Fibromuscular dysplasia of the basilar artery: an unusual case with medico-legal implications

A 28-year-old male car driver was reported to suddenly loose the control over his vehicle, to hit the right and middle crash barrier, and to be unconscious as the car came to a halt in a position at right angles to the road. The car was hit in its left side by an automobile with high velocity, and the 28-year-old driver died. Examination of the brain revealed a massive isolated basal subarachnoid hemorrhage and a complete tearing of the basilar artery. A macroscopically detectable aneurysm was not found. However, histological examination of the large arteries at the base of the brain showed (i) fibromuscular dysplasia (FMD) mostly involving the basilar artery (ii) with a ruptured micro-aneurysm in its upper third part. The observations of the eye witnesses that the driver initially lost control over his car were judged in favour of the accused to be due to that rupture of the micro-aneurysm, while complete transverse tearing of the basilar artery occurred during the car crash due to hyperextension and rotation of his neck. Intracranial FMD is a rare cause in the differential diagnosis of isolated basal subarachnoid hemorrhage. The medico-legal implications of this entity are described in the presented case.     

Occlusion of left and right coronary arteries and coronary sinus following blunt chest trauma

Blunt chest trauma from rapid automobile airbag deployment causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a 37-year-old man who developed extensive anterior and inferior myocardial infarction because of occlusion of both left anterior and right coronary arteries following blunt injury to the chest in a car accident. The patient was scheduled for emergency coronary angiography but left and right coronary ostia were not cannulated because of thrombus formation probably. The patient died, and the autopsy revealed external compression by epicardial hematomas involving separately left and right coronary arteries and the coronary sinus without signs of coronary and/or aortic dissection. To our knowledge, this is the first case presenting occlusion of both coronary arteries secondary to blunt chest trauma causing acute myocardial infarction in a young man without signs of prior coronary artery disease.     

The significance of blocked arteries in the pathogenesis of hemorrhages and of minor hemorrhagic infarctions in the human lung in fat embolism (author's transl)

The significance of blocked arteries with regard to minor hemorrhagic infarctions in the lung in venous and systemic fat embolism is discussed. In an experiment it is proved that blood in the anastomoses between the arteria bronchialis and arteria pulmonalis (blocked arteries) contains fat emboli. It is suggested that these fat emboli may in addition be transported into an area of the lung, which is no longer functional following embolic occlusion of a branch of the arteria pulmonalis.     

Multiple suicidal gunshots to the head

We report two cases of suicide by multiple gunshots to the head. The first victim (of two shots) fired the first shot, which was observed, into his mouth, leading to damage to the left optic nerve and frontal lobe. The man still was able to drive his car home, where he shot himself in his right temple. He died 2 days later. The second victim (of three shots) was a 58-year-old man who was found dead on his bed. Reconstruction of the case disclosed that the first shot had passed through his tongue and slightly damaged the second cervical vertebral body. He then shot himself in his right temple, leading to damage of the temporal lobe. Finally, he shot himself in his left temple, resulting in destruction of the pons. In the first case, an amateurishly modified 8-mm blank revolver firing 6.35-mm- (.25)-caliber ammunition was used; in the second case, a rifle firing 5.6-mm (.22)-caliber ammunition with a reduced charge was used. In both cases, low-energy transfer to brain tissue by the initial bullets was due to low bullet energy or due to the bullets' missing the brain or vital centers.     

Initially suspected killing with a political background identified as accidental carbon monoxide poisoning

During a parish fair the police was called to a conflict between two rival right-wing youth groups in the early morning hours. Shortly afterwards a burning car was discovered near the marquee with a charred male body on the driver's seat. It was assumed that there was a connection between the two events. At autopsy no injuries were found that were not attributable to postmortem consumption by the fire. The BAC value was 1.76 per thousand, the CO-Hb concentration 78%. The body could be identified by comparing pre- and postmortem X-rays of the molars and premolars of the right upper jaw. Reconstruction of the course of events and classification as an accident was possible only after calling in technical experts: The victim had gone back to his car to take a nap and kept the engine running because of the cold temperature. The car had been fitted improperly with a sport exhaust pipe, which caused both the carbon monoxide poisoning and the fire.     

Death following spontaneous recovery from cardiopulmonary arrest in a hospital mortuary: 'Lazarus phenomenon' in a case of alleged medical negligence

We report a possibly first forensic autopsy case of death following a spontaneous recovery from cardiopulmonary arrest (CPA) after clinical declaration of death: 'Lazarus phenomenon'. A 65-year-old male with congenital deafness and dumbness was found unconscious in his room at a public home. During pre-hospital and clinical resuscitation including defibrillation and medications for about 35 min, CPA persisted under electrocardiographic (ECG) monitoring and therefore, his death was pronounced. However, about 20 min later, a police officer who had been called for the postmortem investigation found the patient moving in the mortuary. The patient subsequently showed typical ECG signs and laboratory findings of early inferior wall myocardial infarction and died 4 days later. The forensic autopsy, due to alleged medical negligence, revealed myocardial infarction with thrombotic occlusion of the right coronary artery and secondary hypoxic brain damage. The present case and the related clinical literature suggest that, especially in cases of acute myocardial infarction in elderly patients, a careful observation to confirm death after discontinuation of resuscitation is recommended to provide appropriate medical care, irrespective of the quality or duration of advanced life supporting efforts.     

Discharge of a Pistol Out a Car Window with the Breech Within the Interior of the Car: Analysis of Gunshot Residue on a Car's Interior Surfaces

The defendant, the driver of the questioned car, allegedly extended his right arm over the passenger seat and fired a single shot from a 380 pistol out the passenger window with the pistol's breech within the car. A simulation of this shooting scenario using the same model car, but different year, was conducted to quantitate gunshot residue (GSR) contamination of interior surfaces within the car. The test car's dash and headliner/window frame above the pistol had the heaviest GSR contamination. The dash GSR from airborne deposition documents a firearm discharge within the vehicle. Transfer from GSR‐contaminated hands or clothing to the dash is unlikely. The heavy GSR contamination of the headliner/window frame above the pistol likely documents the window from which the pistol was fired, but additional experiments are needed to verify.     

Unexpected sudden death of a 12-year-old male with congenital single coronary artery

A rare autopsy case of a 12-year-old male with a single coronary artery is reported in which he suddenly and unexpectedly died after a brief period of physical and mental excitation. The single coronary artery originated from the left aortic sinus, then branched out the left circumflex artery and afterwards descended as the left anterior descending artery, while the right coronary artery originated almost at a right angle from the left anterior descending artery. The entire heart as well as the cardiac conduction system depended exclusively on the single coronary artery for oxygenated blood supply, and the unbalanced blood distribution on his exertion probably led to sudden cardiac death. Moreover, in this case, both the deceased's mother (at the age of 20 years) and grandmother on the mother's side died suddenly, thus suggesting a possibility of maternal transmission of this congenital anomaly in his family.     

Papillary fibroelastoma of the aortic valve: a sudden death case of coronary embolism with myocardial infarction

Papillary fibroelastoma is a rare benign tumor, occasionally causing angina or sudden death. We report an autopsy case of an aortic valve papillary fibroelastoma with coronary artery embolism. The patient was a 68-year-old Japanese man who had collapsed suddenly in his house. He was a heavy drinker and had a history of liver disease but no notable cardiac event. The autopsy revealed extensive transmural infarction of the inferior wall of the left and right cardiac ventricles. The distal portion of the right coronary artery (segment 4, NYHA) was completely occluded by tumor emboli of the fibroelastoma. At the site of closure of the aortic non-coronary cusp, there was a typical papillary fibroelastoma, which was considered to have originated the coronary embolization.     

Delayed pericardial tamponade following a stab wound to a branch of the right coronary artery

A 45-year-old man was attacked with a knife and suffered multiple stab wounds to the chest and abdomen. After surgical treatment and hospitalization for 9 days he was discharged in a stable condition. The following day he was found dead in his apartment. The autopsy revealed a pericardial tamponade caused by acute bleeding from an injured branch of the right coronary artery. This case shows that life-threatening late complications in patients with penetrating cardiac wounds may occur despite an initially uneventful course.     

Suicide by insulin injection in combination with beta-blocker application

A 68-year-old non-diabetic physician with a known psychiatric history was found dead in his home. The death scene investigation revealed three used insulin syringes on the coffee table next to the body. The autopsy and the consecutive chemical-toxicological investigation revealed that the deceased committed suicide by injecting an overdose of insulin in combination with a high therapeutic oral bolus application of a beta-blocker (Metoprolol). A surprising morphological finding was a terminal pulmonary thromboembolism in the right pulmonary artery.     

Traumatic bilateral vertebral artery dissection

Traumatic vertebral artery dissection is not often seen by forensic pathologists, and cases investigated are scarce in the forensic literature. We present the case of a 40-year-old woman cyclist who was struck by a car while wearing a helmet, and was neurologically near normal immediately thereafter at Emergency. She presented 48 h later with acute right hemiparesis, decreasing level of consciousness, and unsteadiness. CT revealed massive cerebellar infarction. CT angiography was normal. The patient died in coma 7 days after injury and autopsy revealed bilateral edematous cerebellar infarction and bilateral vertebral artery dissection. Rotational neck injury and mural tear in the wall of the Atlantic parts of both vertebral arteries is suggested as the possible mechanism of the arterial injury. Head and neck injuries are reported as a precipitating cause of vertebral artery injury. The possible influence of trauma may be further underestimated if longer intervals between vessel dissection and ischemia occur. The current case illustrates that "talk-and-die" syndrome may be due to occult vertebral artery dissection, possibly bilateral. In forensic cases of delayed death after mild trauma to the head and neck, the vertebral arteries should be examined for the cause of death.     

Multivascular atheromatous coronary microembolism

We report an unusual case of coronary-multivascular, small coronary artery embolism by atheromatous elements originating in a plaque in the main right coronary artery of a 52-year-old man who died of acute thrombotic occlusion of the severely stenotic left anterior descending vessel. The embolized arteries showed the characteristic multiphasic inflammatory changes of different ages previously described in arteries occluded by this material. The myocardium supplied by the involved channels showed ischemic damage of varying ages. Both these observations indicate that the multiple emboli had been discharged at different times, rather than as a single shower. Finally, we make a plea for the use of the correct term "erosion" rather than "ulcer" for the lesion that is the source of the invasive obstructions.     

Neurosurgical vascular complications associated with aneurysm clips evaluated by postmortem angiography.

Neurosurgical vascular complications were evaluated by postmortem angiography in a consecutive prospective series of 63 patients in Helsinki who suffered a fatal outcome following neurosurgery for ruptured intracranial aneurysm. Operative vascular complications were revealed in 28 (44%) of the cases. Massive intraoperative bleeding resulting from rupture of the aneurysm or adjacent major artery during dissection or clip application complicated the operation in 16 (25%) patients. Clip-induced obstruction of cerebral arteries was detected by angiography in seven cases (11%). In six of the patients an adjacent cerebral vessel was accidentally clipped. In one case a kinking of the clip had caused obstruction of the right anterior cerebellar artery with resulting frontal infarct. A combination of rupture of the internal carotid artery and accidental ligation of the left posterior cerebellar artery occurring simultaneously during the clipping of a ruptured basilar aneurysm was detected in one patient (2%). Other types of complication were revealed in four cases (6%): detachment of clip with re-bleeding; clipping of an uninvolved aneurysm instead of the ruptured one; displacement of the clip beneath the ruptured aneurysm. Operations on ruptured basilar artery aneurysm were significantly (P less than 0.01) more prone to complications. The results indicate that operative vascular complications play a significant role in the mortality of aneurysm patients. Post-mortem angiographic technique with contrast medium that vulcanizes at room temperature is particularly suitable for demonstration of the haemodynamic significance of clip-induced cerebrovascular accidental occlusions, and is the only method at autopsy to reveal an occlusion caused by a kinking of a properly placed aneurysm clip.     

Symmetrical "mirror-image" injuries and the "chessboard" pattern: useful markers of self-mutilation

The evaluation of injuries due to self-mutilation may be complicated by atypical lesions and fabricated histories of the causative events. Four cases are described where one of the most striking findings was the presence of "mirror-image" injuries and/or a "chessboard" pattern of intersecting parallel lines from self-inflicted incised wounds. Case 1: A 32-year-old man was dead in his burnt-out car, with symmetrical, "mirror-image", circular burns from the car cigarette lighter over his forehead, cheeks, ears, upper and lower arms, the dorsal and palmar aspects of the hands, the anterior chest wall including the nipples, the anterior abdomen, thighs, lower legs, and the back of his neck. The deceased had a history of psychotic depression and had died of burns and inhalation of products of combustion. Case 2: A 19-year-old woman who fabricated a history of assault demonstrated multiple, superficial, "mirror-image" injuries of her thighs and forearms. Case 3: A 32-year-old man who exsanguinated from cut wrists showed multiple, superficial, and "mirror-image" incised wounds of the wrists, with a "chessboard" pattern. Case 4: A 26-year-old man died after jumping from a building. He had multiple superficial, "mirror-image" incised wounds of his anterior chest and thighs, with a typical "chessboard" pattern. Given the difficulties that sometimes arise in determining whether injuries have been self-inflicted or not, the finding of symmetrical "mirror-image" injuries, and/or a "chessboard" pattern formed by 2 groups of regular, parallel, superficial incised wounds running at right angles to each other provides compelling evidence of self-mutilation, unless a plausible alternative explanation is available.     

An unusual death by propranolol ingestion

A case of acute intoxication with propranolol is reported. A 60-year-old man was found dead in his car with no evidence of trauma or signs of asphyxia. Near the car, a pharmaceutical box of Inderal, a pharmaceutical formulation containing propranolol, was found. The man was not under therapy with this medication, but circumstantial data suggested the use of this medicine by his sister. High blood levels of propranolol confirmed the suspected drug use and induced us to discuss the probable lethal mechanism of this substance. The analysis of this compound was performed by liquid-liquid extraction followed by gas chromatography/mass spectrometry determination.     

Suicidal gunshot to the head while driving a car

A severe traffic accident occurred on the German autobahn. According to eye witnesses, the car had changed from the left to the right lane at 160 km/h before crashing into a thicket at full speed. In the car, a sports pistol was found in the footwell of the driver's side. The emergency doctor who performed the external examination of the victim's body found a gunshot wound in the region of the driver's right lower jaw. As the prosecutor released the body without further examination, the family of the suicide asked for an autopsy, which demonstrated a lethal suicidal gunshot to the head; toxicological tests proved a previous consumption of cocaine.     

Suicides by starter's pistols and air guns

We report the case of a 25-year-old depressed woman who committed suicide with a starter's pistol loaded with CS tear-gas ammunition. The propellant gases of the contact shot entered her chest through the left sixth intercostal space. Exsanguination was caused by perforations of the pericardium and apex of the heart. Autopsy did not reveal any metallic or other foreign bodies that might have originated from the propellant, the cartridge, or any bulletlike material. Her injuries were thus caused by the propellant alone. 0.5 mg L-1 of the CS degradation product cyanide was detected in the cardiac blood. We also report the case of a 54-year-old man, suffering from depressive psychosis, who committed suicide with an air rifle. The lead-pointed Diabolo bullet entered his brain through the right large wing of the sphenoid bone, traversed the right temporal brain pole, damaged the right middle cerebral artery and the right optic tract, and finally lodged in the left central ganglia. There was extensive basal subdural hemorrhage and tamponade of all cerebral ventricles. Death was attributed to cerebral failure. We furthermore list another 26 cases of suicide by rarely used weapons from 1947 to 1989.     

Study of injuries combining computer simulation in motorcycle-car collision accidents

This paper presents the approach of computer simulation to clarify the questions faced by forensic experts about what causes the various injuries characteristic of two motorcycle victims, including the motorcycle driver and the back seat occupant on the motorcycle, and how to exactly confirm which one of them is the motorcycle driver. Two typical motorcycle-car accident cases were reconstructed to analyze the movement and the load of both the motorcycle driver and the back seat occupant in the collision course. In case one, the back seat occupant suffered fatal head injuries when he fell on the ground after being thrown higher than the motorcycle driver over the top of the car. In case two, the compressive force loaded by the right tibia of the back seat occupant was larger and more durative compared with the motorcycle driver; the back seat occupant suffered a bursting fracture injury of his right tibia. These results might be useful for forensic experts in dealing with similar motorcycle-car collision accidents in the future.