Posttraumatic thrombosis of the middle cerebral artery

Posttraumatic cerebral infarction resulting from carotid or cerebral artery occlusion is rare. Traumatic dissection of the carotid artery is the most frequent cause of infarction, whereas posttraumatic thrombosis of the cerebral artery is very rare. The authors describe a case of posttraumatic thrombosis of the left middle cerebral artery. Early in the morning, a 16-year-old boy was found unconscious in the parking lot of a supermarket. He had received fist blows and kicks to the head, face, body, back, and hip during the night. Computed tomography 10 hours after the violence revealed a gross cerebral infarction in the area of the left middle cerebral artery. He died 9 days after the violence. The autopsy revealed a thrombosis in the left middle cerebral artery. Microscopically, granulation tissue in the intima and a rupture of the internal elastic lamina were observed near the beginning of the artery. It was concluded that the blows to the head and face caused a partial rupture in the arterial wall, leading to thrombosis and cerebral infarction.     

Cervical Arterial Injury After Strangulation—Different Types of Arterial Lesions

After strangulation, cervical arterial injuries (CAI) are uncommon. We report three unusual cases where strangulation induced immediate stroke. CAI were examined using brain CT scan and Doppler ultrasonography in the three cases and then by autopsy in one of the victims. One of the two victims who survived the attempted strangulation had a unilateral carotid dissection, whereas in the other victim, no arterial dissection or thrombosis was observed. As regards the deceased victim, the autopsy confirmed the bilateral dissection showed on CT scan and Doppler ultrasonic examination and revealed that both carotid arteries were dilated up to two times the normal diameter. Microscopic examination showed a major bilateral hemorrhagic dissection of the media with obliterating fibrous endarteritis lesions associated with inflammatory damage. CT scan with arteriography does not demonstrate all the different types of arterial injury, particularly atheromatous embolism, direct compression, or prolonged spasm. Thus, traditional autopsy remains an essential forensic tool after strangulation to show the type of CAI.     

颈动脉钝性损伤法医学研究进展

颈动脉钝性损伤的发生率虽低,但死亡率高,易发生于交通事故、扼勒、缢吊、颈部直接外力作用和高坠等案例中。颈动脉钝性损伤有5种基础成伤机制：颈部直接外力作用,颈部过度伸展和旋转,颅底骨折碎片切割,口腔内扁桃体窝处直接外力作用,头胸部复合伤造成颈动脉被牵拉。国外相关研究文献和个案报道较多,而国内未见系统研究,不多的个案报道中,也有错误鉴定案例。本文对颈动脉钝性损伤的致伤方式、解剖学和生物学基础、成伤机制和法医学鉴定注意事项进行综述,希望能引起国内法医技术人员的重视,并为相关研究和应用提供参考。     

颈内动脉系钝性损伤法医学鉴定现状

颈内动脉系是大脑的主要血供来源。法医学鉴定实践中,颈内动脉系钝性损伤后常出现血栓、动脉瘤或动静脉瘘等并发症,由此引起迟发性脑梗死、颅内出血死亡的案例并不少见。目前国内对颈内动脉系钝性损伤引起死亡的研究以个案报道为主,本文综合国内外相关的文献及案例报道,对此类损伤引起死亡的法医学特点及检查方法进行总结,发现颈内动脉系钝性损伤与头颈部直接暴力或间接暴力致头颈部超生理范围运动牵拉,以及颅底骨折切割等机制有关,多见于颈部机械性窒息、颈部按摩、车祸、高坠等案例。法医学实践中若遇到此类案例,常规检查未发现梗死或出血原因,应注意检查该动脉,正确分析外伤、疾病和死亡之间的关系。鉴于尸体解剖中完整暴露该动脉的难度较大,必要时可借助血管造影技术进行定位,提高鉴定意见的科学性和可靠性。     

An uncommon delayed sequela after pressure on the neck: an autopsy case report

Delayed sequelae after pressure on the neck are rare. Awareness of such sequelae as well as a high degree of suspicion is essential for early detection and proper clinical management. Injuries to the common carotid artery and pseudo aneurysm formation leading to fatal hemorrhage are still rare occurrences after attempts of manual strangulation. When such cases are presented to the forensic pathologist, he has to establish the link between the cause and effect, excluding other possible causes for such complications. In addition, he may have to give opinions in possible medical negligence charges.     

Vertebral artery laceration mimicking elder abuse

Elder abuse was first described almost 30 years ago. Today, approximately 1 in 25 elders is abused each year in the United States. A newly described form of domestic violence, the incidence of elder abuse will surely increase as the elderly population grows. Physical abuse/inflicted trauma is generally considered the most extreme form of elder mistreatment and includes blunt trauma, sexual assault, traumatic alopecia, and burns. Elder homicide is usually due to gunshot wounds, blunt trauma, stab wounds, or asphyxia. However, the difficult aspect of assessing the possible elder abuse homicide victim is delineating such inflicted trauma from accidental trauma. We report the case of a 94-year-old "demented" male, who reportedly fell out of his wheelchair. He was transported to a local emergency room, where he became unresponsive during examination. He experienced respiratory distress and was pronounced dead shortly thereafter. At autopsy, he had periorbital contusions and a midline abrasion between the eyes, with underlying supraorbital contusion. The skull, brain, and spinal cord were unremarkable for signs of trauma. The major traumatic finding was in the neck region. Neck dissection revealed hemorrhage extending from the base of the skull to the level of T-1 and anteriorly about the soft tissues, strap muscles, and vasculature. The strap muscles were individually examined and were free of hemorrhage. The carotid arteries and jugular veins were unremarkable. The larynx, hyoid, and thyroid were intact, with only surrounding hemorrhage. Further examination revealed a horizontal fracture of the C5 vertebral body and a medial laceration of the left vertebral artery at the C5 level; subarachnoid hemorrhage was absent. What initially appeared to be trauma to the neck, worrisome for strangulation or blunt force trauma, was a large retropharyngeal hematoma from the left vertebral artery laceration. Traumatic rupture of the vertebral artery usually occurs at the C1 and C2 levels, with resultant subarachnoid hemorrhage. This is an especially vulnerable location since it is where the artery turns and then enters the skull. Associated injuries include spinal cord transection or contusion, brachial plexus injury, pharyngoesophageal injury, and vertebral fractures. Retropharyngeal hemorrhage may result from deep neck infection, tumor, and trauma. Hemorrhage associated with trauma often involves flexion of the cervical spine, followed by hyperextension. The accumulation of blood slowly impinges on the pharynx/larynx and vasculature structures. The exact injuries and etiology of the hemorrhage must be determined to distinguish strangulation from blunt force trauma. The presentation of signs and symptoms can be helpful in assessing the decedent; however, in the practice of forensic pathology such a history is more often lacking.     

Injuries and fatalities caused by gas-/warning weapons

Detailed report of 5 cases of violation with gas or warning firearms, 3 of them lethal. In one case a modified weapon (elongated barrel) and steel bullets were used, resulting in shot of the head with retained missile and lethal bleeding. In the other cases, regular weapons (8 or 9 mm cartridges) were used for contact shots; violation occurred only by the effect of powder gases. One of these cases was a suizide (lethal temporal gunshot), in the other cases shots by another person: a) shot against the arm with large soft-tissue damage (survived); b) and c) shot against the neck with exceeding rupture of the soft tissues, minimal damage of the neck arteries and in one cases bilateral tears of the hypopharynx. In this case a delayed death after primarily well operated injury occurred after 12 days by bleeding into the airways from ruptured external carotid artery.     

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.     

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.     

Homicidal alcoholic intoxation versus manual neck compression

A case of homicide involving a 49-year-old man is reported. In the course of a booze-up he was forced to excessive consumption of alcohol and was pushed back into a sofa by repeated grasping his neck which finally left him dead. The postmortem examination revealed a small abrasion in the right mandibular region, a contusion of the subcutaneous tissue above the left clavicle, a haemorrhage in the deep muscles of the neck at the right side of the cervical spine, a fatty tissue haemorrhage between the left cornus of hyoid and thyroid cartilage as well as petechiae of the eyelids and conjunctivae. The blood alcohol concentration amounted to 4.00@1000, the urine alcohol concentration to 5.26@1000. Thus, a manual strangulation of the neck versus a lethal alcohol intoxication had to be taken into consideration as cause of death. The morphological findings of the postmortem examination and the pathophysiological concepts of the underlying mechanisms of death in manual strangulation versus lethal alcohol intoxication are discussed with regard to their significance for the juridical assessment.     

The 'break enter and die' syndrome may involve significant injury to major neck vessels

Death from incised wounds of major vessels may occur during illegal entry of premises. Wounds are often relatively unimpressive having been caused by thin shards of glass. Alcohol and/or drugs have often been taken that have impaired coordination and contributed to a failure to take appropriate action. A 37-year-old man slipped and fell while attempting to enter a house through a window that he had just broken. He was found dead surrounded by a large amount of blood. At autopsy, a single horizontal, deeply incised wound of the anterior neck was present with transection of the internal jugular veins bilaterally and the right common carotid artery. Toxicological studies were negative for alcohol and common drugs. Death was due to exsanguination and air embolism. This case demonstrates that the injuries sustained during such activities may be quite extensive and involve major neck vessels. Alcohol and drug intoxication are not necessarily involved.     

Fatal thrombosis of internal carotid artery following minor blunt trauma to the neck

Fatal traumatic thrombosis of the left internal carotid artery occurred in a 38-year-old man following minor blunt cervical trauma during an altercation. There was no external injury observed on the head, face, or neck. Neurologic deficit developed soon after the injury, which progressed to right hemiplegia. His condition deteriorated and he expired on the sixth hospital day. The gross and microscopic findings of the internal carotid artery are presented and the significance of minor cervical blunt trauma and the possible mechanism for the vascular lesion are discussed.     

Entrance, exit, and reentrance of one shot with a shotgun

The case being reported is one of a homicidal shotgun fatality with an unusual wound pattern. A 34-year-old man was shot at close range with a 12-gauge shotgun armed with No. 5 birdshot ammunition. The shot entered the left axillary region, exited through the left infraclavicular region, and thereafter penetrated the left side of the neck, causing tearing of the left common carotid artery and the right internal carotid artery. The entrance wound in the axilla was larger than the other wounds, and before autopsy it was believed that the shotgun had been fired twice, causing one wound in the neck and one wound perforating the infraclavicular region and exiting through the left axillary region. Thus, this case shows that unusual wound patterns in shotgun fatalities can easily lead to incorrect assumptions with regard to number and direction of shots fired unless thorough investigation is carried out postmortem.     

Pressure on the neck calculated for any point along the ligature.

It had been experimentally shown that disfunction of the airways, major arteries and veins occurs in neck compression due to the violence of different strengths. These differences in the vulnerability of the neck anatomical structures determine the sequence and dynamics of the vital function disorders in strangulation, as well as its morphological features. The purpose of this study was to calculate the value of specific pressure P, which affects the neck along the ligature. Mathematical modeling method was used. Cylinder served the model of the human neck. It was found that P-value is directly proportional to the loop tension and inversely proportional to the radius of the curvature and neck-ligature contact area. Thus, in horizontal neck encirclement the strangulation groove forms a circumference, and P-value is invariable along the loop, as in typical cases of homicidal strangulation. In oblique position of the loop it makes an ellipse with changeable curve curvature, as in most hangings. As the formulas and graphs presented show, the increasing deflection of the loop towards the transverse plane results in increase in P-amplitude, mostly at the expense of its minimal indices (up to hundred per cent) rather than maximal ones (within 20% range). At the same time there are narrow zones along the loop, where the P-value remains almost invariable irrespective of loop deflection degree. The results of the study may be useful for investigation of thanatogenesis and pathomorphology of strangulation, including its experimental modeling.     

Fatal and non-fatal bilateral delayed carotid artery dissection after manual strangulation

Carotid artery (CA) dissection and/or thrombosis may occur in a number of medical and forensic relevant situations. However, post traumatic carotid artery dissection is considered rare, and often underestimated due to possible delayed presentation. We describe two cases of carotid artery dissection following strangulation with delayed symptoms as well as discuss medical diagnostic problems and their forensic implications.     

Case report. Delayed death after pressure on the neck: possible causal mechanisms and implications for mode of death in manual strangulation discussed

Death from hypoxic cerebral damage 1 week after manual strangulation is described, with a discussion of the competing pathophysiological mechanisms responsible for the fatal outcome in this case, and in manual strangulation in general.     

An unusual death caused by strangulation

An accidental case of strangulation is reported in which the victim caught his head in the gap of a wooden shed. Before passing into unconsciousness rescue was attempted.     

Fatal dissecting aneurysm of the internal carotid artery with delayed symptoms following facial impact.

A fatal dissecting aneurysm of the internal carotid artery occurred in a 16-year-old male following facial impact in an automobile accident. The patient showed no neurologic deficit until two days after the automobile accident, when he suddenly started having seizures and developed right-sided hemiparesis. There was no evidence of direct trauma to the neck externally or internally. The only injuries observed in the head and face were two skin lacerations in the chin area. His condition rapidly deteriorated, and he expired on the fourth hospital day. The gross and microscopic findings for the internal carotid artery are presented. The possible mechanisms for the vascular lesion and a review of the literature are discussed.     

Suicide by a circular saw

The case of a suicide of a 32-year-old female using an electric circular saw is herein described. The decedent was suffering from depression and was found dead in her room. Beside her right hand was lying a circular saw, which was not running. The autopsy revealed a large gaping wound measuring 15.5 cm in length on the right side of her neck. The right external carotid artery, the right internal jugular vein, and the right internal carotid artery were cut and the injury reached to the cervical vertebra. Therefore, the cause of death was exsanguination. An individual who commits suicide with an electric saw, such as a chain saw, band saw, and circular saw is rare; in particular females rarely select this method as the means of suicide. However, we herein report the case of a female patient with a psychiatric disease who successfully committed suicide with a circular saw.     

Fatal paradoxical air embolism diagnosed by postmortem imaging and autopsy

The recognition and visualization of an arterial gas embolism are difficult. We report a case of sudden death caused by paradoxical air embolism of coronary and cerebral arteries, diagnosed by the pre autopsy computed tomography (CT) scanning. A 54-year-old woman suddenly died after the self-removal of the jugular vein catheter. Postmortem imaging examination using CT scanning showed multiple gas embolisms in the cerebral arteries, pulmonary artery, right atrium and ventricle, left ventricle, aorta, and coronary arteries. These findings suggested that the occurrence of acute ischemia of the brain and heart caused by massive air inflow to the artery. Conventional autopsy revealed a patent foramen ovale of the heart. These results indicated that the patient died of paradoxical air embolization of the coronary and cerebral arteries through a patent foramen ovale because of right-to-left shunting. The use of postmortem imaging as an aid for conventional autopsy has proved to be of advantage in the case of gas embolism.