To describe the case of a 26-year-old man who sustained orthopedic trauma causing multifocal fat emboli throughout the cerebrum, cerebellum, and brainstem in addition to spinal cord infarcts at the C3-C4 and C4-C5 levels.

Fat embolism syndrome is an uncommon but deadly complication that can happen after orthopedic trauma. It can have pulmonary, cutaneous, and central nervous system manifestations. Although the pathophysiology of fat embolism is not well understood, it is postulated that this may happen by either direct release of fat globules into the circulation or by inflammation resulting in formation of fat globules within the circulation. Fat emboli leading to cerebral infarcts are well documented in literature, but spinal cord infarcts are rarely reported.

Case report and review of literature.

A 26-year-old man with methamphetamine use disorder presented after an auto pedestrian accident with right ulnar, right tibial, and right fibular fractures with a GCS of 14. CT of the head and spine showed no acute abnormalities. Shortly afterwards, he had generalized tonic-clonic seizures treated with lorazepam and levetiracetam. However, he declined to a GCS 3T and developed quadriparesis with a repeat CT head showing diffuse cerebral edema. MRI brain showed numerous scattered small foci of diffusion restriction in the bilateral cerebral hemispheres, brainstem, and cerebellum. MRI cervical spine showed multiple small foci of T2/FLAIR hyperintensities at the C3-C5 spinal cord levels. The patient subsequently lost all brainstem reflexes with a nuclear medicine test showing absent cerebral blood flow, thus confirming brain death. 

Although cerebral fat embolism is a recognized sequela of orthopedic trauma, spinal cord fat embolism is a rare complication of orthopedic trauma and should be considered in a patient with normal spinal osseous structures but with abnormal spinal cord signal.