Case of the Month 2016-12, Page 4

A. MRI Brain

For larger images, please click on Peyman 7 Peyman 8 .

Figure 4. Multiple axial diffusion weighted images of the brain.

Figure 5. Brain MR

Imaging findings:
MR Brain without contrast

  • Multifocal acute infarctions consistent with embolic phenomena, possibly fat emboli.
  • FLAIR vascular hyperintensity over the left sylvian fissure and possibly right temporal lobe. There are a few punctate foci of T1 hyperintensity in the vessels, notably in the left sylvian fissure. These are most consistent with fat emboli.

During the hospital course multiple echocardiogram studies were performed.

Please see video: Echocardiogram with bubbles.

Summary of Echocardiogram Findings:

  • Normal left ventricular systolic function. LV Ejection Fraction is 70 %.
  • There is paradoxical motion and flattening of the interventricular septum in diastole, consistent with RV dysfunction.
  • There is severely depressed RV systolic function in a pattern that spares the RV apex (McConnell`s sign), a finding that is sometimes seen with acute pulmonary embolus.
  • Agitated saline bubble study is early positive, suggestive of patent foramen ovale. (Video 1)

Putting it all together:

  • 39-year-old female status post elective abdominal liposuction and reinjection of fat in the gluteal musculature for buttocks augmentation.
  • Patient developed respiratory distress immediately post extubation and focal neurologic symptoms within a few hours of presentation to the hospital.
  • Imaging studies showed ground glass opacities in bilateral lungs, acute infarctions of the kidneys and spleen and multifocal acute cerebral and cerebellar infarctions with fat densities visualized within cerebral vasculature.
  • Echocardiogram of the heart demonstrated severe right heart strain and a PFO.
  • Doppler US studies of bilateral upper and lower extremities were negative for DVTs.

What is the diagnosis?

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