脑干轴索肿胀的半定量研究

目的 探讨轴索肿胀在鉴定脑干损伤中的意义。方法 取明确死于原发性脑干损伤(36例)和脑外疾病(28例)者共64例，分为损伤组(36例)和对照组(其中死于心血管疾病12例、非心血管疾病16例)，并将其死后24h和48h前、后做尸体解剖分为2组，通过对中脑、脑桥和延脑切片、镀银染色，在100倍光镜下采用显微测微器测量每片9条最粗的轴索横径，对所得数据作方差分析、t检验统计学处理。结果 损伤组与对照组(不包括心血管疾病死亡者)相比，中脑、延脑部的轴索肿胀程度有明显差异(P＜0.05)；死后48h内解剖的损伤组与对照组相比无差异(P＞0.05)，但超过48h解剖两组有明显差异(P＜0.05)。结论 中脑、延脑部轴索肿胀与外伤有明显的相关性。轴索肿胀对判断脑干损伤有意义。需排除心血管疾病致死。     

Sudden death due to central alveolar hypoventilation syndrome (Ondine's curse) in a 39-year-old woman with heterotopia of the inferior olive

Failure of automatic involuntary respiration with preservation of voluntary respiratory drive (Ondine's curse) is a rare occurrence which has been reported following a variety of morphologic lesions near respiratory centers in the lower brainstem. We report the case of a 39-year-old woman with a syndrome of fulminant respiratory failure with features of Ondine's curse in whom neuropathologic examination disclosed a preexisting malformation of the lower brainstem, as well as acute local subarachnoid bleeding. Mechanisms in the present case are discussed and a review of similar cases published so far is given. The necessity of sound investigation, including neuropathologic studies in cases of sudden unexplained death, is underlined.     

Concerning survival time in primary hematomas of the brain-stem (author's transl)]

The autopsy on a 54-year old man, who had a motorcycle-accident 17 days before and suffered a head injury, showed a large traumatic hemorrhage in the oral pontine region. The lesion must be considered primarily traumatic because of the brain-stem symptoms which appeared immediately after the accident (immediate unconsciousness, extension spasms, miosis) the macroscopic and histological findings (proliferation around the hemorrhage, hematoidin in the centre of the hemorrhage) and the biomechanical circumstances (impact on the occiput). Furthermore, considering the clinical findings and the autopsy results, pathogenetic factors which might have produced secondary hemorrhage seem to be unlikely. It seems as if the timing of death after traumatic hemorrhage in the oral pontine region depends less on the direct lesion in these areas, but on the extension of the hemorrhage to the caudal brainstem with concomittant edema. For the differentiation between primary and secondary brainstem lesions the duration of the survival time is therefore only of relative significance.     

大鼠急性脑干损伤致死后脑干组织细胞色素C含量的测定

目的探讨细胞色素C含量测定在脑干损伤死后诊断中的意义。方法采用重物自由落体造成的大鼠急性脑干损伤模型,通过酶联免疫(ELISA)的方法,检测脑干损伤致死大鼠与非脑干损伤致死大鼠脑干组织细胞胞浆细胞色素C含量。结果急性脑干损伤组神经元细胞胞浆细胞色素C的含量(8.276±0.425)较非脑干损伤组(2.002±0.514)为高,其差异具有显著性意义(P<0.05)。结论脑干组织细胞色素C含量测定对急性脑干损伤的死后诊断具有参考价值。     

大鼠急性脑干损伤神经细胞凋亡和轴突的变化

目的研究急性脑干损伤早期的病理变化,探讨其在急性脑干损伤中的法医学意义。方法采用自由落体造成大鼠急性脑干损伤模型,HE染色常规观察各部位脑组织的显微形态改变之后,用TUNEL末端标记检测神经细胞凋亡,用LSAB染色显示神经丝蛋白(NF)。结果实验动物模型能够较好的模拟法医案例;脑干损伤的大鼠脑组织淤血、水肿、环状出血,脑皮质内神经凋亡细胞数目明显增多(P<0.01);脑干部位神经轴突排列紊乱、肿胀、断裂。结论上述多种病理变化对急性脑干损伤的死后诊断具有一定的意义。     

大鼠脑损伤分级自由落体打击模型的建立

目的建立一个控制性与重复性好,并可分级的脑损伤动物模型。方法根据自由落体原理,使击锤从不同的高度下落,造成轻、中、重不同程度的大鼠脑损伤,肉眼、光镜观察损伤的程度。结果肉眼、光镜观察下出现可分级的病理学改变。轻度损伤组病理改变局限于大鼠大脑皮质浅层,中度损伤组病理改变可见于大脑皮质及深部白质内的基底核、海马、胼胝体、丘脑,重度损伤组病理改变除中度损伤累及部位外,还累及脑干。挫伤灶周围神经元变性、坏死范围和程度随损伤程度的加重而增大。各组内每只动物所受损伤程度一致。结论该模型制作出常见的闭合性颅脑加速伤损伤,致伤程度较一致,重复性好,可分级,是脑损伤实验研究较合适的动物模型。     

原发性脑干损伤神经元凋亡及caspase3的表达

目的观察原发性脑干损伤（PBSI）致死者脑干神经元凋亡及caspase3的表达情况,探讨其法医学意义。方法选择法医学检案中30例确定为原发性脑干损伤致死者脑干,按伤后不同存活时间（t≤5min、5min〈t≤15min、15min〈t≤1h、1h〈t≤24h）分为4组,以5例非脑干损伤死亡者脑干为对照组;分别运用常规HE、免疫组化和TUNEL染色检测中脑、桥脑及延脑重要核团内神经元凋亡及caspase3的表达情况。结果原发性脑干损伤后15min～24h出现明显神经元细胞凋亡（23.2%～35.9%）和caspase3阳性表达（28%～54%）,并呈现随损伤时间进行性增加的趋势,与对照组有显著性差异（P〈0.01）。结论原发性脑干损伤早期即出现神经元凋亡及caspase3表达增加,并随损伤时间的延长呈进行性增加,可据此辅助诊断原发性脑干损伤死亡。     

Pontomedullary lacerations in unhelmeted motorcyclists and bicyclists: a retrospective autopsy study

ABSTRACT: Pontomedullary lacerations (PMLs) have often been reported in car occupants and pedestrians, are less frequently described in motorcyclists, and are very rarely described in bicyclists. The aim of this study was to determine the frequency of brainstem PMLs among fatally injured motorcyclists and bicyclists as well as the frequency of concomitant cranial, facial, and cervical spine injuries in such cases. A possible underlying mechanism of PML in fatally injured motorcyclists and bicyclists might thus be established. Of 443 cases of fatally injured motorcyclists and bicyclists, a sample of 381 cases of fatally injured motorcyclists and bicyclists with head injury of Abbreviated Injury Scale score of 3 or greater was formed and further analyzed. This group was composed of 345 men and 36 women. The average age was 48.8 ± 20.8 years (range, 15-99 years). In the analyzed sample group, there were 158 motorcyclists and 223 bicyclists. Partial PMLs were present in 44 cases (12%) within the sample of 381 head injuries, which breaks down to 40 men and 4 women. In our study, the impact area on the head and the specific skull base fracture type were good predictors of either PML occurrence or absence (B = -2.036, Wald = 161.312, P < 0.01, for the whole model). Impact to the chin, with or without a skull base fracture, most often led to this fatal injury due to impact force transmission, either through jawbone or vertebral column. Also, lateral head impact, the most frequent in bicyclists, with subsequent hinge fracture, PML, and frontoposterior hyperextension of the head that is associated with upper spine fracture, could be possible mechanisms of brainstem injury in fatally injured motorcyclists or bicyclists. Our study showed that the jawbone, as well as other facial bones, could act as shock absorbers, and their fracture could diminish energy transfer toward the skull and protect the brain and brainstem from injury.     

38例单纯型脑干损伤法医学尸检的回顾性研究

目的报道38例原发性单纯型脑干损伤致死案例法医学尸检所见的脑干损伤、致伤方式和致伤物等特点,并探讨在法医学鉴定中的意义。方法从208例脑干损伤死亡法医学尸检案例中,挑选出38例符合单纯型脑干损伤的案例,分析单纯型脑干损伤发生的案情、损伤的部位和类型等特点。结果38例中男性占绝大多数,农民明显多于其它人员;大多发生于纠纷斗殴中;头部拳击伤18例(47.4%);头皮挫伤19例(50.0%);头皮挫裂创9例(23.7%);未见头皮损伤7例(18.4%);受伤当时昏迷并很快死亡者34例(89.5%);其损伤为局灶性挫伤出血,有32例(84.2%)肉眼未能辨认出,镜检见小灶性出血:其中,桥脑18例(47.4%)、延脑10例(26.3%)、中脑4例(10.5%)、桥脑和延脑均有出血6例(15.8%)。结论原发性单纯型脑干损伤不仅存在,而且能致人死亡;应引起同行的重视。     

Immunohistochemical characterisation and TNF-α expression of the granulomatous infiltration of the brainstem in a case of sudden death due to neurosarcoidosis

Neurosarcoidosis carries a mortality of 10%, over twice that of sarcoidosis overall, although it has been rarely reported as a cause of sudden death. The current evidence suggests that sarcoidosis results from an enhanced immune reaction to a variety of antigens, non-self or self which causes CD4 (helper-inducer) T-cell accumulation with a ratio of helper-inducer T cells to suppressor-cytotoxic T cells usually high in affected organs, activation and release of inflammatory cytokines, and formation of granulomatous lesions. Numerous cytokines and other mediators are produced by both activated macrophages and T lymphocytes bearing the CD4-helper phenotype during the granuloma responses. A number of data suggest that interferon-gamma (IFN-gamma) and cytokines such as TNF-α, IL-2, and IL-18 play a critical role in the formation of granulomas. In this article, we describe the clinical and pathological characteristics of a patient who suddenly died due to acute respiratory failure. Neurosarcoidosis with massive and extensive involvement of the brainstem was established as the cause of death. Western blot analysis in the patient demonstrated the TNF-α presence as a 51-kDa protein in the brain tissue. The immunohistochemical analysis showed a poor positiveness for CD4 in all samples around the granulomas, as well as moderate positiveness for CD8, CD15, and CD20; CD45 and CD68 showed a strong positiveness in all the brain samples. Histological findings, immunohistochemical analysis, and proteomic studies addressed the diagnosis of neurosarcoidosis with involvement of the nucleus of the solitary tract in the brainstem and central hypoventilation as the cause of death.     

大鼠脑干损伤c-fos、c-jun基因的表达

目的探讨脑干损伤后立即早基因c-fos、c-jun的表达在脑干损伤法医学鉴定中的意义。方法采用重物自由落体式建立大鼠脑干损伤快速死亡模型,70只大鼠分为两组,实验组(40只),对照组(30只)。肉眼和HE染色观察脑干组织的形态改变,并通过原位杂交的方法检测大鼠脑干损伤部位c-fos、c-jun基因的表达情况。结果100倍光镜视野下实验组c-fos和c-jun mRNA阳性细胞数计数分别为53.62±9.84和46.85±7.43;对照组c-fos和c-junmRNA阳性细胞数分别为0.9±0.87和1.3±0.67;经统计分析,实验组c-fos、c-jun mRNA基因表达水平较对照组显著增高。结论脑干损伤后损伤部位c-fos、c-jun mRNA基因表达水平增高对脑干损伤快速死亡的法医学鉴定具有参考价值。     

脑干星形细胞胶质原纤维酸性蛋白免疫组化染色的图像分析

目的探讨脑干星形细胞胶质原纤维酸性蛋白(GFAP)免疫组化染色及其图像分析在原发性脑干损伤鉴定中的应用价值。方法26例原发性脑干损伤致死者的脑干样本,分别在其中脑、脑桥及延脑相同部位取组织作GFAP免疫组化染色(LSAB法),并对GFAP阳性物最密集视野做图像分析。21例非颅脑损伤或脑部病变死亡者的脑干作对照样本,所得图像参数测量值进行统计学分析。结果(1)对照组星形细胞的GFAP阳性染色在中脑、脑桥及延脑三个部位分布不等(P<0.05),延脑>中脑>脑桥;损伤组则三个部位无显著性差异(P>0.05);(2)对照组与损伤组相比,GFAP阳性染色细胞的数量在中脑、脑桥及延脑等三个部位中差异均有显著性(P<0.01);(3)死后96h后解剖者,损伤组与对照组有显著差异;(4)伤后30min内死亡者,损伤组与对照组也有显著差异。结论人脑干星形细胞GFAP免疫组化染色的图像分析,对法医学鉴定原发性脑干损伤具有重要参考价值。     

c-fos蛋白及其基因表达改变用于脑干损伤早期死后诊断的可行性研究

探讨人体脑干损伤后c fos蛋白及其基因表达的改变用于脑干损伤早期死后诊断的可行性。采用免疫组织化学和原位杂交技术 ,观察 16例人体脑干损伤后的c fos蛋白及其基因表达的改变。结果发现 :在正常脑干组织的不同部位 ,均有c fos蛋白和c fos mRNA阳性表达 ,且在各例脑干标本之间 ,表达的量及其分布不一致。脑损伤后 ,在脑干组织中也有c fos蛋白和c fos mRNA阳性表达 ,但与正常脑干组织相比无显著性差异。c fos蛋白和c fos mRNA的表达在各例脑干标本之间不一致 ,且在损伤后的改变无明显规律 ,不能用于脑干损伤早期的死后诊断。     

Pathology of sudden death during recreational sports activity: an autopsy study of 31 cases

A growing number of people are involved in recreational physical activity. It is therefore not uncommon for a medical examiner to encounter sports-related sudden deaths and to be faced with the legal implications. The authors examined the clinical and cardiac pathologic patterns in 31 persons who died suddenly during sports activities and underwent autopsy at the Institute of Forensic Medicine of Paris between 1991 and 2001. Twenty-nine male subjects, ranging in age from 7 to 57 years (mean 30 years) and two female subjects, 8 and 60 years old, died suddenly during sports activities. The sports involved were various, with running the most frequent: 13 cases. Cardiomyopathies (10 cases) and coronary artery disease (9 cases) were the most frequent causes of deaths. Despite the severity of lesions, only 4 subjects had a known cardiovascular disease. In conclusion, with regard to prevention, efforts should be continued to improve the sensitivity and specificity of diagnostic tools and screening strategies. In this regard, medicolegal autopsies should be systematically performed in cases of sudden death during sports activities, because they provide accurate and useful information for a better knowledge of sports-related mortality.     

脑干损伤后神经轴突和髓鞘变化的免疫组织化学研究

探讨脑干损伤后神经轴突和髓鞘的病理学改变及其意义。用免疫组织化学显示神经丝蛋白和髓鞘碱性蛋白 ,观察人体脑干组织中的神经轴突及髓鞘在损伤后的病理学改变。在脑干损伤组 ,神经轴突在伤后 0 5h即有不规则肿胀及断裂 ,神经髓鞘在伤后 19～ 2 2h有明显曲折、不完全剥脱及节段性消失 ;而在正常脑干组 ,神经轴突和髓鞘均无明显病理改变。脑干组织中的神经轴突和髓鞘在损伤后将发生改变 ,并可用于脑干损伤的死后诊断     

Wischnevsky's gastric lesions in accidental hypothermia.

We examine the pathogenesis of Wischnevsky's lesions. These gastric lesions were found in 15 of 17 deaths due to accidental hypothermia. Deaths occurred at various minimum temperatures (-2.4-20.4 degrees C); gastric lesions did not always reflect exposure temperatures. However, all victims exposed to temperatures greater than 10 degrees C had severe lesions. At temperatures less than 5 degrees C, on the other hand, severe gastric lesions were seen in victims younger (43.2 years old) than those with mild lesions (61.0 years old). These findings suggest that gastric lesions develop by exposure to temperatures at which the body's response to cold stress continues, or as result of a strong response to short-term stress. Histopathologic examination demonstrated a characteristic finding of cystic dilatation of the capillaries, presumably due to massive reperfusion after functional collapse of the microcirculation in the gastric mucosa.     

Longitudinal brainstem laceration associated with complex basilar skull fractures due to a fall: an autopsy case

This report describes an autopsy case of a rare longitudinal brainstem laceration associated with complex basilar skull fractures. The victim was a 40-year-old male who died immediately after falling from a roof (9.2m in height) of a factory onto a concrete floor. The postmortem examination revealed an incomplete ring fracture of the base of the skull with longitudinal fractures of the sphenoid (clivus of the dorsum sellae turcicae) and occipital bones, cerebral contusions in the frontal and temporal poles, a longitudinal brainstem laceration at the posterior median sulcus of the pons accompanied with multiple contusional hemorrhages in the brainstem and corpus callosum. Related blunt-force injuries were observed in the parieto-occipital region of the head, shoulder and upper back involving the fractures of the cervical and thoracic vertebrae, and sternum and ribs, indicating a huge impact to the occiput and subsequent impression of the vertebral column into the base of the skull due to violent anteroflexion of the neck, which caused the complex basilar skull fractures, contusions and longitudinal laceration of the brainstem.     

Unusual Death of a Transvestite: Identification of Crime Weapon and Survival Time*

Abstract: The authors report a case of a transvestite found murdered near his automobile with several lacerated contused wounds to the face and cranial fractures. Autopsy revealed that the cause of death was a serious head trauma with subdural and subarachnoidal hemorrhages. In order to identify the crime weapon, a scanning electron microscopy (SEM) was used which revealed metallic residue on the skin fragments with the same molecular composition of the car paint. As for survival time, antibody anti‐beta‐amyloid precursor protein (APP) was applied to brain fragments and brainstem tissue, allowing for axonal varicosities (which form 2 to 3 h following death) to be observed under the optic microscope. So, by using SEM we understood that the fatal cranial‐encephalic lesions were the result of the victim’s head being repeatedly struck against the car door while anti‐betaAPP led to the understanding that the time elapsed between injury and death was less than 2 to 3 h.     

脑干损伤致死星形胶质细胞GFAP和ET-1的表达

目的 研究星形胶质细胞GFAP和ET-1的表达在脑干损伤的分子病理学改变并探讨对脑干损伤法医学鉴定中的意义。方法 筛选本中心提供的不同时间急性脑干损伤死亡的脑标本15例及非颅脑损伤死亡标本5例,HE染色常规观察各部位脑组织的显微形态改变之后,用检测单克隆抗体免疫组化SP方法检测胶质细胞GFAP和ET-1的表达,研究其病理变化。结果 生前急性脑干损伤部位GFAP阳性细胞数目增多,细胞形态变大,存在ET-1的表达。结论 上述系列病理变化对于法医实践中急性脑干损伤的死后诊断具有参考价值。     

Brainstem changes in death from head injury

The cortex and brainstem changes in death from head injury were observed. There were hemorrhage, edema and neuron necrosis in brain injury group, and also in disputed group of brainstem injury.