Title : Hypoxic-Ischemic encephalopathy secondary to fat emboli responding to Modafinil treatment: A Case Report and brief literature review
Abstract:
Background: Fat embolism syndrome (FES) is associated with long bone fractures, occurring with a variable frequency of 0,5 to 3,5% after surgical treatment. It affects 90% of open fractures of long bones, being 75% femoral and 19% tibial fractures. Hypoxic - ischemic encephalopathy is a serious condition resulting from low brain perfusion, FES is a possible cause that leads to intraparenchymal damage.
Objectives: This paper aims to report a successful hypoxic-ischemic encephalopathy treatment using modafinila.
Methods: The case reported in this paper was gathered by appreciation of the patient's records and interviews and was discussed in the light of the most recent literature.
Clinical Presentation: A 26-years-old man comes to the Guarulhos Municipal Urgency Hospital after a femoral and tibial injury caused by a motorcycle accident. At admission, he was conscious and oriented. The next day, he evolved into tachypnea, sweating, low conscious level, answering only to painful stimuli, presenting fat emboli syndrome. Succeeding the inferior members external fixation surgery, in the intensive care unit (ICU), the patient went through septic shock with pulmonary foci, pulmonary thromboembolism and three cardiopulmonary arrest. Following the hemodynamic and infectious improvement, the patient progressed to hospital discharge after 40 days. At that time, he presented discrete conscious level and motor improvement. Afterwards, the patient manifested seizures and hydrocephalus was diagnosed. He underwent ventriculoperitoneal shunt surgery, later replaced by external ventricular drain, evolving to post-surgery infectious meningitis. In the permanence of seizure, it was prescribed sodium valproate. Then, modafinil, 100 mg/day, was introduced in the treatment. The patient progressed with improvement of scapular waist, head sustentation, cognitive performance, memory, verbal communication and also was capable of deambulation. Sodium valproate was suspended, as the patient presented progressed.
Discussion: In fat embolism patients, neurological injury is a possible outcome, occasionating hypoxic-ischemic encephalopathy, a condition caused by brain low perfusion. Our patient presented motor and conscious impairment after a femoral and tibial injury that showed improvement by the modafinil administration. This case is in consonance with the literature reports which demonstrates cognition, attention and motor response to the treatment. However, it is still not fully clear which action mechanisms modafinil uses for this matter. Modafinil is an alpha1B noradrenergic receptor stimulant, increasing glutamate and histamine release and decreasing gamma-aminobutyric acid (GABA), reducing apoptosis and gliosis, comprising possible mechanisms for neuronal protection.
Conclusion: Modadinil is a promising treatment for cerebral injuries, promoting cognitive improvement. However, further studies are required to clarify its action mechanism.
- The use of modadinil for hypoxic - ischemic encephalopath
