title: Super-refractory nonconvulsive status epilepticus secondary to fat embolism: A clinical, electrophysiological, and pathological study.
abstract: BACKGROUND
  Fat embolism syndrome (FES) is a rare complication of long-bone fractures and joint reconstruction surgery. To the best of our knowledge, we describe the clinical, electrophysiological, neuroimaging, and neuropathological features of the first case of super-refractory nonconvulsive status epilepticus (sr-NCSE) secondary to fat embolism.
  
  
  METHODS
  An 82-year-old woman was transferred to our intensive care unit because of a sudden decrease of consciousness level, right hemiparesis, and acute respiratory failure in the early postoperative period of knee prosthesis surgery. Brain computed tomography (TC) including angio-CT and CT perfusion was normal. An urgent video-electroencephalography (v-EEG) evaluation showed continuous sharp-and slow-wave at 2.0-2.5 Hz in keeping with the diagnosis of generalized NCSE. Epileptiform discharges ceased after the administration of 5mg of intravenous diazepam, and background activity constituted by diffuse theta waves was observed without clinical improvement. Treatment with levetiracetam (1000 mg/day) and sedation with propofol and midazolam were initiated. Moreover, continuous v-EEG monitoring was also started. Despite antiepileptic therapy, epileptiform activity recurred after the interruption of profound sedation, and valproate and lacosamide were added during the ensuing days. Magnetic resonance imaging (MRI) disclosed small scattered foci of acute ischemic infarcts and diffuse petechiae involving the basal ganglia and pons and centrum semiovale in keeping with fat embolism. Super-refractory nonconvulsive status epilepticus remained without control for 2 weeks. Finally, the patient died. The clinical autopsy revealed a bilateral lung fat embolism associated with a hemorrhagic infarction in the left lower lobe. Fatty lesions were also seen in the intestine and pancreas. Scattered microscopic cerebral infarcts associated with fat emboli in the capillaries were noticed, affecting both supra- and infratentorial structures. In addition, occasional focal areas of ischemic injury showing filiform neurons with reactive astrocytic gliosis background consistent with acute lesions were observed in CA3.
  
  
  CONCLUSIONS
  Fat embolism should be considered a potential cause of sr-NCSE. This article is part of a Special Issue entitled "Status Epilepticus".
authors.affiliation: Department of Neurophysiology, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain; Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain; Department of Physiology and Pharmacology, School of Medicine, University of Cantabria (UNICAN), Santander, Spain. Electronic address: jlfernandez@humv.es.
authors.forename: José L
authors.initials: JL
authors.lastname: Fernández-Torre
authors.affiliation: Department of Intensive Medicine, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain.
authors.forename: Paula
authors.initials: P
authors.lastname: Burgueño
authors.affiliation: Department of Intensive Medicine, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain.
authors.forename: María A
authors.initials: MA
authors.lastname: Ballesteros
authors.affiliation: Department of Intensive Medicine, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain; Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain.
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Hernández-Hernández
authors.affiliation: Department of Pathology, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain.
authors.forename: Nuria
authors.initials: N
authors.lastname: Villagrá-Terán
authors.affiliation: Department of Radiology, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain; Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain.
authors.forename: Enrique Marco
authors.initials: EM
authors.lastname: de Lucas
mesh_terms: D000369:Aged, 80 and over; D000927:Anticonvulsants / Q000627:therapeutic use; D004569:Electroencephalography; D004620:Embolism, Fat / Q000150:complications* / Q000209:etiology; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D019637:Orthopedic Procedures / Q000009:adverse effects*; D013226:Status Epilepticus / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology*
chemical_list: D000927:Anticonvulsants
keywords: Continuous EEG monitoring; Fat embolism; Hippocampal injury; Neuropathological findings; Nonconvulsive status epilepticus