127例蛛网膜下腔出血案例的法医学研究

目的探讨蛛网膜下腔出血(SAH)对保险公司的直接请求权，从而缓解了患者在请求赔偿方面的特点及法医学鉴定要点。方法通过对华西医科大学法医鉴定中心1983—2001年尸检检出的127例各种原因所致的SAH案例进行回顾性分析。结果各类SAH案例，男性明显多于女性，男女性别比为3：1，高峰年龄为21～40岁。按SAH常见特征可分为外伤性、脑血管畸形、动脉瘤、脑血管粥样硬化、中毒、伴发于心脏疾患、其他等八类。其中，外伤性与脑血管畸形最为多见。外伤性SAH与脑血管畸形出血可见于任何年龄，多见于11～50岁，脑血管粥样硬化出血仅见于50岁以上者，动脉瘤破裂出血者并不多见，见于11～50岁。以SAH为死亡原因者，32例，占25％，多见于脑血管畸形与动脉瘤破裂，出血部位多见于脑底及小脑天幕以下。大多数SAH，出血部位多见于大脑表面，较为局限，出血量较少，非死亡的主要原因。结论多数SAH并非导致死亡的主要原因，SAH死亡者，其死亡性质多属自然死亡。     

外伤性蛛网膜下腔出血

蛛膜网下腔出血(Subarachnoid Hemorrhage以下简称SAH)可以引起急死,SAH病因可分为非外伤性和外伤性两大类.构成非外伤性SAH的原因甚多,包括动脉瘤破裂,脑血管畸形,出血性疾病及脑肿瘤出血等.外伤性SAH,严重明显的头颅外伤所致的SAH很易识别,而与轻微头面部和颈部外伤有关的颅内或颅外动脉破裂引起的SAH,尸解时则往往不能给予正确认识,这就造成不正确归类——自然死亡.本文拟着重分析由于轻微或中等程度头面部或颈部外伤引起的SAH.     

脑血管畸形破裂出血致死案例的法医病理鉴定

脑血管畸形并破裂是自发性蛛网膜下腔出血、脑出血的重要原因之一。由于脑血管造影及头颅 CT扫描等影像技术的应用,大大提高了临床诊断的准确率,但本病在不明原因突然死亡的案例中仍占有一定的比例。本文对我院法医学系尸体剖验鉴定为脑血管畸形破裂出血致死案 20例进行分析研究。 1资料与结果 1.1一般情况 　　我院法医学系 14年来尸检总数 656例,脑血管畸形并破裂出血死亡者 20例。占尸检总数的 3.5％。 20例中男性 18例,女性 2例,年龄最大 36岁,最小 27岁,平均 32.2岁。职业状况：农民 6例,工人 4例,城镇居民 5例,其余 5例…     

小脑下后动脉外伤性动脉瘤迟发破裂死亡1例

正颅内动脉瘤是病理性(自发性)蛛网膜下腔出血的最常见原因,大约85%的自发性蛛网膜下腔出血由它所致~([1])。绝大多数颅内动脉瘤为血管自身病变,外伤引起的非常罕见,在颅内动脉瘤中占比不足1%~([2,3])。在颅内动脉瘤破裂致死的法医鉴定实践中,区分外伤性和病理性动脉瘤是首要任务。本文报道一例额面部遭受暴力致小脑下后动脉外伤性动脉瘤形成,先后三次出现蛛网膜下腔出血,最终迟发破裂导致死亡的典型案例。     

头部轻微损伤基底动脉瘤破裂死亡2例

外伤性蛛网膜下腔出血,主要原因为脑挫裂伤时脑内血管和软脑膜血管破裂血液流入蛛网膜下腔形成.而轻微头部外伤诱发基底动脉瘤破裂致蛛网膜下腔出血致人死亡的案例较为少见.     

36例脑血管畸形猝死案例及法医病理学分析

目的探讨脑血管畸形猝死的法医病理学特点和检查方法。方法对1997年至2006年10月四川华西鉴定中心所做36例脑血管畸形猝死病例进行分析。结果脑血管畸形猝死以10~49岁男性为主,有25例(69.44%)。18例(50%)发病前有明显诱因。18例(50%)在发病后1h内迅速死亡。脑血管畸形猝死的病理类型以脑动静脉畸形最为常见,有33例(91.67%)。24例(66.67%)发生于脑底部、桥脑和小脑。破裂出血是脑血管畸形猝死的直接死因,出血类型以蛛网膜下腔出血最为常见,有22例(61.11%)。脑血管畸形部位和形态复杂多变,常规检查方法不能满足鉴定的需要。结论脑血管畸形猝死的鉴定百分之百准确比较困难,熟悉其法医病理学特点,掌握多种检查方法,才能做出客观、全面、准确的鉴定结论。     

11例创伤性颈内动脉颅内段破裂的回顾性分析

目的 回顾性分析创伤性颈内动脉颅内段破裂的损伤特点,为法医学检验与鉴定提供参考.方法 收集11例创伤性颈内动脉颅内段破裂的尸体检验案例,记录并统计死者的性别、年龄、致伤原因、现场失血情况、颈内动脉颅内段破裂部位、破裂处管壁硬化程度、颅脑损伤、血乙醇含量以及死亡原因等信息.结果 11例均为现场死亡,其中交通伤7例,高坠伤...     

蛛网膜下腔出血的法医学鉴定

蛛网膜下腔出血（subarachnoid hemorrhage,SAH）按其发生原因可分为外伤性SAH与病理性SAH,其中外伤性SAH是头部外伤的常见表现形式,同时也往往是法医学鉴定的难点。本文根据法医学实际鉴定经验并参考国内外相关的文献资料,阐述了SAH的法医学鉴定要点、检查要点和死亡机制,并尝试将外伤性SAH分为脑损伤伴发性、脑底血管破裂性及局灶性SAH 3种类型以便于理解。     

浅谈脑血管畸形致猝死的法医学鉴定

引起猝死的第一大原因是心血管系统的疾病,其次是脑血管畸形.脑血管畸形破裂引起蛛网膜下腔出血(SAH)是导致猝死的主要机制.     

6例外伤性蛛网膜下腔出血的机制分析

在法医学鉴定中 ,外伤性蛛网膜下腔出血的案例并不少见。头部轻微的外伤可以造成致命性蛛网膜下腔出血。笔者试图通过对以下几个案例的讨论 ,着重讨论自身疾病和不利因素在成伤中的重要性。并借此探索和解决这些问题的方法。1　案例资料　　例 1　刘某 ,男 ,16岁 ,高中学生。 1995年 4月与同学厮打中被拳头打击头部。伤后无昏迷 ,感头痛伴颈项强直 ,查体见左颞部轻度肿胀、压痛。次日ＣＴ检查发现蛛网膜下腔出血 ,经保守治疗 ,症状缓解后行脑血管造影 ,证实出血来自左侧大脑中动脉颞支一动脉瘤破裂。鉴定意见为 :外伤导致动脉瘤破裂。例 2　…     

原发性蛛网膜下腔出血的讨论——附7例尸检报告

本文报告7例法医病理解剖材料,其中脑血管动静脉畸形引起的5例,动脉瘤与巨细胞性动脉炎引起的各1例。因死亡都是发生在头部外伤之后,故引起申诉。肉眼检查时,7例中有6例未查明病因,诊断系依靠病理组织学检查。本文结合文献复习,重点讨论了检验鉴定的方法和注意事项。文中4个重新鉴定的案例,原结论均未发现本病的病因,甚至有的误认是损伤性蛛网膜下腔出血,此点应引以为戒。     

Cerebrovascular malformation causing sudden death. Analysis of three cases and review of the literature

Three unusual cases of sudden death resulting from cerebrovascular malformation (CVM) are presented. CVMs are highly variable in location and morphology, and may be difficult to detect. Two of the patients discussed here had CVMs that involved the circle of Willis directly, and produced rapidly fatal subarachnoid hemorrhage at the base of the brain; both of these subjects were in their late 30s. One had a history of epilepsy; the other had been completely asymptomatic prior to the catastrophic event. The third was an asymptomatic 6 year old with a cerebellar CVM, who survived long enough for inconclusive neurosurgical intervention. In all three cases, the diagnosis was not made prior to autopsy; in one case, the circumstances of death were initially misleading. The relevant literature is reviewed and discussed, with emphasis on differential diagnosis, anatomic examination, and background investigation.     

Motor-vehicle collision-related death due to delayed-onset subarachnoid hemorrhage associated with anticoagulant therapy

Delayed deaths following injury are not rare. Various mechanisms may be responsible for such deaths, including pulmonary thromboembolism, fat embolism, infection, systemic inflammatory response syndrome, and delayed hemorrhage. In the present case, we describe a death due to delayed subarachnoid hemorrhage following a motor vehicle collision, wherein the hemorrhage occurred ten days after the incident, while the patient remained hospitalized for skeletal trauma. At no time prior to the hemorrhage did the victim show any symptoms of brain injury. Autopsy revealed basilar subarachnoid hemorrhage arising from a cerebral cortical contusion. There was no evidence of aneurysm or arteriovenous malformation. A significant underlying contributing factor in the delayed hemorrhage was the victim's chronic anticoagulant therapy, which was required because of a mechanical heart valve.     

Rupture of an intracranial aneurysm--unusual complication of an electric shock.

Here we report about a 35-year-old electrical engineer who was found dead in his study. Postmortem examination revealed that death resulted because of subarachnoid and intraventricular hemorrhage caused by the rupture of an intracranial aneurysm. Right hand and left cheek revealed electrical marks with metallizations on skin, an electric shock was diagnosed to have preceded death. The close temporal correlation suggests that a sudden rise in blood pressure was caused by the electric current and was thus responsible for the rupture of the aneurysm.     

Hemorrhagic Retinopathy and Optic Nerve Sheath Hemorrhage Associated With Fatal Subarachnoid Hemorrhage from a Ruptured Intracranial Aneurysm Due to Segmental Fibromuscular Dysplasia

Fibromuscular dysplasia is an idiopathic, nonatheromatous, and noninflammatory arterial disease that most commonly affects the renal and carotid arteries. We report a child with subarachnoid and ocular hemorrhage associated with an aneurysm due to fibromuscular dysplasia. Computed tomography following a witnessed collapse revealed diffuse subarachnoid hemorrhage and severe cerebral edema. An autopsy confirmed the radiographic findings and detected bilateral retinal hemorrhages, optic nerve sheath hemorrhages, and a ruptured saccular aneurysm due to focal fibromuscular dysplasia involving the intracranial right vertebral artery. This case documents a fatal subarachnoid hemorrhage in a child with an intracranial saccular aneurysm caused by fibromuscular dysplasia. The associated retinal hemorrhages are easily detected by postmortem monocular indirect ophthalmoscopy.     

Spontaneous intracerebral hemorrhage related to methamphetamine abuse: autopsy findings and clinical correlation

A healthy 31-year-old male abstinent from drug abuse during his recent incarceration developed slurred speech, a severe headache, and left-sided hemiparesis prior to his eventual death 9.5 hours after inhalation of methamphetamine. On postmortem examination, inspection of the brain revealed bilateral subarachnoid hemorrhage, with a prominent intralobar hemorrhage centered within the right frontal cerebral hemisphere. No evidence of vasculitis, infarction, intraventricular hemorrhage, or ruptured aneurysm could be observed. While this is not the first report of a methamphetamine-related stroke, this report describes the autopsy findings of an intracerebral hemorrhage secondary to methamphetamine abuse on autopsy and compares the findings and antemortem history to previously reported methamphetamine cerebral vascular deaths.     

Traumatic basal subarachnoid hemorrhage. Report of six cases and review of the literature

Basal subarachnoid hemorrhage due to rupture of normal extra- and intracranial arteries, in association with minor trauma to the face and neck and alcohol intoxication, has been well described but often goes unrecognized at autopsy. This results in the incorrect classification of the manner of death as natural. Six cases of subarachnoid hemorrhage due to mild-to-moderate blows to the head or neck are presented. All were men in the age range 28-61 years (mean, 38.8 years). Four had blood alcohol levels of 0.09-0.28 g % at autopsy, and five of six were comatose or dead within 30 min of the initiating trauma. Traumatic ruptures of otherwise normal extra- and intracranial arteries were identified in four cases. The site of rupture was not found in one case, and the final case had rupture of a fibrotic intracranial vertebral artery. Multiple sites of incomplete and complete rupture were found in four cases. Postmortem angiography was used in one case to demonstrate the site of rupture prior to removal of the brain. Postmortem angiography and careful gross and histologic examination of extra- and intracranial cerebral arteries is recommended in all cases of basal subarachnoid hemorrhage where minor trauma to the head or neck has occurred prior to collapse or death, especially if the decedent was intoxicated at the time of the trauma.     

Forensic Pathological Examination on 73 Medical Malpractice Cases of PediatricsCSCD

Objective: To analyse 73 medical malpractice cases of pediatrics for discussing the importance of forensic pathology in solving the issues such as medical malpractice of pediatrics. Methods: From January 2002 to August 2016, 73 medical malpractice cases of pediatrics with age of death between 28 days old and 10 years old were collected from Institute of Judical Expertise of Nanjing Medical University. The relationship between causes of death and related medical institutions was retrospectively analysed. Results: In 73 cases, the male to female ratio was 1.70:1, and ages of 28 days old to 1 year old were common (26 cases, 35.62%), followed by ages between 1 year old and 3 years old (21 cases, 28.77%). In 71 cases which had been determined the cause of death by postmortem examination, the main cause of death was disease, especially respiratory diseases (33 cases, 46.48%), followed by cardiovascular diseases (12 cases, 16.90%). In 75 medical institutes which involved with these medical malpractices, most were tertiary medical institutes (32, 42.67%), followed by the sub-secondary (excluding the secondary)medical institutions (23, 30.67%). The clinical diagnosis of 38 cases (52.05%) completely or mostly corresponded with the pathological findings. There were 35 cases (47.95%) undefined or misdiagnosed cases. Conclusion: Autopsy and forensic pathological examination contribute to determine causes of death, which not only provide scientific evidence for medical malpractice of pediatrics, but also enrich and develop clinical medical knowledge, and thus improve diagnosis and treatment level in a certain extent. © 2018 by the Editorial Department of Journal of Forensic Medicine.     

Subarachnoid Hemorrhage and Carbon Monoxide Exposure: Accidental Association or Fatal Link?

This case study reports a fatal subarachnoid hemorrhage (SAH) with concomitant accidental carbon monoxide (CO) exposure in 32‐year‐old man. Autopsy results indicated an antemortem aspiration of smoke, and a massive SAH was identified as the cause of death. Intriguingly, the carboxyhemoglobin level was 30%, suggesting that CO could have played a specific role. Intracranial hemorrhages following CO exposure in brain areas and tissues such as the basal ganglia, globus pallidus, or white matter are rare, but well characterized, whereas SAH related to CO exposure has not been previously described. In this case report, the possible role of CO, either as a primary cause or as a facilitating factor, in the pathogenesis of SAH is discussed. In particular, we propose the hypothesis that the excessive vasodilating effects produced by CO on the cerebral endothelium results in consequential loss of microvascular integrity.