44例肾上腺出血法医尸检分析与探讨

对华西医科大学法医学系１９８３～１９９６年间６８５例尸检中４４例肾上腺出血案例进行统计分析,结果显示肾上腺出血主要以２０～４０岁的男性为主,外伤性肾上腺出血以男性青壮年为主,疾病性肾上腺出血以年幼及老人为主。肾上腺出血双侧多见,主要见于皮髓质交界处,其出血病理分级与外伤及疾病的严重程度,生存时间无明显关系。同时对肾上腺出血的机理进行探讨     

肺动脉血栓栓塞猝死23例法医病理学分析

目的分析肺动脉血栓栓塞(pulmonary thromboembolism,PTE)猝死的法医病理学特点,探讨血栓的演变过程及外伤等邻近事件与PTE猝死的因果关系判定方法。方法对四川华西法医学鉴定中心1998—2008年23例PTE猝死案件进行回顾分析。结果PTE猝死合并外伤、手术、制动等危险因素,其中外伤12例,手术21例;院内发生22例,以伤后住院时间1～2周及术后1周多见。PTE中17例为反复性栓子栓塞,余为一次性栓塞。栓子来源于下肢深静脉系统16例,左侧多见。结论明确栓子的来源、外伤及外科手术等邻近事件对于确定PTE猝死是至关重要的。     

7例小脑出血猝死的报告

小脑出血约占脑出血的10％[1]。有人总结国内6篇报告共20例，仅发现1例为生前诊断，说明临床上误诊率甚高[2]，尤以猝死为主要表现者。为进一步探讨小脑出血病因和猝死机理，现将我们所见7例分析报告如下。材料和方法收集本教研室1955～1989年全部尸检材料，发现因小脑出血猝死者共7例，对其脑标本均作全面详细复查，并在其出血部位及附近取材，石蜡包埋，切片后HE染色镜下观察。结果7例小脑出血所致猝死者的临床病理资料见表。讨论小脑出血，或称自发性小脑出血，是指出血原发于小脑，不包括外伤、肿瘤、感染、中毒等引起的出血[3]。临床…     

巨大垂体腺瘤猝死一例

颅内肿瘤约占全身肿瘤的1．45％～2％，据Cantbkona统计的114例由于肿瘤引起的猝死案例，其中以颅内肿瘤引起摔死最为常见，占44例（42.3％）。颅内能引起猝死的肿瘤多位于小脑和接近延髓处，以脑胶质肿瘤、脑膜瘤及转移瘤为常见。垂体腺瘤引起猝死者少见。一旦瘤体增大压迫脑组织或继发出血，会迅速出现头疼、恶心、呕吐及昏迷等症状，如这一过程发生在头部外伤后不久，易误诊为颅内血肿死亡。现报告一例头部外伤后垂体腺瘤猝死如下。案情某男，32岁。结婚5年，因阳萎无生育能力，近十年较肥胖，两年来常有头昏、头痛、嗜睡、乏力，易感染…     

68例心内膜下出血病理学分析

对７６２例尸检中６８例心内膜下出血进行统计分析，结果显示：心内膜下出血以左心室间隔出血多见，男性心内膜下出血以颅脑外伤多见，女性心内膜下出血以分娩时大出血多见。作者对其发病机理进行了讨论     

脑血管畸形破裂出血猝死4例

脑血管畸形破裂出血猝死４例李功亮（新疆生产建设兵团农六师公安处；新疆五家渠８３１３００）近几年，在法医检案中，遇到四例有轻微头面部外伤而认为是暴力致死的案件要求作法医学鉴定。剖验结果未见头皮下出血、颅骨骨折或脑组织挫裂伤，而表现为硬膜下腔、蛛网膜下腔...     

外伤致右肾上腺髓质脂肪瘤瘤内出血1例

肾上腺髓质脂肪瘤是肾上腺的一种较为少见的良性肿瘤，其无内分泌功能。从1905年Gierke对本病首例报道后，据己有文献报道大约250例，且绝大多数通过尸检证实【’］。关于外伤致肾上腺髓质瘤破裂的案例，近年来在法医检案中还未见报道，现报道1例。1案例某男，33岁，某年！2月12H被人踢伤右腹部，即人当地医院治疗。入院当日自诉右上腹不适，有时疼痛。门日B超报告：肝右叶后方可见22cmXllcm实质性冲声区。诊断：右上腹腹膜后实质性占位（血肿）。Zod、26U两次B超均报告：肝人叶腹膜后血肿。后一直保守治疗，症状未见明显好转。次年2月S…     

9例小脑出血猝死的法医学分析

国内外报道小脑出血的发生率约占全脑出血的3%～12%,一般认为占10%左右。[1]小脑出血有约20%发生猝死。[2]为进一步探讨其出血病因和猝死机制,现将我们检案所见9例分析报告如下。材料和方法收集本教研室小脑出血猝死者共9例对其脑标本均做全面详细复查,并在其出血部位及附近取材,石蜡包埋,切片后HE染色镜下观察。结果9例小脑出血所致猝死者的临床病理资料见表1。讨论小脑出血,又称自发性小脑出血,是指出血原发于小脑,而不包括外伤、肿瘤、感染、中毒等引起的出血。[1]临床上最常见的出血原因是高血压动脉硬化,其次是血管畸形和动脉瘤。本文…     

实验性脑死亡脑外器官变化

研究了原发性脑死亡垂体、肾上腺、胰腺、脾脏等脏器宏观、微观及超微结构的变化规律．结果如下：（1）胰腺腺泡酶原颗粒减少，胰岛细胞核固缩；（2）脾脏被膜下出血，脾窦扩张淤血；（3）肾上腺皮质及髓质细胞疏松，胞核浓缩；超微结构可见束状带细胞线粒体嵴消失，核质溶解；（4）腺垂体细胞核变小，胞质出现空泡，神经垂体胶质细胞增生，纤维组织排列紊乱，染色浅淡；（5）原发性脑死亡可以引起脑外器官包括垂体、肾上腺、胰腺、脾脏的形态结构变化，但远比脑组织本身的变化轻．     

广东地区622例猝死案例的流行病学调查

目的研究广东地区622例猝死案例的流行病学特征,为探讨猝死的发病机制、鉴定指标提供基础依据。方法收集中山大学法医鉴定中心2009至2012年622例确诊猝死的案例,运用统计学方法对一般情况、临床病历、法医学尸体解剖所见及病理学诊断等资料进行回顾性分析。结果 622例中心源性猝死为主要类型,占59.49%,以中青年男性多见(30~50岁男性占43.78%),冠心病为主要病因,发病呈年轻化(≤35岁者占17.89%);心源性猝死、其它系统疾病猝死、不明原因猝死3组之间心脏重量存在明显差异(P0.05);青壮年猝死综合征与心源性猝死组中胸腺肥大或出血阳性率存在差异(P0.05)。结论心源性猝死为猝死主要类型,发病呈年轻化,中青年男性为甚,冠心病为主要病因;胸腺肥大或出血引起个体应激系统障碍可能是致猝死机制之一。     

A forensic pathological study of eighty-two cases of adrenal hemorrhage

OBJECTIVE: To analyze the relationship between adrenal hemorrhage and the cause of death, age and gender. METHODS: Eighty-two cases of adrenal hemorrhage were statistically analyzed. RESULTS: Adrenal hemorrhage occurred mostly in cases of sudden death, infection, trauma and asphyxia. Male had more chance than female to have adrenal hemorrhage. Adrenal hemorrhage caused by sudden death, trauma and poisoning was more frequently seen in young adults, whereas adrenal hemorrhage in children as well as in fetus and newborns was often caused by infection as well as sudden death and asphyxia respectively. Adrenal hemorrhage caused by sudden death and asphyxia was mainly located in medulla, while the infection usually induced hemorrhage in cortex. Adrenal hemorrhage caused by trauma showed an equal opportunity in either the cortex or medulla. CONCLUSION: Our data indicate that adrenal hemorrhage might provide some clues in searching for the cause of death.     

Sudden Death from Cardiopulmonary Arrest on Arrival of a Patient with Pulmonary Tuberculosis: A Case Diagnosed by Postmortem CT and Autopsy

Sudden death due to massive hemoptysis during management of tuberculosis occurs in a considerable number of patients. However, when massive airway hemorrhage occurs in a patient in whom tuberculosis has not been confirmed and a blood is not apparent externally on the face/body, it is difficult to immediately identify the cause of death as airway obstruction by tuberculous bleeding in the airway. We encountered an 83‐year‐old Japanese woman with her medical history included treatment of tuberculosis in her 20s who was in cardiopulmonary arrest on arrival (CPAOA), and the cause of sudden death could not initially be identified. Postmortem CT (PMCT) and autopsy revealed that the cause of sudden death was airway obstruction/asphyxia by tuberculous massive airway hemorrhage. Identification of the cause of death facilitated a subsequent active contact investigation and led to prevention of secondary tuberculosis infection.     

Sudden Death by Spontaneous Epiglottic Hematoma Secondary to High Blood Levels of Warfarin

A 67‐year‐old man was found dead, at his home. On external examination, we found a voluminous purplish black ecchymosis of the anterior neck area. On internal examination, we found a voluminous epiglottis hematoma completely obstructing the upper airway. It was associated with other sites of intra‐abdominal hemorrhage. Toxicological studies revealed the presence of warfarin at a concentration of 8.4 mg/L in peripheral blood, which supposes an INR well above 4.5. To conclude, we supposed death was due to asphyxia secondary to a spontaneous epiglottic hematoma caused by a high blood concentration of warfarin. Hemorrhage in the epiglottis is very rare. To our knowledge, our patient is the only case of “sudden death” reported with spontaneous epiglottic hematoma due to high blood concentration of warfarin. In forensic practice, an anterior neck ecchymosis, without trauma, may suggest hemorrhage into soft airway tissues. Pathology findings make it possible to exclude exogenous trauma.     

Sudden death due to asphyxia by esophageal polyp: two case reports and review of asphyxial deaths

Asphyxia, not an uncommon cause of sudden death, may result from numerous etiologies. Foreign-body aspiration and strangulation are 2 extrinsic causes. Airway obstruction may also be caused by laryngeal edema, asthma, infection, or anaphylaxis. Chronic causes of asphyxia include musculoskeletal diseases (eg, muscular dystrophy, amyotrophic lateral sclerosis), neurologic disorders (eg, myasthenia gravis, multiple sclerosis), respiratory disease (eg, emphysema, chronic bronchitis), or tumors. The manner of death in cases of asphyxiation may be natural, accidental, homicide, or suicide. For the death investigator, determining the cause and manner of death can often be quite challenging.We report here 2 cases of an esophageal fibrovascular polyp causing sudden asphyxial death, review of the literature, and discussion of other differential diagnoses in the case of asphyxial death.     

A comparison of respiratory symptoms and inflammation in sudden infant death syndrome and in accidental or inflicted infant death

Upper respiratory infection and pulmonary inflammation are common in sudden infant death syndrome, but their role in the cause of death remains controversial. Controlled studies comparing clinical upper respiratory infection and inflammation in sudden infant death syndrome with sudden infant deaths caused by accidents and inflicted injuries (controls) are unavailable. Our aim was to compare respiratory inflammation and upper respiratory infection within 48 hours of death and postmortem culture results in these two groups. A retrospective analysis of upper respiratory infection and pathologic variables in the trachea and lung of 155 infants dying of sudden infant death syndrome and 33 control infants was undertaken. Upper respiratory infection was present in 39% of sudden infant death syndrome cases and 40% of control cases. Upper respiratory infection was more likely to have occurred in association with more severe lymphocytic interstitial pneumonitis when sudden infant death syndrome cases and control cases were combined ( P=.04). Proximal and distal tracheal lymphocytic infiltration was more severe in control cases than in sudden infant death syndrome cases ( P=.01 and.01, respectively). Lymphocytic infiltrations of the bronchi, bronchioles, and pulmonary interstitium were similar between groups. Bronchial associated lymphoid tissue was more prominent in control cases ( P=.04). Cultures were positive in 80% of sudden infant death syndrome cases, 78% of which were polymicrobial. Among control cases, 89% were positive, with 94% being polymicrobial. This study confirms that microscopic inflammatory infiltrates in sudden infant death syndrome are not lethal.     

Patent ductus arteriosus as a natural cause of pulmonary hemorrhage in infants: a medicolegal dilemma

Patent ductus arteriosus (PDA) is a recognized risk factor for massive pulmonary hemorrhage (MPH) in the newborn and is generally seen in association with other MPH risk factors such as prematurity. We report 6 cases of sudden and unexpected death of infants older than 4 days with MPH and PDA at autopsy. The cases were reviewed for other factors that could contribute to MPH to ascertain whether PDA is directly linked to MPH. Histology samples were examined for distribution of hemorrhage in the lungs and iron stained for hemosiderin evaluation. All of the cases had clinical histories and scene examinations which raised the differential diagnosis of mechanical asphyxia in the form of so-called overlayings. The diagnostic dilemma of attributing the MPH to the PDA as the sole cause, dual cause, or incidental finding is discussed. These cases illustrate the medicolegal dilemma faced by the pathologist, as well as the need for further research into the potential association of PDA with MPH.     

Ascertainment of the cause and tempo of death in forensic medical practice

In order to develop a method of ascertaining a cause of death and of evaluating its tempo the authors undertook a histological study and a study of a dehydration degree in 76 cases of death due to the below reasons: mechanical trauma, mechanical asphyxia, burn shock, and carbon monoxide intoxication. Acute emphysema of lungs, lack of edemas in lungs and brain, desquamation of pulmonary macrophages, hyperemia of renal capillaries, primary urine in some glomerules, prevalence of ischemic changes with karyopyknosis in medulla and hypohydration of brain were typical of fast death. Prevalence of dystelectasis in lungs, emptying of pulmonary capillaries, evident edema of lungs and brain, desquamation of pulmonary macrophages, lack of primary urine in glomerular capsules, acute circulatory disorders of renal hemodynamics with sweating of fibrin and erythrocyte glomerules into cavities, necrotic nephrosis, pigment cylinders in renal tubules, thrombi in vessels, prevalence of chromatolysis, karyolysis and cytolysis in medulla, pronounced glial reaction as well as pronounced edema of brain and its hyperhydration were typical of slow death.     

Virological analysis in the diagnosis of sudden children death: a medico-legal approach

Infections are considered to be an important cause of unexpected death in children. It has also been assumed that respiratory viruses are involved in the genesis of sudden infant death syndrome (SIDS). The Spanish National Institute of Toxicology and Forensic Sciences act as the forensic reference centre for Spain. We analyse the experience of this centre in the virological study of 64 cases of sudden children death where viral serology, virological cultures, herpesviruses polymerase chain reaction (PCR) and electron microscopy were performed. According to pathological findings, death could only be attributed to an adenovirus infection in one amygdalitis with upper airways stenosis and asphyxia. Human herpes virus 6 (HHV-6) was detected by PCR in one case with pathological findings characteristic of SIDS. Recent infection by respiratory syncytial virus (RSV), Epstein-Barr virus (EBV) and cytomegalovirus (CMV) were also detected. Meanwhile, 85.9% of the cases yielded negative viral results. Twenty-eight infants were finally categorised as SIDS. Pathological findings of infection were detected in 12 patients despite the negativity of viral analyses. Although viral infection is an uncommon cause of sudden children death, a complete microbiological investigation will help to solve the puzzle of SIDS. Definitive guidelines for microbiological analyses need to be updated whilst new pathogens are discovered or new techniques are implemented in order to clarify unsolved cases.     

Sudden Unexpected Death due to Chiari Type I Malformation in a Road Accident Case

This case concerns a sudden death of a patient with Chiari I malformation. A 17‐year‐old female was seen unconscious then fell off a motorbike during the vehicle acceleration. The girl was confirmed dead on the way to hospital, being previously asymptomatic and with a clean medical record. Autopsy findings showed an extremely extra‐long cerebellar tonsillar herniation in the left side and unexplained multiple small cavities in cerebral hemispheres. Microscopic findings revealed loss and abnormal migration of the Purkinje cells, as well as capillary congestion in the herniated tonsil. The cause and mechanisms of this sudden death are considered as the cardiopulmonary dysfunction and arrest resulted from compression of the medulla and cervical cord, which was induced by both the positional insult and minor head trauma. In addition, this study stresses the importance of cervical cord examination in the case of unexpected sudden death following road accidents.     

Asphyxia by tracheobronchial thrombus

Asphyxia secondary to airway obstruction has numerous underlying causes, both acute and chronic. Causes of chronic airway obstruction, such as neoplasms and tracheal scarring, are often clinically apparent well prior to asphyxia. Causes of acute airway obstruction may not be as obvious to clinicians or investigators. These include infections, anaphylactic reactions, status asthmaticus, inhalational injuries, and aspirations, which may result in acute obstruction and sudden death.We report the deaths of 2 individuals, a 43-year-old female and a 78-year-old female, both with adenocarcinoma. The 43-year-old was hospitalized with a stage III, poorly differentiated infiltrating ductal carcinoma of the breast metastatic to the lymph nodes. She was intubated to treat poor respiratory function and acidosis. A bronchoalveolar lavage was consistent with alveolar hemorrhage; no organisms were identified. Blood and "clot" were in her endotracheal tube, so the endotracheal tube was replaced. She became comatose and life support was withdrawn. At autopsy, a large red-gray thrombus obstructed the trachea and extended into the right bronchus. Microscopically, the entire clot was composed of fibrin, red blood cells, and some mucus. Findings of acute respiratory distress syndrome with hyaline membranes were identified. The cause of death was listed as acute respiratory distress syndrome with tracheobronchial thrombus. Experiencing a decline in mental status, the 78-year-old had metastatic adenocarcinoma of unknown primary. She developed sudden respiratory distress and an airway obstruction was discovered. After failure to relieve the obstruction, she decompensated and died. At autopsy, a large, red-gray thrombus obstructed the distal trachea and both bronchi. Microscopically, the thrombus was composed of fibrin, platelets, and red blood cells. The cause of death was asphyxia secondary to airway obstruction by thrombus. We present these 2 unusual cases of asphyxia and review of the literature focusing on asphyxia and the etiology of airway thrombi.