The Role of von Willebrand Factor in Microvascular Surgery in Severely Injured Patients.

Microvascular anastomosis has become a standard surgical technique for reconstruction because of increasing possibilities, indications, and clinical success regarding the survival of the flaps. However, the main dreaded complications exist in thrombosis. Leaving surgical complications aside, systemic problems like disorder of the coagulation-fibrinolysis system are a significant cause of graft loss usually being unrecognized. Reports exist describing a hypercoagulable state with clotting activation and inhibition of fibrinolysis after trauma and delayed surgery considering the secondary homeostasis. In this clinical case, a patient had a large soft tissue defect at the temporal side of the head after severe trauma. After some days of primary stabilization, reconstruction using a free microvascular latissimus dorsi flap was performed. Multiple revisions of the arterial and venous branches had to be performed intraoperatively due to insufficient flap perfusion. After 24 hours, definitive flap loss occurred due to multiple thrombosis in the arterial and venous branches. Postoperative comprehensive coagulation analysis revealed a distinct activation of primary hemostasis with massively increased von Willebrand factor parameters and factor VIII activity as well as acetylsalicylic acid resistance contributing to thrombotic occlusion. In severely injured patients, comprehensive preoperative determination of the coagulation status (especially those of the primary hemostasis) is indispensable before performing free flap reconstruction surgeries to reduce the risk of microvascular flap loss.

Strong PSMA Radioligand Uptake by Rectal Carcinoma: Who Put the "S" in PSMA?

We present a case of a 71-year-old patient with newly diagnosed rectal adenocarcinoma and hepatic metastases. Restaging after chemotherapy revealed a good response of the rectal primary while liver metastases were progressive. As the patient also had a history of prostate cancer, a Ga-PSMA-HBED-CC PET/CT scan was performed to noninvasively further assess hepatic metastases. However, a definite differentiation between tumor entities was not possible because not only the liver metastases but also the rectal primary showed radioligand uptake (moderate and strong, respectively). Consecutive liver biopsy revealed a poorly differentiated adenocarcinoma of intestinal origin.

Congenital glioblastoma multiforme with abnormal vascularity presenting as intracranial hemorrhage in prenatal ultrasound.

BACKGROUND: A rare case of a congenital brain neoplasm with intratumoral massive hemorrhage suggested by prenatal ultrasound examination in a 32-week gestational age male fetus is reported. The child died shortly after birth due to cardiorespiratory insufficiency. METHODS: Autopsy disclosed a large well-delimited tumor with a sponge-like appearance due to high vascularization, which involved nearly the whole left cerebral hemisphere and led to marked hydrocephalus by secondary aqueductal stenosis. Histological and immunohistochemical examination confirmed the diagnosis of a malignant glioma with features of a glioblastoma multiforme (GBM) matching well with previous findings in primary pediatric GBMs. FINDINGS: The present case demonstrates that malignant congenital neoplasms should be considered in the differential diagnosis of fetal intracranial hemorrhage.