头皮创缝合后帽状腱膜下血肿34例分析

帽状腱膜下血肿，在头皮损伤中较为常见，传统概念认为该损伤是一种闭合性头皮损伤，但在法医损伤鉴定中，头皮创缝后形成的帽状腱膜下血肿（以下暂称开放性帽状腱膜下血肿，有待商榷）也颇为多见，且在帽状腱膜下血肿案例中占较高比例。该损伤在临床医学和法医学认识上均存在歧义，在伤情评定时常常引起争议。因血肿自身的特点，复检时血肿多已消失，仅能依据病历及法医初检笔录进行鉴定，故初检时准确的伤情鉴定尤为重要。笔者从914例故意伤害案例中选取34例开放性帽状腱膜下血肿，对其形成机理、对机体的危害及损伤程度评定加以分析探讨…     

不同部位颅脑摔跌伤的特征分析68例

目的探讨不同受力部位颅脑摔跌伤后损伤程度和特征差异。方法收集摔跌所致颅脑损伤68例,根据案情、受伤过程、临床体征、CT影像资料将受伤部位分为颅前部、颅侧部、颅后部;损伤类型分为颅骨骨折、硬脑膜外血肿、硬脑膜下血肿和脑挫裂伤;损伤数量分为单一和多发伤;颅骨骨折分为受力点骨折和非受力点骨折;脑挫裂伤分为冲击伤、对冲伤等。运用非参数统计χ2检验比较其频数分布。结果不同摔跌部位颅骨骨折和颅脑损伤程度存在明显差异(P0.05),颅后部摔跌颅骨骨折远离受力点多见,多发伤为主,而颅前部、颅侧部受力点骨折多见,单处损伤多见;颅后部、颅侧部摔跌后脑挫裂伤发生率高,以对冲部位多见,颅前部摔跌后脑挫裂伤发生率低,冲击伤亦多见。结论摔跌部位不同颅脑损伤程度和特征存在差异,CT检查资料有助于损伤机制推断。     

老年人交通事故精神伤残鉴定的临床特征分析

目的探讨老年人交通事故受伤后精神伤残鉴定临床特征。方法对109例老年人发生交通事故受伤后精神伤残司法鉴定资料进行回顾性分析,并与非老年组进行对照研究。结果老年人多为被动性损伤、受伤后颅内血肿发生率高、致残的原因88．07％是智能及精神障碍所致,损伤程度及伤残等级以中、重度多见。结论最佳评残时机为脑外伤一年后为宜,应结合老年人的心理、生理特点,提高交通安全防范意识。     

256例儿童和少年道路交通事故伤残评定回顾性研究

目的 探讨儿童和少年道路交通事故活体损伤的流行病学、损伤及伤残评定特点。方法 对256例儿童和少年道路交通事故伤残评定资料进行回顾性研究。结果 男性多于女性,多见于6～18岁儿童,交通事故每天10～12时和16～18时最多,车辆类型以小汽车和货车多见,肇事方式多见于机动车与行人相撞,伤者的交通方式以步行多见,损伤部位以头部和四肢多见,损伤类型以骨折、挫伤、创多见,但内脏损伤相对较轻,下肢骨折远多于上肢。损伤程度多评定为轻伤,伤残程度以Ⅸ、Ⅹ级轻度伤残为主(33.2％)。结论 儿童和少年道路交通事故伤残评定应适当放宽标准,伤残评定标准应增加儿童和少年的有关条款。     

39例小脑扁桃体疝性脑挫伤分析

报告39例小脑扁桃体疝性脑挫伤，其中钝器打击33例，枪弹创6例，并对其病理学改变及发生机理进行观察与探讨。认为小脑扁桃体疝性脑挫伤是由于小脑扁桃体在头部遭受暴力的瞬间，撞击枕骨大孔边缘所发生的一类远区脑挫伤。见于加速性损伤，多数与冲击性脑挫伤相伴随，常累及延髓，且以线状颅骨骨折多见，伤后死亡较为迅速。熟悉该类损伤，对分析损伤性质，确定和解释死因以及估计伤后存活时间有一定的实际意义。     

脑室系统周围脑组织损伤致死1例

某男，39岁。2005年11月，被人用脚踹击头部后在30min内死亡。尸表检验见：右顶部有片状头皮下出血；左枕部有头皮下血肿。颅脑解剖检验见：颅骨无骨折。蛛网膜下腔弥漫出血，遍布额叶、顶叶、颢叶、小脑脑表面及外侧裂、脚间池、环池，以脑底面为著。脑沟脑回轻度肿胀，双侧小脑扁桃体疝及轻度海马钩回疝形成。完整剥离Willis环，未见动脉粥样硬化斑块形成，无动脉瘤和血管畸形。冠状切面可见蛛网膜下腔出血以脑底部为著，脑室系统内出血和凝血，中脑被盖部、双侧侧脑室枕角及三脑室周围脑实质质软，呈粉红色。其余脑实质未见著变。     

2855例暴力性伤害案特征研究

目的了解我国暴力性伤害损伤特征. 方法调查四川省8个市县1990～1997年公安局登记在案且经过法医学鉴定的所有暴力性伤害案件2 855 例,并进行统计分析. 结果伤者及侵害者均以青年男性为主, 20～39岁多见.文化程度在伤者以中专及中学多见,侵害者则以小学文化水平为主.致伤方式最常见的为钝器伤,其中拳打、脚踢最为多见(57.2%).损伤部位以头面部最为多见(37.3%).损伤类型多为挫裂创及刺、砍、切创(40.3%).损伤程度以轻伤多见(42.4%). 结论[ HT 根据暴力性伤害特征制定相应预防措施,对我国社会治安的稳定具有重要意义.     

2 855例暴力性伤害案特征研究

目的了解我国暴力性伤害损伤特征. 方法调查四川省8个市县1990～1997年公安局登记在案且经过法医学鉴定的所有暴力性伤害案件2 855 例,并进行统计分析. 结果伤者及侵害者均以青年男性为主, 20～39岁多见.文化程度在伤者以中专及中学多见,侵害者则以小学文化水平为主.致伤方式最常见的为钝器伤,其中拳打、脚踢最为多见(57.2%).损伤部位以头面部最为多见(37.3%).损伤类型多为挫裂创及刺、砍、切创(40.3%).损伤程度以轻伤多见(42.4%). 结论[ HT 根据暴力性伤害特征制定相应预防措施,对我国社会治安的稳定具有重要意义.     

颅脑损伤后精神障碍的相关因素分析

目的 探讨颅脑损伤后精神障碍的相关因素。方法 对42例颅脑损伤伤者的法医学鉴定资料进行回顾性分析,颅脑损伤诊断按照病史资料和颅脑CT/MRI确定;精神障碍按照CCMD-Ⅱ-R、CCMD-3及龚氏修订的韦氏智力量表(WAIS-RC)确定;伤残程度评定根据《道路交通事故受伤人员伤残评定》标准。将所获得的结果,进行统计学分析。结果 精神障碍以脑震荡后综合征居首位(26.2％),其次是遗忘综合征(21.4％)、神经症(16.6％)等。精神障碍以脑伤的低伤残等级多见(Ⅹ级52.4％,Ⅷ级14.3％,Ⅶ级19.0％),但整体差异无显著性意义(P>0.05)。精神病性精神障碍多分布于脑器质性损伤(脑挫裂伤54.8％,脑干损伤16.7％);非精神病性精神障碍多分布于脑功能性损伤,其中脑震荡占21.4％,其差异有高度显著性(P<0.01);智力缺损多见于脑器质性损伤(P<0.05),80.6％分布于脑伤的Ⅹ级、Ⅷ级和Ⅶ级(P<0.01)。结论 颅脑损伤后精神障碍及智力缺损的发生与颅脑损伤的类型、性质有关,与颅脑损伤的严重程度并不平行。     

外伤性头皮血肿的CT表现及法医学分析

外伤性头皮血肿是一种最为常见、多发的头皮软组织损伤,致伤原因多由钝性外力所致,它主要包括:浅筋膜下血肿、帽状腱膜下血肿和骨膜下血肿3种类型[1]。根据《人体轻伤鉴定标准(试行)》之规定,外伤性帽状腱膜下血肿为轻伤。因此,在法医临床学损伤程度评定中,准确鉴定上述3种不同     

颅脑损伤部位与智力评估分析

目的探讨颅脑损伤部位与智力损伤的关系。方法315例颅脑外伤者根据疾病诊断分成8组：蛛网膜下腔出血组、脑震荡组、硬膜外血肿组、硬膜下血肿组、颞叶损伤组、额叶损伤组、顶叶损伤组、枕叶损伤组、广泛性损伤组和其他组，按中国修订韦氏成人智力量表进行测试，分析性别、年龄、文化程度、损伤部位与智商水平的关系。结果颅脑外伤后的平均总智商（FIQ）为64．45±16．09。性别对颅脑外伤后的智商水平影响不明显（P=0．578）；老年颅脑外伤后的智商水平较青年和中年高（P〈0．01）；文盲者颅脑外伤后的智商水平较文化程度高者低（P〈0．01）。各组智商水平高低为：其他组〉蛛网膜下腔出血组、脑震荡组〉硬膜外血肿组、硬膜下血肿组〉颞叶损伤组、额叶损伤组、顶叶损伤组、枕叶损伤纽〉广泛性损伤组。同时左额叶损伤组的智商水平较右额叶损伤组低；右颞叶损伤组的操作智商（PIQ）明显比左颞叶损伤组低，而言语智商（VIQ）则反之（P〈0．01）。结论颅脑外伤后的智力损伤与损伤部位密切相关。     

Elderly deaths due to ground-level falls

This study analyzed 237 fatal ground-level falls occurring in decedents aged 65 years or older reported to the Seattle-King County Medical Examiner's Office during the year 2007. Head injuries accounted for 109 (46%) of the deaths, and nonhead injuries accounted for 128 (54%) of the deaths. Falls occurred in similar locations in both groups. Compared with those of nonhead injuries, decedents of head injuries were younger (82 vs 87.5 years), were more often male (58% vs 45%), died sooner after their injury (9 days vs 23 days), and were more likely treated with anticoagulants, especially warfarin (48% vs 16%). Subdural hematoma was the most common specific traumatic lesion, occurring in 86% of the decedents of head injury; skull fractures occurred in 13%. Decedents of head injury who were treated with anticoagulants, on average, sustained less severe head injury than those who were not treated with anticoagulants.     

23例头面部拳掌伤致脑干损伤致死病理学分析

目的 观察头面部拳掌伤，及钝器打击伤致脑干损伤死的病理形态学特点，并探讨其成伤机理。方法 对23例拳击(A组)与30例钝器打击(B组)采用作者建立的脑干损伤取材方法，于脑干各颅神经根部作水平面切6块，HE染色光镜检查。结果 2组脑干损伤具有相同的病理形态学改变。A组水肿显著(71.6％)，B组以组织撕裂、挫碎为多(76.6％)；A组颅神经损伤多为单根(47.6％)，B组2根以上占53.7％，最多可达4根；A组单纯脑实质挫伤多(50％)，B组多伴发血肿或挫挤带。结论 拳、掌和钝器打击头面部致脑干损伤的病理形态学相同，但钝器打击比拳、掌致脑干损伤严重且广泛。提示脑干损伤致命与其受力部位、发病机理关系密切，而与受力强度关系不大。     

重型颅脑损伤患者P300与智商的相关性

目的研究重型颅脑损伤患者认知功能的改变以及事件相关电位(event-related potential,ERP)中的P300成分与智商的关系。方法对40例重型颅脑损伤患者进行听觉P300检查并用中国修订韦氏成人智力全量表测定智商,另外用40例正常成年人作为对照组也进行P300的检查。结果病例组P300潜伏期较正常组明显延长(P<0.01),病例组P300的潜伏期与操作智商和总智商之间呈显著负相关(r=-0.335、-0.344,均P<0.05)。结论ERP是测定重型颅脑损伤患者认知功能变化的一项客观指标。     

听力测试组合在听觉障碍鉴定中的应用

目的分析不同听力测试方法对听阈评估的作用,探讨组合听力测试在听觉障碍法医学鉴定中的应用。方法对87例外伤后听力损伤者进行听力测试,将纯音听阈测试(PTA)、声导抗、40HzAERP、ABR、ASSR、DPOAEs进行组合。听阈评估采用PTA+ABR+40HzAERP/ASSR,损伤定位采用PTA+声导抗+ABR/40HzAERP+DPOAEs。根据致伤方式的不同,分为头部损伤组和耳损伤组。比较组间DPOAEs阳性率,比较纯音听阈、40HzAERP、ABR及ASSR对听阈评估的作用。结果头部外伤组DPOAEs阳性率明显高于耳损伤组(P<0.05);纯音语频听阈异常耳与40HzAERP语频阈值及ABR比较,纯音语频阈值异常率较40HzAERP及ABR明显高,主、客观听阈明显不符。26耳40HzAERP与ASSR比较,两者在0.5kHz、1kHz、2kHz反应阈均值数相关性较好(r=0.862),ASSR语频均值较40HzAERP低,平均差17dB。结论纯音听阈与ABR、40HzAERP或ASSR组合测试对听阈的评估有互补作用。40HzAERP与ASSR均可以用于语音频率的听阈评估。声导抗、ABR、40HzAERP与DPOAEs多项检查组合,有助于确定损伤部位。     

Capacity for physical action in traumatically-induced epidural hemorrhage

Authors report the case of a 55-year-old man with a nearly normal capacity to act for appr. 48 hours following epidural hematoma due to a blunt trauma of the head with skull fracture. The man was amnestic for the period of time since the trauma. According to the computertomographic findings, the cause for the mild clinical symptoms was a pre-existent atrophy of the brain.     

脑外伤所致精神障碍司法鉴定400例分析

目的探讨精神疾病司法鉴定中颅脑损伤所致精神障碍的临床特征及相关因素。方法收集脑外伤后司法鉴定案例资料,按照神经外科GCS评分把脑损伤所致精神障碍鉴定案例分为重型(A组)、中型(B组)及轻型(C组)颅脑损伤;对案例的临床症状进行分析,根据中国精神障碍分类与诊断标准(第三版)(CCMD-3)进行精神障碍诊断,并探索临床症状与脑外伤程度之间的关系。结果轻、中度颅脑损伤所致精神障碍以器质性神经症样综合征最多见。重度颅脑损伤所致精神障碍中以智能损害综合征为多。三组间有显著性差异(P≤0.01)。结论在精神疾病司法鉴定中,不同严重程度的颅脑损伤所致的精神障碍有不同的临床特征。     

Spinal epidural haematoma after blunt trauma to the neck and hyperflection of the cervical spine

Spinal epidural haematomas (sEDH) can be regarded as rare events, in principle a spontaneous and a traumatic aetiology can be distinguished. Spontaneous spinal epidural haematomas can arise, e.g. from vascular malformations, coagulopathies, etc. On the other hand, traumatic sEDH are related to, e.g. spinal trauma or intraoperative vascular injuries. With regard to clinical significance, spinal epidural haematomas accompanied by transient mild neurological symptoms up to lethal outcomes have been observed. We report on a 53-year-old male alcoholic who was found in the kitchen of his asylum in a grotesquely fixed body position, with his head and cervical spine in a maximum anteflected position. A general practitioner had ruled for a non-natural manner of death due to "broken neck" and alcohol intoxication, therefore, the prosecution authorities called for a medicolegal autopsy. At autopsy, paravertebral soft tissue haemorrhage in between the shoulder blades was disclosed. Furthermore, a spinal epidural haematoma, extending from the foramen magnum down to the middle portion of the thoracic spine was found. No fractures of vertebrae nor lesions of spine ligaments or bleedings of intervertebral discs were found. Blood alcohol concentration was determined 1.92 g/l and urine alcohol concentration was 1.76 g/l. Further morphological findings were cerebral oedema and cardiac hypertrophy; the urinary bladder was found filled to bursting. Neuropathological investigations confirmed the presence of the spinal epidural haematoma and assigned lethal significance to this finding. There were no histological signs of axonal injury. Reconstruction revealed that when sitting on a chair in a drunk condition, the individual's upper part of the body had fallen backwards in the corner and subsequently got stuck with maximum anteflection of the head and cervical spine, causing rupture of vessels and spinal epidural haematoma. Acute respiratory failure caused by impairment of the phrenic nerve following spinal epidural haematoma with potential synergism of alcohol intoxication was ascertained as the cause of death.     

Delayed sudden death in an infant following an accidental fall: a case report with review of the literature

Several controversies exist regarding ultimately lethal head injuries in small children. Death from short falls, timing of head injury, lucid intervals, presence of diffuse axonal injury (DAI), and subdural hematoma (SDH) as marker of DAI are the most recent controversial topics of debate in this evolving field of study. In this area of debate, we present a case of delayed death from a witnessed fall backwards off a bed in a 9-month-old black male child who struck his head on a concrete floor and was independently witnessed as "healthy" postfall for 72 hours until he was discovered dead in bed. Grandmother, babysitter, and mother all independently corroborated under police investigation that the child "acted and behaved normally" after the fall until death. Autopsy showed a linear nondisplaced parietal skull fracture, diastasis of adjacent occipital suture, subgaleal hemorrhage with evidence of aging, small posterior clotting SDH, marked cerebral edema, and a small tear of the midsuperior body of the corpus callosum consistent with focal axonal injury (FAI). No DAI was seen, and there were no retinal hemorrhages. All other causes of death were excluded upon thorough police and medical examiner investigation. Although this seems to be a rare phenomenon, a delayed, seemingly symptom-free interval can occur between a clinically apparent mild head injury and accidental death in a young child.