Acute Aortic Dissection Diagnosed after Embalming: Macroscopic and Microscopic Findings

A 58‐year‐old man died suddenly in Madagascar and poisoning was suspected. The body was embalmed after death and the general state of preservation was good. We found a major aortic dissection with a large false lumen from the aortic root to the common iliac arteries and a hemopericardium with formalinized blood clot. The intimal tear was on the ascending aorta, and an intramural hemorrhage was noted at the right coronary artery, attesting to a retrograde dissection. Microscopic studies confirmed aortic dissection with extensive intramural hemorrhage and also confirmed the retrograde dissection to the right coronary artery with a reduction of 90% of the true lumen. Classically, aortic dissection occurs in individuals with hypertension and individuals with genetic disorders of collagen formation. The diagnosis is often first established at the postmortem examination. Aortic dissection is therefore dealt with largely in necropsy studies. The usual cause of death is rupture into the pericardial sac. One case of bloodless dissection has been reported but the sudden death was explained by acute myocardial ischemia secondary to dissection of the left coronary artery. In our case, we found major hemopericardium and also intramural hemorrhage at the right coronary artery. We were able to make the diagnosis of aortic dissection and exclude the suspicion of homicide 15 days after death and after embalming.     

Fatal ischemic stroke due to dissecting aneurysm of the intracranial arteries presenting as sudden unexpected death in childhood

Sudden unexpected death is any nontraumatic death in healthy individuals with normal activities for age until acute demise. Whereas not uncommon in adults and infants, it is considered a rarity in children, with most cases due to infection or occult cardiovascular abnormalities. Pathologic intracranial findings are rarely found in sudden unexpected death in childhood, with most cases due to occult intracranial neoplasms. Cerebral arterial dissection is an uncommon cause of arterial ischemic stroke in childhood. Outcome is poor, with more than 20% of patients dying. We report 4 cases of sudden unexpected death due to arterial ischemic stroke after cerebral arterial dissection in childhood and present a review of the literature.     

Sudden Cardiac Death in a Young Man with Migraine-associated Arrhythmia

A 31-year-old man with migraine-induced syncope and bradycardia with subsequent pacemaker implantation died unexpectedly. Clinically unsuspected cardiac anomalies were found at autopsy including myocardial bridging of the left anterior descending artery and shelf-like coronary artery ostia. Nortriptyline was identified by toxicologic analysis. A review of the autopsy findings, the historical information, and the effects of the possible arrhythmogenic circumstances is undertaken and the potential contributions to the death are discussed. Cardiac arrhythmias have been documented during migraines. Coronary artery bridging has been known to lead to ischemia and infarction, ventricular tachycardia, and sudden death; however, these are very rare sequelae. Congenital coronary artery anomalies have been linked to sudden cardiac death, but only rarely cause death in people younger than 31 years. Migraines and the autopsy findings described have been associated with cardiac arrhythmia and sudden death. Altogether, they led to the unexpected death of this young man.     

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。     

Tuberculous Abdominal Aortic Aneurysm with Alimentary Tract Hemorrhage: A Case Report with Medico-legal Implications

An autopsy case of sudden death induced by alimentary tract hemorrhage was presented,which was caused by the unexpected rupture of clinically unrecognized tuberculous abdominal aortic aneurysm(TAAA).The initial diagnosis was made of the syndrome of coronary heart disease and hypertensive disease.The detailed autopsy showed that the alimentary tract hemorrhage was caused by a sudden rupture of the mass after posture changing was ascertained as the cause of death.The diagnosis of TAAA was determined by the autopsy findings.Analysis for the medical dispute of TAAA was described,and the difficulty of the diagnosis and medico-legal implications were also discussed.     

Influenza A/H1N1 (2009) Infection as a Cause of Unexpected Out‐of‐Hospital Death in the Young*

Abstract: In March 2009, a new strain of influenza A/H1N1 virus was identified in Mexico, responsible for a pandemic. Worldwide, more than 13,500 patients died, most often from acute respiratory distress syndrome. Because sudden death cases were rare, involving mostly young apparently healthy persons, influenza A/H1N1 (2009)‐related deaths may be misdiagnosed, which can raise medico‐legal issues. Case history: we report on an unexpected out‐of‐hospital death involving a young male with no past medical history and no vaccination. Fever was his only symptom. Laboratory tests: histology showed patchy necrotic foci with mononuclear inflammation in the lungs. The heart was histologically normal, but virological analyses using molecular biology on frozen myocardial samples showed high virus load. In conclusion, this case report shows that influenza A/H1N1 (2009) virus can be a cause of sudden cardiac death in the young and demonstrates the importance of quantitative virological analyses for the diagnosis of myocarditis.     

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.     

Sudden Death Caused by Anomalous Origin of the Coronary Artery During Exercise

Anomalous origin of the coronary artery (AOCA) is a rare, but important cause of sudden cardiac death among young athletes. Nine autopsy cases (8 male, 1 female; mean age, 17.9 years; age range, 11–31 years) of sudden death during or just after exercise caused by AOCA were reviewed. The exercises performed at the time of death were running (4 cases), soccer (2 cases), and baseball, swimming and kendo (Japanese swordsmanship) (1 case each). In 6 cases, the left coronary artery arose from the right sinus of Valsalva, and in 3, the right coronary artery from the left sinus. The coronary arteries passed between the pulmonary artery and the aorta with an acute angle takeoff from the orifice. Three cases had cardiovascular manifestations prior to death. In cases with cardiovascular manifestations, novel imaging methods should be considered to prevent sudden death.     

二维红外光谱用于急性心肌缺血猝死的鉴别研究

目的采用衰减全反射-傅里叶变换红外光谱(ATR-FTIR)技术检测急性心肌缺血猝死大鼠的血清分子特征,探讨二维红外光谱鉴别急性心肌缺血猝死的法医学价值。方法成年雄性SD大鼠随机分为急性心肌缺血猝死组(实验组)和空气栓塞死组(对照组),血清样本行ATR-FTIR检测,应用OMNIC软件进行光谱预处理并求二阶导数光谱,分别计算两组原始光谱及二阶导数光谱的相似度,并应用Matlab R2010a软件建立二维光谱模型。结果实验组与对照组的大鼠血清的原始红外光谱在峰形、峰位、峰强度均极其相似,相似度达99.78%,二阶导数光谱显示出两者相似度降至98.62%,二维光谱模型显示两组光谱在1 625cm~(-1)、1 550cm~(-1)、1 080cm~(-1)及860cm~(-1)附近的成分差异,且它们的自动峰个数不相同,提示两组在蛋白质、糖原、核酸等分子含量存在较明显差异。结论仅从一维光谱上难以区分出两组的分子差异,二维红外光谱可以直观、有效地反映出急性心肌缺血猝死与空气栓塞死的大鼠血清分子差异,有望应用于法医学死因鉴别。     

A retrospective analysis of cardiovascular deaths: A 5-year autopsy study of 1045 cases in Antalya,Turkey

This study aims to identify the macroscopic and microscopic changes that occur in the heart in different causes of cardiovascular death and sudden cardiac death in autopsy cases and evaluate the difficulties that a forensic practitioner may encounter during autopsies. All forensic autopsy cases in the Morgue Department of the Council of Forensic Medicine, Antalya Group Administration between January 1, 2015, and December 31, 2019, were examined, retrospectively. The cases were chosen according to inclusion and exclusion criteria, and their autopsy reports were examined in detail. It was determined that 1045 cases met the study criteria, 735 of which were also met the sudden cardiac death criteria. The top three common causes of death were ischemic heart disease (n = 719, 68.8%), left ventricular hypertrophy (n = 105, 10%), and aortic dissection (n = 58, 5.5%). The frequency of myocardial interstitial fibrosis was significantly higher in deaths due to left ventricular hypertrophy than in deaths due to ischemic heart disease and other causes (χ²(2) = 33.365, p < 0.001). Despite detailed autopsy and histopathological examinations, some heart diseases that cause sudden death may still not be detected.     

97例心性猝死的法医病理学分析

目的探讨心性猝死（SCD）的特点、病理基础及致死因素和诱因等。方法对本系2002年12月至2006年12月期间，所作450例法医病理检案的97例心性猝死案例进行分析研究。结果97例SCD患者中，冠心痛猝死38例，心肌炎23例，心肌痛16例，高血压性心脏病12例，主动脉瘤破裂4例，肺栓塞4例。结论SCD病程短骤、凶险，以老年男性多见，冠心病占首位。由于猝死的因素繁多，因此对猝死事件的法医学鉴定要根据其发生特征和变化规律，作出客观、全面、准确的签定结论。     

Subaortic Pseudoaneurysm of the Left Ventricle Complicating Staphyloccal Endocarditis*

Abstract: Subaortic pseudoaneurysms are rare but can be a cause of sudden death in young individuals. This case report involves a 20‐year‐old Vietnamese male who died suddenly from rupture of a subaortic pseudoaneurysm with resultant hemopericardium with tamponade. He had a history of bicuspid aortic valve with recent but healed Staphylococcal endocarditis. A review of the literature reveals few similar cases and enlightens the association between aortic bicuspid valve, endocarditis, and subvalvular aortic aneurysm. The pathogenesis as well as recent studies that identified aneurysm predisposing genes in patients with bicuspid aortic valve will be discussed.     

Causes of Sudden Death in Patients with Obstructive Sleep Apnea

There are few autopsy studies of patients dying suddenly with obstructive sleep apnea (OSA). Twenty‐five forensic autopsies of unexpected sudden death in individuals with OSA were reviewed. The causes of death were as follows: cardiomyopathy (n = 11); sudden unexpected death without morphologic findings (SUDNA, n = 6); and other cardiovascular diseases not related to OSA (n = 8). The cardiomyopathy group comprised five hearts with concentric left ventricular hypertrophy without dilatation and six with left ventricular diameter >4 cm (dilated cardiomyopathy). Four of six hearts in the SUDNA group showed right ventricular dilatation compared with seven of 11 showed cardiomyopathy and one of eight miscellaneous. The degree of obesity was greatest in the dilated cardiomyopathy group (10 of 11 obese) followed by the SUDNA group (four of six obese). The cardiac findings in patients dying suddenly and unexpectedly with OSA include nonspecific cardiomyopathy, other cardiac conditions, and hearts without a morphologic cause of death, which show frequent right ventricular dilatation as the only finding.     

Acute Bacterial Meningitis with Coincident Methamphetamine Use: A Case Report and Review of the Literature

Methamphetamine is a synthetic stimulant that can adversely affect the central nervous system and the immune system. Through various mechanisms, methamphetamine is toxic to neurons, endothelial cells, lymphocytes, granulocytes, and macrophages resulting in systemic damage. Reported is the sudden demise of an otherwise healthy 31‐year‐old woman with a history of stimulant abuse. At autopsy, acute bacterial meningitis was identified. Microbiology cultures grew a single isolate of Streptococcus pneumoniae. Toxicology was positive for amphetamine (0.13 mg/L) and methamphetamine (0.8 mg/L). The cause of death was classified as acute bacterial meningitis with methamphetamine use. Either the acute bacterial meningitis or the methamphetamine toxicity would have been sufficient to result in death; however, the concurrent pathophysiology of the two entities must be understood. A review of the current literature assesses the mechanisms of injury attributed to acute and chronic methamphetamine use, bacterial meningitis, and the synergy between the two.     

Diagnostic dilemma of sudden deaths due to acute hemorrhagic pancreatitis

Sudden death due to acute pancreatitis has been rarely determined. A review of 3305 autopsies performed between 1991 and 2001 at the Council of Forensic Medicine found 12 cases (0.36%) with sudden death due to acute hemorrhagic pancreatitis without symptoms. A history of chronic alcohol ingestion was obtained from family in four cases (33%), and no stones were found in the bile ducts or in the gall bladders. During the autopsies, hemorrhage and edema were localized on the head of the pancreas in three cases and the whole pancreas in nine cases. The most common extrapancreatic pathology was found in the lung including pulmonary edema, alveolar hemorrhage, pleural effusion, and pulmonary congestion. There was no correlation between pulmonary and pancreatic damage. It is suggested that the forensic pathologists who are dealing with sudden unexpected death must not ignore the examination of pancreatic and extrapancreatic regions to avoid missing acute pancreatitis.     

Sickle Cell Trait Mimicking Multiple Inflicted Injuries in a 5-Year-Old Boy

Abstract:  Sickle cell disease (SCD) and sickle cell trait (SCT) can be associated with sudden unexpected death in the pediatric population, usually due to pulmonary complications occurring within the acute chest syndrome (ACS). Musculoskeletal complications can occur and are classically limited to bone infarcts. The occurrence of bone pathology centered upon the epiphyseal growth plate in SCD/SCT is extremely rare, and multiple such injuries in a single patient have not been previously reported. Herein, we describe a case of sudden unexpected death in a 5-year-old child with undiagnosed SCT due to the ACS, with widespread epiphyseal and periosteal bone lesions mimicking multiple inflicted injuries at autopsy. This case highlights the importance of clinicopathological correlation and is the first to describe SCT pathology as a mimic of nonaccidental injury.     

Fatal pulmonary haemorrhage from a perforated and possibly iatrogenic thoracic aortic aneurysm

A 56-year-old man, with Noonan's syndrome, underwent surgical correction of an aortic co-arctation almost two decades before his sudden and unexpected demise. The immediate cause of death was massive pulmonary haemorrhage, which was preceded by recurrent mild haemoptysis that was attributed to pneumonia, clinically. Autopsy revealed the presence of a saccular thoracic aortic aneurysm, arising from the apparently weakened anastomosis left by the previous operation. The aneurysm had eroded into the apical segment of the left lung, where it perforated with consequent severe, acute pulmonary haemorrhage. It was observed that the anastomotic line traversed the aneurysmal wall, with the resultant formation of a true aneurysm, rather than merely a pseudo-aneurysm. It is postulated that this finding of an iatrogenic true aneurysm represents a rare, delayed complication of aortic surgery.     

316例急死的法医学分析

对重庆地区316例急死进行分析。结果表明:男性多于女性,中青年及小于10岁的婴幼儿居多,第三季度增多,呼吸系统疾病居首位,其次为循环系统疾病,死亡场所是医院占多数。     

The Institution of a Standardized Investigation Protocol for Sudden Infant Death in the Eastern Metropole,Cape Town,South Africa,,

The rate for the sudden infant death syndrome (SIDS) in Cape Town, South Africa, is estimated to be among the highest in the world (3.41/1000 live births). In several of these areas, including those of extreme poverty, only sporadic, nonstandardized infant autopsy, and death scene investigation (DSI) occurred. In this report, we detail a feasibility project comprising 18 autopsied infants with sudden and unexpected death whose causes of death were adjudicated according to the 1991 NICHD definitions (SIDS, n = 7; known cause of death, n = 7; and unclassified, n = 4). We instituted a standardized autopsy and infant DSI through a collaborative effort of local forensic pathology officers and clinical providers. The high standard of forensic investigation met international standards, identified preventable disease, and allowed for incorporation of research. We conclude that an effective infant autopsy and DSI protocol can be established in areas with both high sudden unexpected infant death, and elsewhere. (SUID)/SIDS risk and infrastructure challenges.