Diagnosing paradoxical fat embolism syndrome after cemented hip arthroplasty

The diagnosis of cerebral fat embolism syndrome (FES) is not linear. In this case report, a 79-year-old woman underwent urgent cemented hip arthroplasty 24 h after a femoral neck fracture. Immediately after the procedure she had a brief episode of altered state of consciousness. After 4 h, she presented with multiple neurological symptoms which led to activation of the stroke alert system. Various new neurological deficits appeared during the day. She had 2 brain CT scans, which were normal. Transthoracic echocardiogram showed a patent foramen ovale with an exuberant aneurysm. Electroencephalogram showed nonconvulsive status epilepticus, which was promptly treated. Brain MRI showed findings compatible with cerebral FES. After ruling out acute ischaemic stroke, conditions that lead to multiple embolic strokes in different vascular territories had to be considered due to the diverse neurological deficits. The embolization hypothesis was also supported by the sudden onset of the symptoms. Even though FES is an exclusion diagnosis, the patient's brain MRI showed the distinct radiographic features of fat microembolism. Perioperative neurological deficits are not uncommon, particularly in elderly patients. Accurate diagnosis and appropriate management are crucial to ensure favourable outcomes and prevent long-term sequelae.