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Because of a painful right-sided coxarthrosis a 57-year-old female patient underwent a cementless total arthroplasty under general anesthesia. Except for Asperger's syndrome and an occlusion of a vein in her left eye she stated no other diseases or complaints, especially no cardiac problems. Postoperatively she developed neurological symptoms of left-sided hemiparesis and hemihypesthesia. A cranial computer tomography was performed and a right-sided infarction of the thalamic region was found. A patent foramen ovale (PFO) and atrial septal aneurysm were detected 5 days later. The incidence of a PFO is given as 25% of the population. A paradoxical air embolism in the presence of a PFO is a feared complication in neurosurgical interventions in a semi-sitting or sitting position. Corpuscular emboli, such as bone, cement, fat or wound debris may be the reason for paradoxical embolisms in combination especially with partial or total hip replacement. The kind of embolism in the case described could not be clarified. Deep vein thrombosis or cardiac arrhythmia could be excluded. Therefore, it can be considered most likely that the operation site was the source of the embolism. The trigger for a paradoxical embolism is a reversal of the pressure difference between the right and left atria: normally the left atrial pressure exceeds the right atrial pressure by ca. 2-4 mm Hg, resulting possibly in a small clinically irrelevant left-to-right shunt. If the pulmonary arterial circulation is compromised and pulmonary vascular resistance increases, the pressure gradient between the left and right atria reverses and a right-to-left shunt can occur causing a paradoxical embolism. Positive end-expiratory pressure (PEEP) ventilation during anesthesia could be an important reason for a shunt reversal between the right and left atria and therefore favoring a paradoxical embolism but the pathophysiological role of PEEP has not yet been finally clarified., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Three case histories are presented, in which terminal hydration was omitted. Two patients were in the terminal phase of a menigiosis carcinomatosa and Creutzfeldt-Jacob disease, the third was completely aphasic and hemiplegic after ischemic stroke. All three died peacefully without signs of suffering or thirst. The psychological aspects of therapeutic-palliative change and the archetypical horror of death are considered. The moral justification is discussed in relation to the "Principles for Physicians Accompanying the Dying" of the German chamber of physicians. The respect of the patient's will is the guiding principle. These ethical controversies should be discussed sincerely and frankly so that the society is enabled to follow.

The compartment syndrome (cs) is characterized by an increased tissue pressure in a limited space. Pathophysiologically, it is a multifactorial disease that is potentially induced by an initial trauma and develops according to the existence of cofactors. Cofactors are, for instance, the circulation of the patient and the initial treatment of the impending cs. In particular, the microcirculation is altered with endothelial destruction, development of a capillary leak, protein loss from intravasal space and the development of an interstitial and intracellular third space. An impaired drainage of the lymphatic and venous system causes a venous infarction. An arterial infarction results if the tissue pressure exceeds the arteriolar pressure. An accompanying ischemia reperfusion mechanism increases the trauma load. In disadvantageous cases, the patients are in danger of developing a multi-organ deficiency syndrome (MODS) by an uncontrolled inflammatory reaction, by intravasal volume loss and by a myonephropathic systemic reaction. Clinically, the patients suffer a disproportionate amount of pain, followed by neurological signs. Especially in noncompliant patients, tissue pressure measurement is useful. Resuscitation of the circulation as well as splitting of casts is important. In case of a manifest cs, dermatofasciotomy has to be performed as an emergency operation. Even if cs is diagnosed early and fasciotomy is carried out early, the development of sequellae cannot be avoided in every single case.

The case we present here is that of a fifty-year-old male patient who first came to the Orthopedic Hospital for out-patient treatment suffering from symptoms of lumboischialgia. Shortly afterwards, he developed symptoms characteristic of paraplegia. It was only 21 days after the initial symptoms had manifest themselves that the tentative previous diagnosis, suspected "spinal infarct", could be confirmed by magnetic resonance tomography (MRT). Possibilities offered by differential diagnosis are discussed; the discussion is followed by an enumeration of this highly heterogeneous group of illnesses.

As in the case in other organs, there are infarctions in the eye due to arterial sclerosis. Here, the classic risk factors apply. In addition to such infarctions, there are reversible perfusion disturbances caused by vascular dysregulation. These very frequently lead to slight, transient functional failures which are scarcely noticed by the patient. In more seldom cases, such dysregulation can contribute to the pathogenesis of various disease entities. Of these, the ocular vasospastic syndrome, migraine, glaucoma, apoplexy of the optic nerve, and vein thrombosis were examined.

Small parafoveolar scotomas in microinfarction of the optic pathways are often not demonstrated, or only inaccurately so, in conventional kinetic perimetry. By using Amsler's grid it is possible to determine accurately the shape and position of such visual field defects. Some remarkable variants of these scotomas are described.

Intestinal infarction in the absence of organic vascular occlusion received increasing attention in recent years. The clinical picture is discussed based on results in 9 cases, an attempt to suggest a possible pathophysiological mechanism is made. Prophylactic digitalisation especially in the elderly patient in the absence of severe heart failure and in cases with already low mesenteric perfusion may lead to a further vasoconstriction and to hemorrhagic enteropathy. Therapeutic possibilities are discussed.

In a woman, 29, two times resection and anastomosis of the small intestine because of extended infarction was performed. Following peritonitis and septic shock a progressive respiratory insufficiency developed and patient died 48 hours later despite intensive ventilatory treatment. Autopsy findings were manifold vascular damage (aorta) and thromboembolisms in mesenteric vessels and iliac veins too. Patient received oral contraceptives over several years, changed the preparation previously and contraceptive therapy was continued with another one. Thromboembolic complications may understood as undesirable side effects of the contraceptives. By microscopy of lung thrombosis in capillaries was seen and in small arteries too, as embolism carried by the blood stream. In pathogenesis of shock lung macrothrombosis as an aetiologic factor is to be discussed.

Fourty-four patients with abdominal complaints were analysed for blood lactate levels prior to surgery. Exploratory surgical diagnoses were co-related with blood lactate levels and these co-relations are summarised here. Rise in blood lactate level was found to be significant in all cases of mesenteric infarction (n = 10). The lactate levels were also high in all cases of general peritonitis (n = 4) and 50% (5 out of 10) of cases of bowel strangulation. In all the other surgical explorations, besides the above mentioned, blood lactate was found to lie within a normal range. From the aforesaid study, although pertaining to a small group, it seems plausible that patients presenting with abdominal diseases associated with an elevated blood lactate level represent a surgical emergency. Measurement of blood lactate level can be of great help in the diagnosis of acute surgical emergencies needing early exploration, especially in cases of mesenteric infarction.

"Lacunar stroke" is described and 4 characteristic lacunar syndromes are presented. These small infarcts frequently occur in patients with essential hypertension. At their peak they cause a relatively minor neurologic deficit and are followed by almost complete recovery. Arterigraphic examination is not indicated as only the small arteries are involved. Treatment consists exclusively of control of hypertension. The prognosis is usually good. The small infarcts arise from pathologic changes and occlusions of penetrating arteries. Localization of the pale softenings which produce the typical lacunar syndromes is briefly discussed.

A ten-year-old female poodle was presented for left hindlimb lameness. Radiographically, irregular intramedullary densities of long bones (bone infarcts) and a lytic lesion in the left distal femur were detected. Two years after the first examination, the lesions in the distal femur were definitely identified as osteosarcoma and the dog was euthanized. Pathological and histological changes of the bone infarcts as well as of the osteosarcoma are described. Regarding bibliographical data, occurrence and aetiopathogenesis of osteosarcoma associated with multifocal bone infarction in man and dog are discussed.

A 65-year-old female patient with pulmonary embolism developed widespread, extremely painful hemorrhagic necroses of the skin and subcutaneous tissue of the lower extremities 5 weeks after initiation of anticoagulation therapy. Due to the clinical and histopathologic findings and the course of the disease, a diagnosis of cholesterol embolization was made. The characteristic features of this clinical entity and differential diagnostic considerations are discussed.