Objective:

To report a case of cerebral fat embolism syndrome (CFES) occurring without initial pulmonary involvement following long-bone fractures, highlighting its clinical implications.

Approach:

• Case Presentation: A 23-year-old male with multiple lower-extremity fractures developed neurological symptoms 12 hours post-injury, despite normal oxygenation and imaging findings.
• Diagnostic Imaging: Brain MRI revealed a characteristic 'starfield' pattern indicative of CFES, while early pulmonary imaging showed no abnormalities.
• Management: Supportive care included airway protection, mechanical ventilation, EEG monitoring, antiseizure therapy, and organ support.

Key Findings:

• CFES can occur without initial pulmonary symptoms or imaging abnormalities.
• Normal early neuron-specific enolase levels do not exclude severe neurological injury.
• The patient developed refractory status epilepticus and severe disorder of consciousness despite comprehensive treatment.

Interpretation:

This case illustrates a pulmonary-sparing form of CFES, emphasizing the importance of early brain MRI in cases of unexplained neurological deterioration post-fracture.

Limitations:

• Theabsenceofadefinitiveright-to-leftshuntcouldnotbeconfirmedduetotheinabilitytoperformaValsalvamaneuver,whichmaylimitunderstandingofthepathophysiology.

Conclusion:

Severe CFES may manifest without prior respiratory symptoms, necessitating vigilance in monitoring neurological status after long-bone fractures.