to brainstem by **3 paired peduncles**
|
||||
- Superior cerebellar peduncle (brachium conjunctivum) connects cerebellum to cerebrum via midbrain
|
||||
- Middle cerebellar peduncle (brachium pontis) connects to pons
|
||||
- Inferior cerebellar peduncle (restiform body) connects to medulla
|
||||
- **Brainstem**
|
||||
- **3 anatomic divisions**
|
||||
- **Midbrain (mesencephalon)**: Upper brainstem, connects pons & cerebellum with forebrain
|
||||
- **Pons**: Bulbous midportion of brainstem, relays information from brain to cerebellum
|
||||
- **Medulla**: Caudal (inferior) brainstem, relays information from spinal cord to brain
|
||||
- Functional divisions
|
||||
- Ventral part: Large descending white matter tracts; contains midbrain cerebral peduncles, pontine bulb, medullary pyramids
|
||||
- Dorsal part: Tegmentum, common to midbrain, pons & medulla; contains cranial nerve nuclei & reticular formation
|
||||
- **Midbrain (mesencephalon)**
|
||||
- 3 main parts: Cerebral peduncles, tegmentum (cranial nerve nuclei, gray matter nuclei, white matter tracts), & tectum (quadrigeminal plate)
|
||||
- Ventral: Cerebral peduncles (crus cerebri) containing corticospinal, corticobulbar & corticopontine tracts
|
||||
- **Dorsal tegmentum**: Ventral to cerebral aqueduct
|
||||
- White matter tracts: Medial longitudinal fasciculus, medial lemniscus, lateral lemniscus, spinothalamic tract, central tegmental tract
|
||||
- Gray matter: Substantia nigra & red nucleus
|
||||
- Upper midbrain: Contains CNIII nucleus, at superior colliculus level
|
||||
- Lower midbrain: Contains CNIV nucleus, at inferior colliculus level
|
||||
- **Tectum (quadrigeminal plate)**: Dorsal to cerebral aqueduct
|
||||
- Superior & inferior colliculi, periaqueductal gray matter
|
||||
- Cerebral aqueduct (of Sylvius) passes through dorsal midbrain between tectum posteriorly & tegmentum anteriorly, connecting 3rd & 4th ventricles
|
||||
- **Pons**
|
||||
- 2 main parts: Ventral (white matter tracts), dorsal tegmentum (continuation of midbrain tegmentum with cranial nerve nuclei, gray matter nuclei, white matter tracts)
|
||||
- Ventral: Longitudinal fibers primarily from corticospinal, corticobulbar & corticopontine tracts
|
||||
- Dorsal tegmentum: White matter tracts & CN nuclei
|
||||
- White matter tracts: Medial longitudinal fasciculus, medial lemniscus, lateral lemniscus, trapezoid body, spinothalamic tract, central tegmental tract
|
||||
- Upper pons: Contains main nuclei of CNV
|
||||
- Lower pons: Contains nuclei of CNVI, VII & VIII
|
||||
- **Medulla**
|
||||
- Ventral: Olives & pyramids
|
||||
- Dorsal tegmentum: White matter tracts & CN nuclei
|
||||
- White matter tracts: Medial longitudinal fasciculus, medial lemniscus, spinothalamic tract, central tegmental tract, spinocerebellar tract
|
||||
- CN nuclei: CNIX, X, & XI (bulbar portion) in upper & mid medulla; CNXII nuclei in mid medulla
|
||||
- ### Ventricular System & Subarachnoid Space
|
||||
|
||||
|
||||
- Cerebral ventricles consist of paired lateral, midline 3rd, & 4th ventricles
|
||||
- Communicate with each other as well as central canal of spinal cord & subarachnoid space
|
||||
- Direction of CSF flow
|
||||
- Lateral ventricles → foramen of Monro → 3rd ventricle → cerebral aqueduct → 4th ventricle → foramina of Luschka & Magendie → subarachnoid space
|
||||
- Bulk of CSF resorption through arachnoid granulations in superior sagittal sinus
|
||||
- **Lateral ventricles**
|
||||
- Paired, C-shaped, curve posteriorly from temporal horns, arch around/above thalami
|
||||
- Each has body, atrium, **3 horns (frontal, temporal, & occipital)**
|
||||
- Occipital horn typically largest
|
||||
- Asymmetry is common, often L > R
|
||||
- Sizes change with maturity, more prominent in preterm infants
|
||||
- **Atrium/trigone**: Confluence of horns
|
||||
- Contains glomus of choroid plexus
|
||||
- Lateral ventricles communicate with each other & 3rd ventricle via Y-shaped foramen of Monro
|
||||
- **3rd ventricle**
|
||||
- Thin, usually slit-like, between thalami
|
||||
- May not see fluid, just bright echogenic line on US
|
||||
- 80% have central adhesion between thalami (massa intermedia)
|
||||
- Communicates with 4th ventricle via cerebral aqueduct (of Sylvius), passing through dorsal midbrain
|
||||
- **4th ventricle**
|
||||
- Infratentorial, diamond-shaped cavity (rhomboid fossa) along dorsal pons & upper medulla
|
||||
- Fastigium: Blind ending, dorsally pointed midline outpouching from body of 4th ventricle
|
||||
- Important marker for true midline vermian plane on US
|
||||
- Communicates with subarachnoid space via foramina of Magendie & Luschka
|
||||
- Terminates inferiorly at obex, which communicates with central canal of spinal cord
|
||||
- **Choroid plexus**
|
||||
- Produces CSF
|
||||
- Glomus (enlargement of choroid plexus in atrium) thickest area
|
||||
- Tapers & extends anteriorly to foramen of Monro & roof of 3rd ventricle
|
||||
- Tapers laterally into roof of temporal horns
|
||||
- Present in roof of 4th ventricle but **never extends into frontal or occipital horns**
|
||||
- **Subarachnoid space/cisterns**
|
||||
- CSF spaces between pia & arachnoid
|
||||
- Numerous trabeculae, septa, membranes cross subarachnoid space & create smaller compartments termed cisterns
|
||||
- **Supratentorial/peritentorial cisterns**: Suprasellar, interpeduncular, ambient (perimesencephalic), quadrigeminal cistern, & cistern of velum interpositum
|
||||
- **Infratentorial (posterior fossa) cisterns**: Prepontine, premedullary, superior cerebellar, cisterna magna, & cerebellopontine
|
||||
- All cisterns communicate with each other & with ventricular system
|
||||
- Midline cystic structures (normal variants)
|
||||
- **Cavum septi pellucidi**: Anterior to foramen of Monro, between anterior horns of lateral ventricles
|
||||
- 85% closed by 3-6 months after birth, some remain open into adulthood
|
||||
- Once closed called septum pellucidum
|
||||
- **Cavum vergae**: Posterior to foramen of Monro, interposed between bodies of lateral ventricles
|
||||
- Posterior extension of cavum septi pellucidi
|
||||
- Begins to close from posterior to anterior from 6-month gestation; 97% closed by full term
|
||||
- **Cavum velum interpositum**: Potential space above choroid in roof of 3rd ventricle & below fornices
|
||||
- Typically seen in premature infants
|
||||
|
||||
## ANATOMY IMAGING ISSUES
|
||||
|
||||
- ### Imaging Approaches
|
||||
|
||||
|
||||
- **Anterior fontanelle**most commonly used approach
|
||||
- **Sagittal scans**
|
||||
- Midline scan: Best view for corpus callosum, cerebellar vermis
|
||||
- Sweep side-to-side from this position documenting key areas
|
||||
- **Caudothalamic groove**: Most common site of germinal matrix hemorrhage
|
||||
- Size of lateral ventricle
|
||||
- Far lateral to assess degree of sulcal development
|
||||
- **Coronal scans**
|
||||
- Important to maintain symmetrical imaging of each 1/2 of brain
|
||||
- Symmetrical structures (from anterior to posterior) include: Frontal horns, bodies & trigones of lateral ventricles; caudate nuclei, putamen, internal capsule, & thalami
|
||||
- Midline structures (from anterior to posterior) include: Interhemispheric fissure, genu & anterior body of corpus callosum, cavum septi pellucidi, 3rd ventricle, brainstem
|
||||
- **Posterior fontanelle**
|
||||
- Best view to evaluate occipital horns for intraventricular hemorrhage
|
||||
- Can misinterpret clot adherent to choroid plexus from anterior fontanelle approach alone
|
||||
- **Mastoid fontanelle**
|
||||
- Located at junction of squamosal, lambdoidal, occipital sutures
|
||||
- Transducer placed about 1 cm behind helix of ear & 1 cm above tragus
|
||||
- Allows assessment of brainstem & posterior fossa
|
||||
- Best view for 4th ventricle, posterior cerebellar vermis, cerebellar hemispheres, & cisterna magna
|
||||
- **Transtemporal**
|
||||
- Temporal bone anterior to ear is thin, allowing imaging of brainstem even after sutural closure
|
||||
- Best view for cerebral peduncles & 3rd ventricle
|
||||
- ### Imaging Pitfalls
|
||||
|
||||
|
||||
- Need to know changing appearance with gestational age at birth; normal gyral pattern in 26-week preterm infant would be abnormal in term infant
|
||||
- Slit-like lateral ventricles common in infants, not to be mistaken for cerebral edema
|
||||
- Glomus of choroid plexus can be bulbous & irregular, not to be mistaken for blood clot
|
||||
- Evaluate with color Doppler & posterior fontanelle view
|
||||
- Echogenic material in frontal or occipital horns is clot; choroid does not extend into these horns
|
||||
|
||||
55345e53-a3c9-4dfc-b082-0266dcaee622
|
||||
|
||||
|
||||
## Images
|
||||
|
||||
|
||||
### Gyri and Sulci
|
||||
|
||||
|
||||
*Lateral surface of the brain depicts the major gyri and sulci. The frontal lobe extends from the frontal pole to the central sulcus. The supramarginal and angular gyri are part of the parietal lobe. The superior temporal gyrus contains the primary auditory cortex, and also forms the temporal operculum. The insular cortex lies within the sylvian fissure beneath the frontal, temporal, and parietal opercula.*
|
||||
|
||||
|
||||
*Lateral surface of the brain depicts the major gyri and sulci. The frontal lobe extends from the frontal pole to the central sulcus. The supramarginal and angular gyri are part of the parietal lobe. The superior temporal gyrus contains the primary auditory cortex, and also forms the temporal operculum. The insular cortex lies within the sylvian fissure beneath the frontal, temporal, and parietal opercula.*
|
||||
|
||||
|
||||
*Lateral surface of the brain depicts the major gyri and sulci. The frontal lobe extends from the frontal pole to the central sulcus. The supramarginal and angular gyri are part of the parietal lobe. The superior temporal gyrus contains the primary auditory cortex, and also forms the temporal operculum. The insular cortex lies within the sylvian fissure beneath the frontal, temporal, and parietal opercula.*
|
||||
|
||||
|
||||
*Surface anatomy of the cerebral hemisphere, seen from above, shows the gyri and lobules on the left, and the sulci on the right. The central (Rolandic) sulcus separates the anterior frontal lobe from the posterior parietal lobe. The precentral gyrus of the frontal lobe is the primary motor cortex while the postcentral gyrus of the parietal lobe is the primary sensory cortex. On ultrasound, the sulci appear echogenic while the adjacent gyri are hypoechoic.*
|
||||
|
||||
|
||||
### Midline, Subarachnoid space
|
||||
|
||||
|
||||
*This midline sagittal graphic shows a medial view of the cerebral hemisphere. The corpus callosum represents the major commissural fiber. The fornix and cingulate gyrus are important in the limbic system. The cingulate gyrus is involved with emotion formation and processing, learning, and memory.*
|
||||
|
||||
|
||||
*Sagittal midline graphic through the interhemispheric fissure depicts subarachnoid spaces with CSF (blue) between the arachnoid (purple) & pia (orange). The central sulcus separates the frontal lobe (anterior) from the parietal lobe (posterior). The pia mater is closely applied to the brain surface, whereas the arachnoid is adherent to the dura. The ventricles communicate with the cisterns and subarachnoid space via the foramina of Luschka and Magendie. The cisterns normally communicate freely with each other.*
|
||||
|
||||
|
||||
### Ventricular System
|
||||
|
||||
|
||||
*Schematic 3D representation of the ventricular system, viewed in the sagittal plane, demonstrates the normal appearance and communicating pathways of the cerebral ventricles. CSF flows from the lateral ventricles through the foramen of Monro into the 3rd ventricle, and from there through the cerebral aqueduct into the 4th ventricle. CSF exits the 4th ventricle through the foramina of Luschka and Magendie to the subarachnoid space.*
|
||||
|
||||
|
||||
### Standard US Planes Via Anterior Fontanelle
|
||||
|
||||
|
||||
*Graphic shows the common coronal planes used in ultrasound brain scanning: Plane A to F from front to back. Cerebral cortex (CC); body of lateral ventricle (BV); frontal horn (FH); occipital horn (OH); massa intermedia (M); pineal recess (PR); 3rd ventricle (3); temporal horn (TH); supraoptic recess (SR); infundibular recess (IR); 4th ventricle (4); cerebellum (CB).*
|
||||
|
||||
|
||||
*Graphic shows the common sagittal planes used in ultrasound brain scanning: Plane A to C from midline to lateral. Cerebellum (CB); cerebral cortex (CC); corpus callosum (Coc); cavum septi pellucidi (CSP); frontal horn (FH); foramen of Monro (FM); occipital horn (OH); temporal horn (T); 3rd ventricle (3); 4th ventricle (4).*
|
||||
|
||||
|
||||
### Coronal US Via Anterior Fontanelle
|
||||
|
||||
|
||||
*The 1st of 9 coronal ultrasounds of the brain through the anterior fontanelle in a term infant shows the frontal lobes lie in the anterior cranial fossa with orbital cavities deep to the floor of the skull base.*
|
||||
|
||||
|
||||
*An image centered more posteriorly demonstrates a slightly more echogenic white matter region of the brain parenchyma known as the centrum semiovale. Parts of the skull base, including the sella turcica and anterior clinoid, can be seen.*
|
||||
|
||||
|
||||
*Image acquired just anterior to the foramen of Monro. The frontal horns of lateral ventricles are now seen. No choroid plexus should be present in the frontal horns. Any intraventricular echogenic material seen at this level should raise the suspicion of blood clot. The head of the caudate nucleus is inferior and lateral to the frontal horn and is separated from the lentiform nucleus by the internal capsule.*
|
||||
|
||||
|
||||
*The 4th of 9 coronal ultrasounds through the anterior fontanelle in a term infant is shown. This image is taken at the level of the foramen of Monro. The lateral ventricles are seen with the body of the caudate nucleus and anterior portions of the thalami below. It is not uncommon that the ventricles are asymmetric.*
|
||||
|
||||
|
||||
*Just slightly more posterior, the choroid plexus is present on the floor of the lateral ventricles and roof of the 3rd ventricle. The 3 echogenic foci of the choroid plexus, 1 on the roof of the 3rd ventricle and 2 located bilaterally on the floor of the lateral ventricles, are known as the 3-dot sign.*
|
||||
|
||||
|
||||
*A more posterior coronal image at the level of the quadrigeminal cistern is shown. Another ultrasound landmark, known as the echogenic star, is seen, which comprises the choroidal fissures as the upper limbs and tentorium cerebelli as the lower limbs. Inferiorly, the vermis appears echogenic, while the cerebellar hemispheres on both sides are hypoechoic.*
|
||||
|
||||
|
||||
*The 7th of 9 coronal ultrasounds obtained through the anterior fontanelle in a term infant is shown. This image is taken at the trigone of the lateral ventricles. The glomus of the choroid plexus appears highly echogenic, nearly occupying the whole trigone.*
|
||||
|
||||
|
||||
*This image, slightly posterior to the trigone, shows mildly echogenic white matter regions within the corona radiata, lateral and parallel to both trigones of the lateral ventricles. These regions are known as the periventricular halo, a normal finding, present in almost all normal mature and premature neonates. The echogenicity of the halo should be less than that of the choroid plexus and symmetrical in appearance.*
|
||||
|
||||
|
||||
*The most posterior coronal image shows the cortex of the occipital lobe with multiple echogenic sulci extending medially from the lateral margin of the brain. The falx is in midline.*
|
||||
|
||||
|
||||
### Coronal T1 MR
|
||||
|
||||
|
||||
*The 1st of 9 coronal T1 MR images through the cerebral hemispheres from anterior to posterior is shown. The images are taken through planes/levels corresponding to those commonly used for ultrasound scans through the anterior fontanelle. The 3 major frontal gyri are shown: Superior frontal gyrus, middle frontal gyrus, and inferior frontal gyrus, separated by the superior and inferior frontal sulci. The straight gyrus (gyrus rectus) is the most medial, covering the base of the frontal lobe.*
|
||||
|
||||
|
||||
*Slightly more posteriorly, the major white matter tracts, the centrum semiovale, are seen.*
|
||||
|
||||
|
||||
*This image shows the frontal horns. Immediately below each frontal horn is the caudate head, separated from the lentiform nucleus by the internal capsule.*
|
||||
|
||||
|
||||
*The 4th of 9 coronal T1 MR images through the cerebral hemispheres from anterior to posterior is shown. The images are taken through planes/levels corresponding to those commonly used for ultrasound through the anterior fontanelle. This image is taken at the level of the foramen of Monro where both lateral ventricles unite, becoming the 3rd ventricle in the midline.*
|
||||
|
||||
|
||||
*This image shows the thalami on either side of the 3rd ventricle.*
|
||||
|
||||
|
||||
*This image slightly more posterior shows the quadrigeminal cistern in the midline. Together with choroidal fissures and tentorium cerebelli on both sides, it gives rise to the characteristic echogenic star appearance on coronal ultrasound scanning.*
|
||||
|
||||
|
||||
*The 7th of 9 coronal T1 MR images through the cerebral hemispheres from anterior to posterior are shown. The images are taken through planes/levels corresponding to those commonly used for ultrasound scans through the anterior fontanelle. The glomus of the choroid plexus is prominent within the trigones of the lateral ventricles.*
|
||||
|
||||
|
||||
*More posterior image shows the posterior parietal lobes and occipital lobes. Cerebral hemispheres are separated by the interhemispheric fissure, which contains the falx cerebri. The ventricular system and cerebellum are no longer seen at this level. The primary visual cortex is on the medial aspect of the occipital lobe.*
|
||||
|
||||
|
||||
*This most posterior image shows gyri of the occipital lobe and a portion of the superior sagittal sinus, which arches posteriorly to the torcular Herophili.*
|
||||
|
||||
|
||||
### Sagittal US Via Anterior Fontanelle
|
||||
|
||||
|
||||
*The 1st of 6 sagittal ultrasounds of the brain through the anterior fontanelle in term infant is shown. This image, obtained in the midline, shows the corpus callosum as a hypoechoic curving line. Callosal and cingulate sulci are parallel to and above the corpus callosum. The midline also allows evaluation of the posterior fossa structures, including the brainstem anteriorly and the vermis posteriorly. The 4th ventricle is well seen in this plane and appears as a triangular fluid-filled structure at the level of the mid vermis.*
|
||||
|
||||
|
||||
*Parasagittal image obtained angling slightly lateral to midline: The thalamus and echogenic sulci can now be seen more clearly.*
|
||||
|
||||
|
||||
*Parasagittal image obtained by angling more laterally shows the caudothalamic groove, the junction between the caudate nucleus and the thalamus. This is the area of the vascular germinal matrix, which is vulnerable to hemorrhage in preterm infants.*
|
||||
|
||||
|
||||
*This parasagittal image shows the glomus of the choroid plexus in the trigone. The glomus tapers anteriorly as it courses along the floor of the lateral ventricle to the foramen of Monro and continues along the roof of the 3rd ventricle. It also tapers posteriorly from the trigone into the temporal horn of each lateral ventricle. Glomus may appear bulbous and irregular at the trigone and should not be mistaken as a blood clot.*
|
||||
|
||||
|
||||
*This parasagittal image is obtained just lateral to the lateral ventricle. The echogenic white matter of the brain just posterior and superior to the ventricular trigone is known as the peritrigonal blush or halo, representing radiating white fiber tracts (corona radiata). The peritrigonal blush is more prominent in premature than in term neonates.*
|
||||
|
||||
|
||||
*This is the last and most lateral sagittal image obtained, showing the mature sulcal pattern with hyperechoic sulci and hypoechoic gyri.*
|
||||
|
||||
|
||||
### Sagittal T1 MR
|
||||
|
||||
|
||||
*The 1st of 6 sagittal T1 MR images through the cerebral hemispheres from midline to lateral is shown. The images are taken through planes/levels corresponding to those commonly used for ultrasound scans through the anterior fontanelle. The midline sagittal image shows the corpus callosum, the largest commissural fiber connecting both cerebral hemispheres.*
|
||||
|
||||
|
||||
*Parasagittal image just off the midline is shown. The tentorium cerebelli is a dural fold separating the brain into supratentorial and infratentorial compartments.*
|
||||
|
||||
|
||||
*More lateral image shows the caudothalamic groove between the caudate head and thalamus. The parietooccipital sulcus is an important landmark, differentiating the parietal from the occipital lobes.*
|
||||
|
||||
|
||||
*This image shows a prominent choroid plexus within the atrium of the lateral ventricle, which tapers posteriorly and extends into the temporal horn.*
|
||||
|
||||
|
||||
*This parasagittal image shows the sylvian fissure bound superiorly by the frontal operculum and inferiorly by the temporal operculum. The central sulcus separates the frontal lobe anteriorly from the parietal lobe posteriorly.*
|
||||
|
||||
|
||||
*This image shows the most lateral portion of the sylvian fissure. The temporal lobe is inferior to the sylvian fissure. The superior temporal gyrus contains the primary auditory cortex. The middle temporal gyrus connects auditory, somatosensory, and visual association pathways. The inferior temporal gyrus is the higher visual association area.*
|
||||
|
||||
|
||||
### Premature Infant (23 weeks 6 days)
|
||||
|
||||
|
||||
*This coronal image of a very premature infant, born at 23-weeks 6-days gestational age, shows a very large, square, open sylvian fissure. The opercula have not yet grown to cover the insula.*
|
||||
|
||||
|
||||
*Sagittal image through the caudothalamic groove in the same case shows the parietooccipital sulcus. The cortex otherwise appears "flat" without gyri/sulcal formation.*
|
||||
|
||||
|
||||
*Another sagittal image further lateral shows similar findings with no cortical gyri/sulci seen.*
|
||||
|
||||
|
||||
### Sylvian fissure at different ages
|
||||
|
||||
|
||||
*A different infant born at 29 weeks 1 day shows more advanced development of the sylvian fissures. The frontal, temporal, and parietal lobes all have opercula, which have grown to cover the insula.*
|
||||
|
||||
|
||||
*At 31 weeks 6 days the opercula have grown to cover the insula.*
|
||||
|
||||
|
||||
*Another coronal image through the level of the sylvian fissure in a full-term infant shows multiple gyri and sulci over the convexities of the brain. It is important to understand the developmental anatomic changes; lack of cortical sulci may be normal for preterm infants, depending on the gestational age at delivery, but is very abnormal at term.*
|
||||
|
||||
|
||||
### Sagittal US Via Posterior Fontanelle
|
||||
|
||||
|
||||
*Although routine scanning is performed via the anterior fontanelle, the posterior fontanelle is another alternative, particularly when it is difficult seeing more posterior structures in the brain.*
|
||||
|
||||
|
||||
*This scan through the posterior fontanelle in a 26-week premature infant was performed to better evaluate the corpus callosum. The splenium is particularly well seen in this view.*
|
||||
|
||||
|
||||
*Color Doppler image shows flow within the choroid plexus of the glomus. The posterior fontanelle view can be helpful to differentiate bulky choroid from clot. The occipital horn does not contain choroid plexus, and any echogenic material in the occipital horn should raise the suspicion of intraventricular hemorrhage.*
|
||||
|
||||
|
||||
### Axial US Through Temporal Bone
|
||||
|
||||
|
||||
*Graphic of the transtemporal acoustic window is shown. The transducer is placed more anterior and superior than the mastoid fontanelle approach. The temporal bone anterior to the ear is thin enough to allow imaging of the brainstem even after closure of the temporosquamosal suture. This acoustic window allows the best assessment of cerebral peduncles and the 3rd ventricle.*
|
||||
|
||||
|
||||
*Transtemporal axial scan in a 29-week premature infant shows intracranial anatomy in a plane similar to CT or MR.*
|
||||
|
||||
|
||||
*The temporal bone anterior to the ear is thin, allowing imaging of the brainstem even after sutural closing. This is the best view for the cerebral peduncles and midbrain.*
|
||||
|
||||
|
||||
### Cerebellum and posterior fossa
|
||||
|
||||
|
||||
*Sagittal midline graphic of the posterior fossa shows the anterior brainstem and posterior cerebellum separated by the 4th ventricle. The brainstem consists of midbrain (mesencephalon), pons, and medulla. The cerebellum has superior (tentorial), inferior (suboccipital), and anterior (petrosal) surfaces. The primary (tentorial) fissure and horizontal (petrosal) fissures divide the vermis and cerebellar hemispheres into lobules.*
|
||||
|
||||
|
||||
*This midline sagittal view shows the brainstem. The pons is easily identified by its anterior bulge.*
|
||||
|
||||
|
||||
*A coronal image through the anterior fontanelle of a premature infant, born at 29 weeks 1 day, shows symmetric cerebellar hemispheres. The vermis is midline, covers the 4th ventricle, and is more echogenic than the rest of the cerebellum.*
|
||||
|
||||
|
||||
### Posterior fossa via mastoid approach
|
||||
|
||||
|
||||
*The mastoid/posterolateral fontanelle is located at the junction of temporosquamosal, lambdoidal, and occipital sutures. It allows assessment of brainstem and posterior fossa structures, which are not well demonstrated in the standard planes through the anterior fontanelle. The transducer is placed ~ 1 cm behind the helix of ear and 1 cm above the tragus. This acoustic window allows the best visualization of 4th ventricle, posterior cerebellar vermis, cerebellar hemispheres, and cisterna magna.*
|
||||
|
||||
|
||||
*The mastoid approach allows for detailed evaluation of the posterior fossa structures. This is a premature infant (27 weeks 5 days), which is evident by the lack of cortical gyri and cerebellar folia.*
|
||||
|
||||
|
||||
*Another mastoid view in an infant born at 37 weeks shows maturation with extensive folia on the surface of the cerebellum.*
|
||||
|
||||
|
||||
### Cavum Septi Pellucidi et Vergae
|
||||
|
||||
|
||||
*Coronal graphic with an axial insert shows a classic cavum septi pellucidi with a posterior extension, the cavum vergae. It creates a finger-like CSF collection between the lateral ventricles.*
|
||||
|
||||
|
||||
*The cavum septi pellucidi can be quite large, especially in premature infants and should not be confused with an elevated 3rd ventricle or intracranial cyst.*
|
||||
|
||||
|
||||
*Midline sagittal image in this 27-week premature infant shows a cavum septi pellucidi continuing posteriorly into the cavum vergae. This is a common finding in premature infants. The cavum vergae is closed in 97% of full-term infants and the cavum septi pellucidi is closed in 85% of infants by 3-6 months of age; however, it can remain open until adulthood.*
|
||||
|
||||
|
||||
### Cavum Velum Interpositum
|
||||
|
||||
|
||||
*Sagittal graphic with an axial insert shows a cavum velum interpositum. Note the elevation and splaying of the fornices. Also noted is the inferior displacement of the internal cerebral veins and 3rd ventricle.*
|
||||
|
||||
|
||||
*Midline sagittal ultrasound shown a mildly complex cavum velum interpositum.*
|
||||
|
||||
|
||||
*This premature infant has a cavum septi pellucidi, vergae, and interpositum. Like a cavum septi pellucidi and vergae, a cavum velum interpositum is more common in premature infants.*
|
||||
|
||||
|
||||
### Vascular anatomy
|
||||
|
||||
|
||||
*This graphic shows the arteries, sinuses, and veins, which can be seen seen on a routine midline sagittal view. The anterior cerebral artery and its 2 main branches, the pericallosal and callosomarginal arteries, are easily seen on midline color Doppler ultrasound. The basilar artery is also easily identified, running anterior to the brainstem. The middle cerebral and posterior cerebral arteries are better evaluated in an axial plane using a transtemporal or mastoid approach.*
|
||||
|
||||
|
||||
### Midline color Doppler
|
||||
|
||||
|
||||
*Midline sagittal color Doppler image, obtained via the anterior fontanelle, shows the pericallosal artery running in the callosal sulcus, just above the corpus callosum. In a normal newborn, the pericallosal artery should be close to the surface of the corpus callosum. While in callosal agenesis, this artery remains far from the 3rd ventricle and takes an upward oblique direction.*
|
||||
|
||||
|
||||
*The anterior cerebral artery divides into the pericallosal artery, which continues along the corpus callosum, and the callosomarginal artery, which courses superiorly to travel above the cingulate gyrus within the cingulate sulcus.*
|
||||
|
||||
|
||||
*Multiple cortical branches of the callosomarginal artery are seen traveling within cortical sulci.*
|
||||
|
||||
|
||||
### Circle of Willis
|
||||
|
||||
|
||||
*The circle of Willis illustrated in situ shows its intricate relationship to adjacent structures. It located in the suprasellar cistern just below the diencephalon. The hypothalamus, infundibular stalk, and optic chiasm lie in the middle of the circle. The horizontal (A1) anterior cerebral artery segment passes above the optic nerves (CNII); the posterior communicating artery passes above the oculomotor nerves (CNIII). The anterior communicating artery is near the midline, below the interhemispheric fissure.*
|
||||
|
||||
|
||||
*The circle of Willis is shown in isolation and turned 90° counterclockwise to match the plane of the ultrasound.*
|
||||
|
||||
|
||||
*Transtemporal axial color Doppler in a premature infant with ventriculomegaly from an intracranial hemorrhage shows the circle of Willis. The anterior and middle cerebral arteries are the terminal branches of the internal carotid artery. The posterior cerebral artery is the terminal branch of the basilar artery. These 3 crucial arteries communicate via the anterior and posterior communicating arteries in a complete circle of Willis. The transtemporal approach provides the best window for evaluating the circle of Willis.*
|
||||
|
||||
|
||||
### Cerebral Arteries
|
||||
|
||||
|
||||
*Doppler waveform of a cortical branch of the anterior cerebral artery shows a low-resistance waveform with abundant diastolic flow. Velocity of the cerebral artery is a reliable reflection of intracranial pressure.*
|
||||
|
||||
|
||||
*Doppler waveform of the middle cerebral artery in the coronal plane is obtained by angling the beam laterally toward the sylvian fissure. A low-resistance arterial waveform is again noted.*
|
||||
|
||||
|
||||
*Color Doppler ultrasound obtained by a parasagittal scan through the anterior fontanelle shows the thalamostriate arteries. Anteriorly, the caudate nucleus is supplied by the anterior thalamostriate artery while the thalamus posteriorly is supplied by the posterior thalamostriate artery. The thalamostriate arteries arise from the middle cerebral artery.*
|
||||
|
||||
|
||||
### Cerebral veins and sinuses
|
||||
|
||||
|
||||
*This graphic shows the the connections between the major dural sinuses and deep cerebral veins. The internal cerebral veins and basal veins of Rosenthal drain into the vein of Galen, which in turn drains into the straight sinus.*
|
||||
|
||||
|
||||
*Sagittal color Doppler scan through the anterior fontanelle shows a superficial cortical vein traversing the subarachnoid space and draining into the superior sagittal sinus.*
|
||||
|
||||
|
||||
*Spectral Doppler waveform of the superior sagittal sinus shows the waveform of the sinus to be pulsatile, under the effect of transmitted cardiac pulsations.*
|
||||
|
||||
|
||||
*Color Doppler ultrasound obtained by a midline sagittal scan through the anterior fontanelle shows the relationship of the vein of Galen and straight sinus. The vein of Galen is seen under the splenium of the corpus callosum. It receives drainage from the paired internal cerebral veins and basal veins of Rosenthal. The vein of Galen continues inferiorly into the straight sinus. The straight sinus, superior sagittal sinus, and transverse sinuses converge posteriorly, forming the torcular Herophili.*
|
||||
|
||||
|
||||
*In the angled coronal plane, the straight sinus is seen in the midline between the lateral ventricles.*
|
||||
|
||||
|
||||
*Other sinuses can be evaluated using different acoustic windows. The transverse sinus can be accessed via a mastoid fontanelle approach, as shown here. The cerebral venous system is valveless, and pulsed Doppler waveforms typically show cardiac pulsations.*
|
||||
|
||||
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|
||||
---
|
||||
title: "Fat Emboli Cerebral Infarction"
|
||||
docid: "f202ed78-4256-4d0b-b15a-2af1088e7c51"
|
||||
authors:
|
||||
- key: "8d5254e9-8dda-478b-8f08-bdee97a32c79"
|
||||
value: "Karen L. Salzman, MD, FACR"
|
||||
- key: "318f80ab-6abb-4067-a809-2ebdaa5a30c9"
|
||||
value: "Kalen Riley, MD, MBA"
|
||||
breadcrumbs:
|
||||
-
|
||||
name: "Brain"
|
||||
slug: "brain"
|
||||
treeNodeId: "0361042c-9c90-48e4-864e-a2e6428ee9c9"
|
||||
-
|
||||
name: "Diagnosis"
|
||||
slug: "diagnosis"
|
||||
treeNodeId: "948c6f1e-8e18-45f3-bd9d-7a04ab0b8708"
|
||||
-
|
||||
name: "Pathology-Based Diagnoses"
|
||||
slug: "pathology-based-diagnoses"
|
||||
treeNodeId: "d60fe914-7897-46a0-9cd2-f88ffb322f16"
|
||||
-
|
||||
name: "Stroke"
|
||||
slug: "stroke"
|
||||
treeNodeId: "7a135176-0a69-4fc9-b200-59569fbf5166"
|
||||
-
|
||||
name: "Cerebral Ischemia and Infarction"
|
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slug: "cerebral-ischemia-and-infarction"
|
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treeNodeId: "11d50e7d-f3e9-4071-b2b7-26b11ab40ea6"
|
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-
|
||||
name: "Fat Emboli Cerebral Infarction"
|
||||
slug: "fat-emboli-cerebral-infarction"
|
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treeNodeId: null
|
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category: "Brain"
|
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documentVersionId: "a7e5f3e7-e8d0-4e84-8325-2b94fb1344e5"
|
||||
imageCount: 13
|
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lastUpdated: "08/21/25"
|
||||
pageDescription: "Fat Emboli Cerebral Infarction"
|
||||
pageKeywords: "Brain, Diagnosis, Pathology-Based Diagnoses, Stroke, Cerebral Ischemia and Infarction, Fat Emboli Cerebral Infarction"
|
||||
pageTitle: "Fat Emboli Cerebral Infarction | STATdx"
|
||||
enhancedTitle: "Fat Emboli Cerebral Infarction"
|
||||
type: "DX"
|
||||
references: true
|
||||
cases: 1
|
||||
breadcrumbs:
|
||||
- "Brain"
|
||||
- "Diagnosis"
|
||||
- "Pathology-Based Diagnoses"
|
||||
- "Stroke"
|
||||
- "Cerebral Ischemia and Infarction"
|
||||
- "Fat Emboli Cerebral Infarction"
|
||||
---
|
||||
## KEY FACTS
|
||||
|
||||
- ### Terminology
|
||||
|
||||
|
||||
- Acute stroke related to fat emboli
|
||||
- ### Imaging
|
||||
|
||||
|
||||
- Acute ischemia with appropriate clinical history
|
||||
- Long bone or pelvic fractures, cardiac surgery, joint replacement surgery
|
||||
- Often mimics thromboembolic stroke
|
||||
- Commonly affects gray matter and white matter (WM)
|
||||
- May affect deep and periventricular WM
|
||||
- May affect deep gray nuclei
|
||||
- May show typical vascular territory or mimic "watershed" infarct
|
||||
- NECT: Typically negative acutely
|
||||
- Hypodense MCA sign related to fat within MCA
|
||||
- T2/FLAIR: Multiple small, scattered hyperintense foci
|
||||
- DWI: Multiple foci of + restriction: **Starfield pattern**
|
||||
- T2* GRE/SWI: May show extensive petechial hemorrhages
|
||||
- T1WI C+: May see faint enhancement of lesions
|
||||
- ### Top Differential Diagnoses
|
||||
|
||||
|
||||
- Acute cerebral ischemia-infarction
|
||||
- Posterior reversible encephalopathy syndrome (PRES)
|
||||
- Vasculitis
|
||||
- Septic emboli
|
||||
- Diffuse axonal injury (DAI)
|
||||
- ### Pathology
|
||||
|
||||
|
||||
- Fat emboli can pass through pulmonary capillaries without shunting lesions and result in systemic embolization (brain, kidneys most commonly)
|
||||
- ### Clinical Issues
|
||||
|
||||
|
||||
- Fat embolism syndrome: Pulmonary, CNS, and cutaneous manifestations
|
||||
- Hypoxia, deteriorating mental status, petechiae
|
||||
- Neurologic dysfunction varies from confusion to encephalopathy with coma and seizures
|
||||
- Uncommon but potentially life threatening
|
||||
- Fat embolism syndrome after fractures: Up to 2.2%
|
||||
|
||||
## TERMINOLOGY
|
||||
|
||||
- ### Definitions
|
||||
|
||||
|
||||
- Acute stroke related to fat emboli
|
||||
|
||||
## IMAGING
|
||||
|
||||
- ### General Features
|
||||
|
||||
|
||||
- #### Best diagnostic clue
|
||||
|
||||
|
||||
- Acute ischemia with appropriate clinical history
|
||||
- Often mimics thromboembolic stroke
|
||||
- Hypodense MCA sign related to fat within MCA
|
||||
- #### Location
|
||||
|
||||
|
||||
- Commonly affects both gray (GM) and white matter (WM)
|
||||
- May affect deep and periventricular WM
|
||||
- May affect deep gray nuclei (basal ganglia and thalamus)
|
||||
- May involve typical vascular territory (MCA, PCA, ACA)
|
||||
- May mimic "watershed" infarct
|
||||
- #### Size
|
||||
|
||||
|
||||
- Punctate to large vascular territory
|
||||
- ### CT Findings
|
||||
|
||||
|
||||
- NECT: Typically negative acutely
|
||||
- Hypodense MCA sign related to fat within MCA is rare
|
||||
- ### MR Findings
|
||||
|
||||
|
||||
- T1WI: Typically normal
|
||||
- T2WI: Multiple small, scattered hyperintense foci in WM and GM
|
||||
- May affect only deep gray nuclei (BG and thalamus)
|
||||
- FLAIR: Multiple small, scattered hyperintense foci in WM and GM
|
||||
- DWI/DTI: Acute diffusion restriction
|
||||
- Starfield pattern with innumerable tiny punctate foci of DWI restriction in multiple vascular distributions
|
||||
- T2* GRE/SWI: Multiple foci of "blooming" common, related to petechial hemorrhages
|
||||
- Some authors consider this feature pathognomonic
|
||||
- T1WI C+: May see faint enhancement correlating with areas of DWI restriction and T2 hyperintensity
|
||||
- ### Imaging Recommendations
|
||||
|
||||
|
||||
- #### Best imaging tool
|
||||
|
||||
|
||||
- MR with DWI
|
||||
|
||||
## DIFFERENTIAL DIAGNOSIS
|
||||
|
||||
- [Acute Cerebral Ischemia-Infarction](/document/acute-cerebral-ischemiainfarction/7a3ed4a9-ae05-4d64-ae8e-6a30105501e1)
|
||||
- Wedge-shaped T2 hyperintensity in typical vascular territory (MCA, PCA, ACA)
|
||||
- DWI restriction
|
||||
- PWI shows abnormal perfusion
|
||||
- [Acute Hypertensive Encephalopathy, PRES](/document/posterior-reversible-encephalopath-/84176f2c-fc9d-4497-8af9-1430b9f0187c)
|
||||
- T2/FLAIR hyperintensity in cortex/subcortical WM of posterior circulation
|
||||
- May affect BG and thalami
|
||||
- Typically reversible
|
||||
- [Vasculitis](/document/miscellaneous-vasculitis/221f737a-6bfa-4331-b296-402e40973f7e)
|
||||
- Irregularity, stenosis, and vascular occlusion of 2nd- and 3rd-order arterial branches
|
||||
- T2/FLAIR subcortical and BG hyperintensities
|
||||
- Patchy enhancement is common
|
||||
- May see associated hemorrhage
|
||||
- May be DWI + acutely
|
||||
- ### Septic Emboli
|
||||
|
||||
|
||||
- Areas of DWI restriction in multiple vascular territories of variable size
|
||||
- Will typically enhance
|
||||
- Clinical history (endocarditis, cardiac vegetations, IV drug use, etc.) may be key differentiating feature
|
||||
- ### Diffuse Axonal Injury
|
||||
|
||||
|
||||
- Trauma patient
|
||||
- Punctate lesions at corticomedullary junction, corpus callosum, deep GM, brainstem
|
||||
- Typically DWI + with T2*/SWI hypointense, "blooming"
|
||||
|
||||
## PATHOLOGY
|
||||
|
||||
- ### General Features
|
||||
|
||||
|
||||
- #### Etiology
|
||||
|
||||
|
||||
- Fat emboli can pass through pulmonary vasculature without shunting lesions, resulting in systemic embolization; most common in brain and kidneys
|
||||
- Fat emboli often result from long bone or pelvic fractures
|
||||
- May result as complication of cardiac surgery, intracardiac right-to-left shunt, or venous-arterial shunt
|
||||
- Coronary artery bypass or valve replacement surgery
|
||||
- May result from hip or knee replacement surgery
|
||||
- Rarely reported as complication of sickle cell disease related to bone marrow necrosis
|
||||
- Onset is typically 2 hours to 2 days after trauma or surgery
|
||||
- Pathologic hallmark is arteriolar fat emboli with perivascular microhemorrhages
|
||||
|
||||
## CLINICAL ISSUES
|
||||
|
||||
- ### Presentation
|
||||
|
||||
|
||||
- #### Most common signs/symptoms
|
||||
|
||||
|
||||
- Fat embolism syndrome: Pulmonary, central nervous system, and cutaneous manifestations
|
||||
- Main criteria: Hypoxia, deteriorating mental status, and petechiae
|
||||
- Secondary signs: Tachycardia, fever, anemia, and thrombocytopenia
|
||||
- Neurologic dysfunction varies from confusion to encephalopathy with coma and seizures
|
||||
- Cerebral manifestations of fat embolism syndrome are variable: Headache, lethargy, irritability, delirium, stupor, seizures, coma
|
||||
- #### Other signs/symptoms
|
||||
|
||||
|
||||
- Many cases are subclinical and remain undiagnosed
|
||||
- High-resolution chest CT findings of fat emboli: Bilateral ground-glass opacities and thickening of interlobular septa
|
||||
- ### Demographics
|
||||
|
||||
|
||||
- #### Epidemiology
|
||||
|
||||
|
||||
- Uncommon but potentially life threatening
|
||||
- Incidence of fat embolism syndrome after bone fractures is 0.9-2.2%
|
||||
- Reports of incidence up to 5-10% if multiple fractures
|
||||
- ### Treatment
|
||||
|
||||
|
||||
- Supportive measures, including supplemental oxygenation, mechanical ventilation (if necessary) and fluid resuscitation, are mainstays of therapy
|
||||
|
||||
## DIAGNOSTIC CHECKLIST
|
||||
|
||||
- ### Consider
|
||||
|
||||
|
||||
- Fat embolism as cause of stroke in patient with appropriate history
|
||||
- In patient with hypoxia, skin petechia, and acute stroke, think fat emboli
|
||||
|
||||
da014c5b-868c-4cc4-a0b4-f9658a6a64d4
|
||||
|
||||
## References
|
||||
|
||||
## Selected References
|
||||
|
||||
1. [Amseian G et al: Brain microbleeds resulting from presumed extensive fat emboli in a patient with bone marrow necrosis following a sickle cell disease vaso-occlusive crisis. Emerg Radiol. 32(1):125-9, 2025](http://www.ncbi.nlm.nih.gov/pubmed/?term=39333401%5Bpmid%5D)
|
||||
1. [Salunkhe R et al: Unusual presentation of cerebral fat embolism syndrome post-femur fracture: a case study and diagnostic insights. Cureus. 16(7):e64819, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=39156416%5Bpmid%5D)
|
||||
1. [Kanda N et al: Prospective study examining the probability of cerebral fat embolism based on magnetic resonance imaging. Heliyon. 9(3):e14073, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36915523%5Bpmid%5D)
|
||||
1. [Singh A et al: Cerebral fat embolism syndrome at a single trauma center. J Stroke Cerebrovasc Dis. 31(12):106794, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36215903%5Bpmid%5D)
|
||||
1. [Gadde JA et al: Neuroimaging of patients in the intensive care unit: pearls and pitfalls. Radiol Clin North Am. 58(1):167-85, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31731899%5Bpmid%5D)
|
||||
1. [Uzelac A: Imaging of altered mental status. Radiol Clin North Am. 58(1):187-97, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31731900%5Bpmid%5D)
|
||||
1. [Bhatt AA et al: Beyond stroke-uncommon causes of diffusion restriction in the basal ganglia. Emerg Radiol. 25(1):87-92, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=28871382%5Bpmid%5D)
|
||||
1. [Skalski KA et al: Hemorrhagic and non-hemorrhagic causes of signal loss on susceptibility-weighted imaging. Emerg Radiol. 25(6):691-701, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30136160%5Bpmid%5D)
|
||||
1. [Rutman AM et al: T2*-weighted and diffusion magnetic resonance imaging differentiation of cerebral fat embolism from diffuse axonal injury. J Comput Assist Tomogr. 41(6):877-83, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28708729%5Bpmid%5D)
|
||||
1. [Zakhari N et al: Unusual cerebral emboli. Neuroimaging Clin N Am. 26(1):147-63, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26610666%5Bpmid%5D)
|
||||
1. [Eriksson EA et al: Fat embolism in pediatric patients: an autopsy evaluation of incidence and Etiology. J Crit Care. 30(1):221.e1-5, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25306239%5Bpmid%5D)
|
||||
1. [Kosova E et al: Fat embolism syndrome. Circulation. 131(3):317-20, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25601951%5Bpmid%5D)
|
||||
1. [Kuo KH et al: Dynamic MR imaging patterns of cerebral fat embolism: a systematic review with illustrative cases. AJNR Am J Neuroradiol. 35(6):1052-7, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=23639561%5Bpmid%5D)
|
||||
1. [Kellogg RG et al: Massive cerebral involvement in fat embolism syndrome and intracranial pressure management. J Neurosurg. 119(5):1263-70, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23952720%5Bpmid%5D)
|
||||
1. [Medina FJ et al: Cerebral fat embolism detection with susceptibility-weighted images in sickle cell disease. Neuroradiol J. 25(4):411-4, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=24029033%5Bpmid%5D)
|
||||
1. [Abend NS et al: Hypodense middle cerebral artery with fat embolus. Neurocrit Care. 6(2):147-8, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17522799%5Bpmid%5D)
|
||||
1. [Koch S et al: Cerebral fat microembolism and cognitive decline after hip and knee replacement. Stroke. 38(3):1079-81, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17255544%5Bpmid%5D)
|
||||
1. [Aydin MD et al: Cerebral fat embolism: pulmonary contusion is a more important etiology than long bone fractures. Clin Neuropathol. 24(2):86-90, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15803808%5Bpmid%5D)
|
||||
1. [Lee TC et al: The hypodense artery sign. AJNR Am J Neuroradiol. 26(8):2027-9, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16155153%5Bpmid%5D)
|
||||
1. [Simon AD et al: Contrast-enhanced MR imaging of cerebral fat embolism: case report and review of the literature. AJNR Am J Neuroradiol. 24(1):97-101, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12533333%5Bpmid%5D)
|
||||
1. [Yoon SS et al: Acute fatal stroke immediately following autologous fat injection into the face. Neurology. 61(8):1151-2, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=14581689%5Bpmid%5D)
|
||||
1. [Parizel PM et al: Early diagnosis of cerebral fat embolism syndrome by diffusion-weighted MRI (starfield pattern). Stroke. 32(12):2942-4, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11740000%5Bpmid%5D)
|
||||
1. [Forteza AM et al: Transcranial doppler detection of fat emboli. Stroke. 30(12):2687-91, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10582998%5Bpmid%5D)
|
||||
1. [Wegener K et al: A case of cerebral fat embolism demonstrating no pathophysiological involvement of lung dysfunction. Eur Neurol. 42(1):65-6, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10523138%5Bpmid%5D)
|
||||
1. [Ghatak NR et al: Cerebral fat embolism following cardiac surgery. Stroke. 14(4):619-21, 1983](http://www.ncbi.nlm.nih.gov/pubmed/?term=6658941%5Bpmid%5D)
|
||||
|
||||
## Cases
|
||||
|
||||
- {'cases': [{'authors': [{'key': 'f184750a-90b4-47a7-907b-23b05d70357a', 'value': 'Chang Yueh Ho, MD'}], 'caseVersionId': 'b4123f39-01b7-4aee-84a9-2f7e1e765116', 'description': "Axial NECT (#1) shows bilateral occipital hypodensity with loss of the gray-white differentiation (black arrows) at the junction of the MCA and PCA vascular distributions. Note the scalp hematoma related to the patient's recent trauma (white arrows). Axial NECT (#2) shows multiple hypodensities (black arrows) with loss of the gray-white differentiation in the frontal lobes at the junctions between the ACA and MCA vascular distributions and posteriorly at the MCA and PCA vascular distributions.\n\nAxial T2WI MR (#3) and axial FLAIR MR (#4) show bilateral occipital hyperintensities (black arrows). The left-sided lesion shows heterogeneous T2 hypointensity (white arrows) suggesting acute blood products. Axial T1WI MR (#5) shows left occipital hypointensity (black arrow) with central isointensity (white arrow) again confirming blood products. Axial DWI MR (#6) shows hyperintensity of the left occipital lesion (arrow) indicating acute infarct. Axial ADC (#7) shows hypointensity of the left occipital lesion (arrow) from reduced diffusivity indicating infarct. Axial T2WI MR (#8) and FLAIR (#9) MR show multiple hyperintensities (arrows) in multiple vascular distributions indicating embolic phenomenon. Axial DWI MR (#10) demonstrates multiple foci of hyperintensity (arrows) in multiple vascular distributions indicating embolic infarction. Axial ADC (#11) demonstrates corresponding hypointensity from reduced diffusivity (arrows) in multiple vascular distributions confirming embolic infarction.\n\nSagittal reformat CT (#12) of the left knee shows fracture through the base of the tibial plateau (arrows).\n\nAP radiograph of the left humerus (#13) shows a comminuted fracture (curved arrow). Long bone fractures are a primary risk factor for fat emboli causing cerebral infarcts. Note the chest wall emphysema (arrow) from pneumothorax. AP radiograph of the right humerus (#14) shows an an olecranon avulsion fracture (arrow).\n\nComment: Fat emboli should be considered in post-traumatic cerebral ischemia with multiple vascular distributions and associated long bone fractures. These ischemic regions may have a propensity for blood products.", 'history': 'Go-karting accident, hit a parked truck; follow-up head CT demonstrates new infarcts not seen on head CT at admission; diagnostic angiogram (not included) was negative for dissection or other occlusion.', 'imagePoolId': '5a7c6a13-71f9-496c-bb4c-d36d2470e0b4', 'name': 'Multiple infarcts with long bone fractures', 'teachingPoint': None, 'demographics': '38 Years old male'}, {'authors': [{'key': '8d5254e9-8dda-478b-8f08-bdee97a32c79', 'value': 'Karen L. Salzman, MD, FACR'}, {'key': 'b049ee34-939e-4e28-8aad-f747a8f9efb0', 'value': 'Ulrich Rassner, MD'}], 'caseVersionId': 'cf0126cb-5324-47d2-8048-99999787613c', 'description': 'Typical MR case of acute stroke related to fat emboli in a patient status post hip surgery.\n\nAxial DWI images (#1-6) show extensive hyperintense foci related to acute fat emboli. The ADC map (#7) at the level of the lateral ventricles shows low signal in the areas of DWI hyperintense foci, indicating restricted diffusion related to acute ischemia. \n\nAxial FLAIR images (#8-10) show multiple areas of hyperintense foci (arrows) related to the multifocal areas of ischemia. \n\nAxial post-contrast images show subtle enhancement in some of the regions of ischemia (curved arrows, #11-12).\n\nComment: Fat embolism syndrome is rare and occurs in ~ 2% of patients with fractures. The fat emboli may pass through the pulmonary capillaries without a shunting lesion.', 'history': 'Patient with history of recent hip arthroplasty and acute neurologic symptoms.', 'imagePoolId': '645b0017-07e0-44da-893e-91ceb61e15bd', 'name': 'Multifocal emboli', 'teachingPoint': None, 'demographics': '68 Years old female'}], 'caseType': 'typical', 'name': 'TYPICAL'}
|
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||||
## Images
|
||||
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||||
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||||
### Selected Images
|
||||
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||||
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||||
*Axial FLAIR MR in a 35-year-old with confusion after a femur fracture from a mountain biking injury shows abnormal hyperintensities in the bilateral corticomedullary junctions <img src='img/arrows/CS.png' alt='cyan solid arrow'/> and subcortical white matter <img src='img/arrows/CO.png' alt='cyan open arrow'/> related to infarcts from fat emboli. Involvement of the basal ganglia was also present (not shown).*
|
||||
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||||
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||||
*Axial FLAIR MR in a 35-year-old with confusion after a femur fracture from a mountain biking injury shows abnormal hyperintensities in the bilateral corticomedullary junctions <img src='img/arrows/CS.png' alt='cyan solid arrow'/> and subcortical white matter <img src='img/arrows/CO.png' alt='cyan open arrow'/> related to infarcts from fat emboli. Involvement of the basal ganglia was also present (not shown).*
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||||
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||||
*Axial DTI trace MR in the same patient shows extensive punctate foci of diffusion restriction throughout the cortex and white matter <img src='img/arrows/CS.png' alt='cyan solid arrow'/> in a starfield pattern typical of fat embolism.*
|
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||||
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||||
*Axial SWI MR in a 35-year-old man with multiple fractures shows extensive foci of susceptibility artifact or "blooming" related to petechial hemorrhages. These hemorrhages are often seen in patients with cerebral fat emboli. Microhemorrhages persist from the acute to chronic phases of fat embolism.*
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*Axial SWI MR in the same patient shows extensive foci of susceptibility artifact in the cerebellum. These microhemorrhages are characteristic of cerebral fat emboli and help clarify the diagnosis.*
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||||
### Additional Images
|
||||
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||||
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||||
*Axial DWI MR shows bilateral ischemia related to fat emboli. Imaging mimics other more typical causes of acute ischemia.*
|
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||||
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||||
*Axial DWI MR shows innumerable punctate foci of restriction throughout the white matter and gray matter of this 68-year-old with mental status changes status post hip surgery. Note the extensive involvement of the basal ganglia and thalami.*
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||||
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||||
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||||
*Axial DWI in the same patient shows the extensive foci of restriction related to acute ischemia from the patient's fat emboli. Note the more focal involvement of the left MCA territory with frontal and temporal lobe involvement. Microhemorrhages are also common with fat emboli.*
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*Axial FLAIR MR in an unresponsive 43-year-old after surgery for a pathologic acetabular fracture related to metastatic breast cancer shows abnormal hyperintensities in the bilateral deep gray nuclei <img src='img/arrows/CS.png' alt='cyan solid arrow'/> and periventricular and subcortical white matter <img src='img/arrows/CC.png' alt='cyan curved arrow'/> related to fat emboli.*
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*Axial T1 C+ MR in the same patient shows patchy enhancement of the lesions within the deep gray nuclei <img src='img/arrows/CS.png' alt='cyan solid arrow'/> and subcortical white matter <img src='img/arrows/CC.png' alt='cyan curved arrow'/>, most prominent in the occipital lobes.*
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||||
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||||
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||||
*Axial DWI trace MR shows extensive punctate foci of diffusion restriction throughout the cortex and white matter this 30-year-old with mental status changes status post femur fracture repair. These bright foci have been described as the starfield pattern in the setting of fat emboli.*
|
||||
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||||
|
||||
*Axial SWI MR in the same patient shows extensive foci of susceptibility artifact or blooming related to extensive petechial hemorrhages. The microhemorrhages persist from the acute to chronic phases of fat embolism. Differential considerations include traumatic diffuse axonal injury (DAI), which is typically less severe and also shows linear and punctate foci. At times, differentiating between DAI and cerebral fat emboli may be difficult given the imaging overlap.*
|
||||
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||||
|
||||
*Axial DTI trace MR in an 81-year-old with altered mental status after hip fracture repair shows multiple foci of hyperintensity involving the cortex and corticomedullary junctions related to fat embolism. Imaging mimics multiple embolic infarcts.*
|
||||
|
||||
|
||||
*Axial SWI MR in the same patient shows scattered foci of susceptibility artifact related to petechial hemorrhages <img src='img/arrows/CS.png' alt='cyan solid arrow'/>. Petechial hemorrhages are often seen in patients with fat embolism.*
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Some files were not shown because too many files have changed in this diff Show More
Reference in New Issue
Block a user