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Ann Thorac Surg 2000;70:1793
© 2000 The Society of Thoracic Surgeons

Scientific abstract

Massive cerebral fat embolism from hip surgery: a histologic study with alkaline phosphatase staining and thick celloidin sections

William R. Brown, PhD, Dixon M. Moody, MD, David A. Stump, PhD, David M. Colonna, MD, Douglas J. Kilgus, MD

Departments of Radiology, Anesthesiology, and Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA

Introduction. Cerebral fat embolism is a potentially dangerous complication known to occur in some cases of orthopedic surgery, cardiothoracic surgery, and fractures of large bones. The fat emboli enter the venous system and circulate to the lungs, except in cardiac surgery, where cardiopulmonary bypass (CPB) is employed, in which case the emboli bypass the lungs and circulate directly to the brain. Fat emboli can also pass through the lungs or a patent foramen ovale and circulate to the brain. The amount of cerebral fat that can occur after orthopedic surgery, where there is not a patent foramen ovale, is not well studied. We investigated one such case to quantify the fat occluding cerebral blood vessels.

Methods. Brain tissue was obtained at autopsy from a 77-year-old female who died during surgery. She had a femoral fracture near a hip replacement. A metal plate was being attached to the femur with screws after injection of methyl methacrylate into the bone. Coronal brain slices, 1 cm thick, were cut and fixed in ethanol. Blocks were embedded in celloidin, sectioned 100 µm thick, and stained for alkaline phosphatase, which outlines arterioles and capillaries. Emboli could be seen as swellings in the vessels and were counted in an area of the basal ganglia. They were scored as small, medium, or large to estimate the embolic load (volume of emboli).

Results. There were approximately 5,000 emboli/cm2. This is about 100 times more than the greatest number of cerebral fat emboli we found in studies of 54 CPB patients. The embolic load was about 250 times greater because the emboli tended to be larger (longer) than those previously studied in CPB patients.

Conclusions. Massive cerebral fat embolism may occur during orthopedic surgery, even in patients who do not have a patent foramen ovale.

Issues. The causes and consequences of cerebral fat embolism during orthopedic surgery are not well understood.






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