Correspondence
Article Type
Disclosures
Response to Letter Regarding Article, “Fat
Embolism Syndrome”
None.
Downloaded from http://circ.ahajournals.org/ by guest on June 16, 2017
We thank Drs van Dam and Broekman for their comment on the
challenging issue of intracranial pressure (ICP) monitoring in fat embolism syndrome.1 As they note, the evidence base for ICP monitoring is
limited and recommendations are confined largely to expert opinion.
Further adding to this difficulty is the diverse range of pathologies for
which ICP monitoring is used, including traumatic brain injury, intracranial hemorrhage, ischemic stroke, hydrocephalus, and cerebral edema
from metabolic and inflammatory causes. Drs van Dam and Broekman
correctly identify a limitation in the work by Kellogg et al2 in that only 1
patient in the case series underwent ICP monitoring. Beyond this single
case, however, Kellogg et al provide a cogent argument for a theoretical
benefit of ICP monitoring in fat embolism syndrome complicated by
severe neurological impairment. The central nervous system dysfunction in fat embolism syndrome is likely inflammatory in origin with
resultant cerebral edema. This process is reversible, with significant
recovery expected in the majority of comatose patients. Prompt recognition and alleviation of elevated ICP in this population may prevent
avoidable, irreversible secondary harm caused by intracranial hypertension.2–4 Conversely, patients with severe traumatic brain injury have a
far worse prognosis independent of intracranial hypertension, perhaps
explaining the failure to demonstrate a benefit in randomized trials of
ICP monitoring in patients with severe traumatic brain injury. Helbok
et al5 support a pathology-specific approach to the consideration of ICP
monitoring, recommending that “ICP and [cerebral perfusion pressure]
monitoring should be used in [subarachnoid hemorrhage], ICH, and
other nontraumatic brain injury conditions in patients who are at risk
of elevated ICP based on clinical and/or imaging features.” The authors
acknowledge that this recommendation is supported by a “low quality
of evidence.”5 We agree with Drs van Dam and Broekman that there is
limited evidence to inform the routine use of ICP monitoring in patients
with fat embolism syndrome, but we do find sufficient rationale to consider ICP monitoring in this group of critically ill patients with potentially reversible central nervous system dysfunction.
Ethan Kosova, MD, MPH
Department of Medicine
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA
Brian Bergmark, MD
Gregory Piazza, MD, MS
Cardiovascular Division
Department of Medicine
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA
References
1. Kosova E, Bergmark B, Piazza G. Fat embolism syndrome. Circulation.
2015;131:317–320. doi: 10.1161/CIRCULATIONAHA.114.010835.
2. Kellogg RG, Fontes RB, Lopes DK. Massive cerebral involvement in fat
embolism syndrome and intracranial pressure management. J Neurosurg.
2013;119:1263–1270. doi: 10.3171/2013.7.JNS13363.
3.Sie MY, Toh KW, Rajeev K. Cerebral fat embolism: an indication
for ICP monitor? J Trauma. 2003;55:1185–1186. doi: 10.1097/01.
TA.0000100833.57027.1F.
4.Kawati R, Larsson A. Brain death due to fat embolism - could
moderate hypercapnia and prone position be blamed for the
tonsillar herniation? Ups J Med Sci. 2013;118:276–278. doi:
10.3109/03009734.2013.818600.
5.Helbok R, Olson DM, Le Roux PD, Vespa P; Participants in the
International Multidisciplinary Consensus Conference on Multimodality
Monitoring. Intracranial pressure and cerebral perfusion pressure monitoring in non-TBI patients: special considerations. Neurocrit Care.
2014;21(suppl 2):S85–S94. doi: 10.1007/s12028-014-0040-6.
(Circulation. 2015;132:e192. DOI: 10.1161/CIRCULATIONAHA.115.016794.)
© 2015 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.115.016794
e192
Response to Letter Regarding Article, ''Fat Embolism Syndrome''
Ethan Kosova, Brian Bergmark and Gregory Piazza
Circulation. 2015;132:e192
doi: 10.1161/CIRCULATIONAHA.115.016794
Downloaded from http://circ.ahajournals.org/ by guest on June 16, 2017
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