Stressful events as a trigger of sudden death: a study of 43 medico-legal autopsy cases

The reports relating emotional stress to sudden death are largely anecdotal. In addition to experimental and electrophysiological studies, an opportunity for a better understanding of possible stress-related sudden death (SSD) may be provided by medico-legal autopsies. The goal of our autopsy study was to analyze cardiovascular pathologic findings in cases of SSD and if possible identify mechanisms by which the stressful event (SE) could be the cause. Forty three cases were studied (29 males and 14 females). In all cases, the SE and the death were witnessed. The age range was 22 to 90 years in males (mean, 52) and 30 to 92 years in females (mean, 64). Death occurred in all cases without premonitory symptoms. In 20 cases, death occurred during the SE and in the other 23 cases occurred within 2 h of the event. SE included fear, 15 cases; altercation, 21 cases; sexual activity, 3 cases; police questioning or arrest, 4 cases. According to police reports, in 40 cases (90%), the victims had no previous clinical history of cardiovascular disease. At autopsy, the heart weight in males ranged from 255 to 1000 g with a mean of 517 g and in females the range was 250–700 g with a mean of 417 g. In only 3 cases, gross and microscopic examination of the heart was normal. In 2 of the remaining 40 cases the subjects died of subarachnoid hemorrhage. In 38 cases, a cardiac cause of death was found as follows: coronary heart disease, 27 cases; cardiomyopathy, 6 cases; aortic valvular stenosis, 2 cases and right ventricular dysplasia, 3 cases. A coronary artery thrombosis was found in 8 cases of sudden coronary death. Post myocardial infarction fibrosis was present in 25 cases (92%) of sudden coronary death. In conclusion, it appears from our autopsy study that SSD occurs primarily in those individuals with severe heart disease, especially coronary heart disease.     

Sudden death caused by malignant testicular tumors

Sudden unexpected death of apparent healthy young males due to malignant tumours are extremely rare in forensic autopsy material. We report on three such cases dying of pulmonary embolism caused by metastazing tumour of the testis. In each subject the tumour was localized to the right testis and consisted of two types of tumour tissue: Seminoma and embryonic carcinoma, the latter of which was always the metastazing one. Each of the cases represent different aspects of forensic medicine. In the first subject the tumour had remained undiagnosed in a recent medical examination. The second one underwent surgery because of acute abdomen and died intraoperatively and the third one died suddenly during antibiotic treatment, because the tumour had been mistakenly diagnosed as orchitis.     

Uncertainty of determining cause of death in a medicolegal material without autopsy. An autopsy study

In constrast to other studies, this investigation was made on cases of medicolegal deaths that would not normally be autopsied. 223 females and 322 males, whose deaths were found to be natural before as well as after autopsy, were studied. The cause of death was estimated by external medicolegal examination, and after autopsy.In 79 females and 109 males, i.e. 35% and 34% respectively, estimated cause of death was found to be different after the autopsy. This was mostly because ischaemic heart disease as a cause of death was overestimated at the external medicolegal examination. No constant relationship between differing causes of death and age group could be demonstrated. Underdiagnoses and overdiagnoses tended to outweigh each other. Pneumonia, pulmonary embolism, cor pulmonale and aortic stenosis were clearly underestimated before autopsy. In addition, a variety of diseases that were not even mentioned at the medicolegal examination was found (subarachnoid haemorrhage, uraemia, perforated and bleeding gastric ulcers, tuberculosis).The same unreliability in the estimated cause of death therefore exists among cases not normally autopsied as found in retrospective studies of cases where autopsy is performed under all circumstances at the request of the police.False information will thus be given to the mortality statistics among the approximately 5000 cases of medicolegal deaths not autopsied in Denmark per year, most of these being natural deaths. Besides, contagious and inherited diseases could be overlooked, relatives given false information and the value of scientific studies in causes of death diminished.The conclusion is that autopsy is still essential to ensure continuous control and correction of causes of death.     

Death caused by myocarditis in Wayne County, Michigan: a 9-year retrospective study

This paper reviews 72 cases of death caused by myocarditis between the years 1996 and 2004, autopsied at the Office of the Wayne County Medical Examiner in Michigan. Myocarditis as a cause of sudden and unexpected death represented 1.3% of all natural deaths in Wayne County during said period. The year 1999 contained the highest number of deaths of this cause (18), where the average number of myocarditis deaths was 8 per year for this 9-year span. In this study, each case was reviewed based on information gathered from investigative, autopsy, and toxicology reports. Significantly, 58% of these cases were male, and 63.4% were African American. Myocarditis caused death in every age group between 7 months and 67 years, but adults between the ages of 19 and 67 were most significantly affected (75%). Flu and/or cold were the most common symptoms experienced in the days directly proceeding death (28%), followed by shortness of breath (17%) and sudden collapse (15%). Sixty-nine percent of these 72 cases were pronounced dead after ACLS (advanced cardiac life support) protocol by emergency medical services or hospital attendants. Cardiomegaly was observed in 24 cases of adults aged 19 or older (54%), and flabby/soft myocardial tissue was observed grossly in 16% of all 72 cases.     

Cosleeping and sudden unexpected infant deaths in Kentucky: a 10-year retrospective case review

This retrospective case review investigates modifiable risk factors in sudden unexpected infant deaths, including those attributed to sudden infant death syndrome, and examines the impact of cosleeping with adults or siblings. The study examines sudden unexpected infant deaths from 1991 to 2000 in the state of Kentucky, excluding homicides and deaths from identifiable natural causes. Meta-analysis provides a cosleeping prevalence control in normal infants. Based on the findings described herein, we conclude that cosleeping may represent a risk factor in sudden unexpected infant deaths and that a full scene investigation, including whether the infant was cosleeping, should be sought in all cases of sudden infant death.     

Sudden death resulting from lesions of the cardiac conduction system

Sudden unexpected deaths in young persons with noncontributory histories, autopsy results, and drug screen results are a common problem in forensic pathology. As part of the evaluation of such cases, the cardiac conduction system (CCS) should be studied. To determine the type and incidence of lethal CCS lesions, the authors reviewed their files of sudden unexpected cardiac deaths with particular attention to cases with causes of death in the conduction system. Cases of sudden cardiac death in patients aged < or=40 years during a 10-year period (Michigan) and a 4 year-period (Spain) were selected from the files. From this group, cases were identified in which the cause of death was a lethal change in the CCS. The portions of the heart containing the CCS were excised, and at least one hematoxylin and eosin slide and at least one trichrome or elastic trichrome slide per block were studied. In the two centers, 381 cases of sudden cardiac death were identified. The most common causes of sudden cardiac death were arteriosclerotic narrowing of the coronary arteries, cardiomyopathy, and myocarditis. In 82 cases, there was no identifiable cause of death even after complete gross and microscopic autopsy was performed, a medical history was obtained, and a drug screen was performed. In 11 cases, the CCS contained lesions that were considered lethal: narrowing of the atrioventricular node artery by fibromuscular hyperplasia (7 cases) and atrioventricular node tumors (4 cases). The 11 cases accounted for 2.9% of the 381 cases of sudden cardiac death and 11.8% of the indeterminable cases. It was concluded that examination of the CCS in deaths in which the gross and microscopic autopsy, history, and drug screen fail to provide a cause of death can yield a cause of death in a significant percentage of cases. If heart block was not documented during life and no explanatory lesions were found during routine cardiac examination, examination of the CCS can yield valuable information.     

Neoplastic disease in a medicolegal autopsy material. A retrospective study in northern Sweden

Only a small fraction of sudden unexpected deaths are caused by neoplastic disease and thus subject ot medicolegal autopsy. The medicolegal autopsy forms an opportunity to study not only medically diagnosed and treated neoplasms, but also the natural evolution of untreated disease. In a series of 7,020 consecutive medicolegal autopsies in northern Sweden, we found 171 cases with malignant and/or intracranial neoplasms. In 41 cases, sudden death was caused by previously unknown tumors. The most common mechanisms of death in this group were disseminated cancer, intracranial tumors, pulmonary thromboembolism, hemoptysis, and aspiration of blood, and the most common locations were the bronchi and the lung. In some of these cases, the mechanism was sometimes dramatic, raising a question of violent death or intoxication. In 30 cases, sudden unexpected death was caused by previously known tumors, and also in this group disseminated cancer was the most common cause of death, and the most common locations were the bronchi and the lung. In 22 cases, tumors were found suicidal cases; in 14 of these, the tumor was considered to be a major causative factor to the suicide, while in eight cases the tumor was considered to be an incidental finding. The expected number of cancers in the 1,060 suicides investigated in this series was 27, according to the official cancer prevalence data. Thus, a possible over-representation of suicides among persons with cancer seems doubtful and needs further exploration.     

Aortic Dissection and Sudden Unexpected Deaths: A Retrospective Study of 31 Forensic Autopsy Cases

Acute aortic dissection (AAD) is the most common cause of sudden unexpected death related to aortic diseases. A retrospective study of 31 sudden unexpected deaths caused by AAD was conducted at Xi'an Jiaotong University Forensic Center from 2001 to 2012. We summarized the forensic characteristics of AAD and assessed the clinically diagnostic accuracy of AAD. The characteristics of sudden unexpected death due to AAD were male predominant (male: female = 6.7:1), relatively young with the mean age of 44, and predominance of type A dissection (77.4%). Cardiac tamponade was the most frequent cause of sudden death (87.1%). Of the 31 cases, 26 (83.9%) patients were not recognized clinically and were misdiagnosed with acute myocardial infarction, coronary artery disease, cholecystitis, acute gastroenteritis, renal/urinary lithiasis, or acute pancreatitis. In summary, AAD can be difficult to recognize, diagnosis is therefore sometimes delayed or missed. The medicolegal death investigation can help physicians have a better understanding of AAD.     

Blood alcohol in sudden and unexpected deaths

Blood alcohol concentration was determined in 1672 sudden and unexpected natural and non-natural out-of-hospital deaths. The material covered all medicolegal autopsies in the province of Uusimaa which has a population of approximately 1.1 million inhabitants. In general, the prevalence of cases with alcohol in the blood at the time of death was high but varied considerably according to sex, age, and the cause and manner of death. The blood alcohol result was positive in 36% of the male and in 15% of the female material. In 59% of the alcohol-positive male and in 54% of the alcohol-positive female cases the actual concentrations were at least 1.5%. Acute use of alcohol was regarded as a significant condition contributing to death in 23% of the whole male and in 8% of the whole female material. These gross results and the details presented indicate that the acute use of excess alcohol is a factor contributing to non-natural but also to sudden and unexpected natural deaths to an extent that is not generally known. The results also emphasize that simple blood alcohol determination should be a routine procedure in the autopsy praxis of all sudden and unexpected natural and non-natural out-of-hospital deaths.     

Evaluation of diagnostic tools applied in the examination of sudden unexpected deaths in infancy and early childhood

During the period between 1984 and 1999, 309 cases of sudden unexpected death in infancy and early childhood (0-3 years) were investigated at the Institute of Forensic Medicine in Oslo. In 73 cases, an explainable cause of death was found. In this non-sudden infant death syndrome (SIDS) group, 42 cases were due to disease, 14 to accidents, 7 to neglect/abuse and 10 cases were due to homicide. In 43 cases, there were pathological findings at the autopsy or suspect features in the history and/or circumstances, which were, however, insufficient to explain death ("borderline" SIDS). In the remaining 193 cases, nothing of significance was detected ("pure" SIDS).The purpose of the present study was to evaluate the importance of the different diagnostic tools used in diagnosing non-SIDS and borderline SIDS cases. The definition of SIDS requires a negative history as well as a negative autopsy result. Thus, the following variables were analysed: circumstances, medical history and autopsy, which included a gross pathological investigation, histology, neuropathology, microbiology, radiology and toxicology. In diagnosing deaths due to disease, histology, neuropathology and microbiology were the most important diagnostic tools. In contrast, information about the circumstances of death and the gross pathological findings at autopsy most often revealed the cause of death in accidents and cases of neglect/abuse and homicide.Following the drop in SIDS rate in Norway after 1989, the share of pure SIDS in proportion to the total population of sudden unexpected deaths in infancy and early childhood has decreased. The increasing proportion of non-SIDS and borderline SIDS cases presents a challenge to improve the quality of the investigation in cases of sudden death in infancy and early childhood.     

Alcohol-Related Mortality Risk in Natural and Non-Natural Death Cases

Abstract:  Determination of the associations between alcohol influence and sudden natural death represents challenges for medicolegal investigations. The aim of this study was to investigate the prevalence of alcohol influence in medicolegal autopsies. In our study of natural and non-natural deaths cases (5496 total: 4045 males, 1451 females) were examined. Blood alcohol concentrations (BACs) were detected by headspace gas chromatographic method. We investigated the alcohol-related mortality using hierarchical log-linear statistical models. Severe BACs were detected among suicidal victims in the oldest age group (>65 years) (In F  = 0.442) and among the homicide victims between the age of 40–65 years (In F  = 0.234). Correlations we found between manner-of-death and sex suggested that the rate of males in accidents (ln F  = 0.140) and the rate of females in homicides (ln F  = 0.193) were higher. It was concluded that the accurate statistical mortality database may provide a huge support for the determination of alcohol effects on human health and mortality.     

Ascending Aortic Rupture through a Penetrating Atherosclerotic Ulcer: A Rare Cause of Sudden Unexpected Death

Spontaneous rupture of the aorta through an atherosclerotic lesion without preexisting aortic aneurysm, dissection, or history of trauma is very rare. Without prompt aortic repair, all cases result in sudden death with a definitive diagnosis made only intraoperatively or during autopsy. The phenomenon has been uniformly found in individuals with hypertension. The author reports a sudden unexpected death caused by spontaneous rupture of the ascending aorta in a 57‐year‐old man with a history of hypertension. The ascending aortic wall showed a longitudinal intimal tear measuring approximately 1 cm in length and rupture of the ascending aorta through an atherosclerotic ulcer, leading to massive hemopericardium and eventual death. Chronic hypertension and a penetrating atherosclerotic ulcer of the ascending aorta were the apparent underlying etiologies of the aortic rupture in the present case. This case illustrates not only the association between a rupture and a penetrating atherosclerotic ulcer with a silent death, but also raises awareness of possible such deaths.     

Inferior Vena Cava Tumor Thrombosis Secondary to Metastatic Uterine Cancer: A Rare Cause of Sudden Unexpected Death

Pulmonary tumor thromboembolus (PTTE) secondary to uterine cancer is a rare cause of sudden unexpected deaths in the elderly population. Additionally, tumor extension to the inferior vena cava (IVC) makes it rarer. No such cases have been previously reported in the forensic literature. We report this phenomenon in a previously healthy 70‐year‐old woman with no other known risk factors for the development of deep vein thrombosis. The deceased was found dead while watching television with her relatives. Autopsy examination revealed that her death was attributed to a saddle embolus lodged in the main pulmonary arteries. A uterine tumor was discovered, and microscopic examination revealed low‐grade endometrial stromal sarcoma with angiolymphatic invasion. The tumor cells were also found in the embolus and the remnant thrombosis attached to the inner wall of the IVC. This case demonstrates a sudden unexpected death caused by acute PTTE following seeding of uterine cancer into the IVC and raises awareness of such events.     

Sudden unexpected death in epilepsy: neuropathologic findings

Sudden unexpected death in epilepsy refers to sudden death of an individual with a clinical history of epilepsy, in whom a postmortem examination fails to uncover a gross anatomic, toxicologic, or environmental cause of death. Evidence of terminal seizure activity may not be present. One to two percent of natural deaths certified by the medicolegal death investigator are attributed to epilepsy. Detailed microscopic examination of the brain has increasingly afforded the identification of structural changes representative of epileptogenic foci. The authors present 70 cases of death attributed to sudden unexpected death in epilepsy. These cases were classified as follows: individuals who lacked a gross brain lesion, those who had a brain lesion demonstrable at autopsy, and those who lacked neuropathologic evaluation because of decomposition or because only an external examination was done. All of the subjects had a clinical history of seizures. The authors confirm that various microscopic findings, including neuronal clusters, increased perivascular oligodendroglia, gliosis, cystic gliotic lesions, decreased myelin, cerebellar Bergmann's gliosis, and folial atrophy, are present in a higher percentage of the brains of sudden unexpected death in epilepsy subjects than in the brains of age- and sex-matched control subjects.     

Is there progress in the autopsy diagnosis of sudden unexpected death in adults?

Sudden death is now currently described as natural unexpected death occurring within 1h of new symptoms. Most studies on the subject focused on cardiac causes of death because most of the cases are related to cardiovascular disease, especially coronary artery disease. The incidence of sudden death varies largely as a function of coronary heart disease prevalence and is underestimated. Although cardiac causes are the leading cause of sudden death, the exact incidence of the other causes is not well established because in some countries, many sudden deaths are not autopsied. Many risk factors of sudden cardiac death are identified: age, gender, heredity factors such as malignant mutations, left ventricular hypertrophy and left ventricle function impairment. The role of the police surgeon in the investigation of sudden death is very important. This investigation requires the interrogation of witnesses and of the family members of the deceased. The interrogation of physicians of the rescue team who attempted resuscitation is also useful. Recent symptoms before death and past medical history must be searched. Other sudden deaths in the family must be noted. The distinction between sudden death at rest and during effort is very important because some lethal arrhythmia are triggered by catecholamines during stressful activity. The type of drugs taken by the deceased may indicate a particular disease linked with sudden death. Sudden death in the young always requires systematic forensic autopsy performed by at least one forensic pathologist. According to recent autopsy studies, coronary artery disease is still the major cause of death in people aged more than 35 years. Cardiomyopathies are more frequently encountered in people aged less than 35 years. The most frequent cardiomyopathy revealed by sudden death is now arrhythmogenic right ventricular cardiomyopathy also known simply as right ventricular cardiomyopathy (RVC). The postmortem diagnosis of cardiomyopathies is very important because the family of the deceased will need counseling and the first-degree relatives may undergo a possible screening to prevent other sudden deaths. In each case of sudden death, one important duty of the forensic pathologist is to inform the family of all autopsy results within 1 month after the autopsy. Most of the recent progress in autopsy diagnosis of sudden unexpected death in the adults comes from molecular biology, especially in case of sudden death without significant morphological anomalies. Searching mutations linked with functional cardiac pathology such as long-QT syndrome, Brugada syndrome or idiopathic ventricular fibrillation is now the best way in order to explain such sudden death. Moreover, new syndromes have been described by cardiologists, such as short-QT syndrome and revealed in some cases by a sudden death. Molecular biology is now needed when limits of morphological diagnosis have been reached.     

Pediatric toxicologic deaths: a 10-year retrospective study

A 10-year retrospective study of pediatric toxicologic deaths was performed at the Medical University of South Carolina (Charleston, SC) from January 1989 to December 1998. During this time, 709 pediatric forensic autopsies were performed on children younger than 18 years of age. Eleven deaths were determined to be secondary to toxic exposures (excluding carbon monoxide poisonings secondary to fires). The remaining deaths were reviewed for the presence of alcohol or illicit drugs. The 11 toxicologic deaths were analyzed for age, sex, race, type of toxic exposure, cause and manner of death, location of incident, witness, and, in the younger age group, the primary caregiver at the time of exposure. The deaths had a bimodal age distribution (6 deaths in victims ages 15 to 17 and 5 deaths in victims ages 4 or younger), involving a wide range of toxins. The teenage group was composed of five males and one female, all white. The preschool group had three females and three males, all black. The manner of death ranged from accidental to suicidal to homicidal. In addition, in eight neonatal and fetal deaths, the victims tested positive for maternal cocaine use, and five of these victims tested positive for cocaine or benzoylecgonine. However, the cause of death was not stated to be cocaine in any of these neonatal and fetal cases.     

Sudden death due to undiagnosed Wilms' tumor in an adult

Sudden unexpected deaths due to natural causes constitute a large number of cases encountered by the forensic pathologist. In a majority of such cases, heart disease is responsible for sudden death. Rare disease entities resulting in sudden death are occasionally encountered and may not fit the classic epidemiological profile. We present a case of sudden death due to a previously undiagnosed Wilms' tumor (WT) in an adult. The pathology of WT is discussed, as is the topic of sudden death due to previously unrecognized malignancy.     

窒息死亡的法医病理学分析

目的探讨窒息死亡的法医病理学特点。方法对四川大学华西法医学鉴定中心1982年10月1日～2006年9月30日所作160例窒息死亡尸体剖验病理材料进行统计分析。结果窒息死亡案例占整个法医学检案的9.9%,年龄:30～39岁的死者占整个研究对象的29.4%,平均年龄为31.25岁。性别:男性103例,女性57例。男女比例1.81∶1。死亡方式:意外死亡最多(63.1%),其次为自杀(24.4%)和他杀(12.5%)。死亡原因:缢死最多(21.9%),其次为CO中毒(17.5%)、溺死(16.25%)等。医疗纠纷共计39例,均为新生儿窒息,主要发生在乡镇医院和县级医院(76.92%)。结论加强法制教育,提高安全隐患意识等是减少窒息死亡的重要手段。提高城乡医疗水平,加强窒息急诊抢救的临床技能是防止窒息引起医疗纠纷的关键。     

Causes of sudden natural death in Jamaica: a medicolegal (coroner's) autopsy study from the University Hospital of the West Indies

Medicolegal (coroner's) autopsies are an important source of epidemiological data. A large proportion of them comprise sudden natural deaths and an analysis of such cases has never been undertaken at the University Hospital of the West Indies, the only teaching hospital in Jamaica. In a retrospective study, 841 cases of sudden natural deaths comprising 51.3% of the medicolegal autopsies conducted over the 15-year period, January 1983 to December 1997, were analyzed. There were 459 males and 382 females (M:F ratio = 1.2:1); 35 patients (4.1%) were less than 1 year of age, and the mean age of the remainder was 53.7+/-21.8 years. The peak age group was the seventh decade accounting for 21.9% of cases. The most common causes of death were cerebrovascular accidents (13.6%), pneumonia (9.4%), pulmonary embolism (7.4%), ischaemic heart disease (7.0%) and diabetes mellitus (6.1%). These findings contrasted with those from developed countries in which ischaemic heart disease is the commonest cause of sudden death. Hypertension was associated with the majority of cases of cerebrovascular accident and congestive cardiac failure (78.1 and 61.9%, respectively). Sickle cell disease represented one of the 10 most common causes of death accounting for 2.5% of cases. Documentation of autopsy-based data such as these is important in the planning of medical services in a developing country.     

The most severe chronic organ findings in official public health autopsies--a medico-sociologic contribution

At the Vienna Institute, in the year 1986, 79 carcinoma findings were recorded in 1736 cases of natural death. The most common were carcinomas of the respiratory and gastrointestinal tracts. Seventeen unidentified tumors were found to have been the cause of death. Public health autopsies, therefore, contribute to the clarification of tumor disease and thus to cancer statistics. Although diagnosed fatal cancer cases correspond to only 0.33% of all cancer deaths in Vienna, the question arises why a patient with very advanced cancer is not under medical care and why the affliction is revealed only in autopsy, the purpose of which is to elucidate sudden, unexpected deaths. The comparatively few individual cases should nevertheless give cause for reflection and are discussed from a medicosociological view, taking into consideration the statistical and epidemiological data relating to cancer diseases.