The narrow spinal canal - medicolegal aspects (author's transl)]

The constitutional anomayl of a narrow spinal canal was found in a neuroradiological department in 31 cases. The cervical stenosis can be defined in the following way: Inside diameter of cervical canal (anterior-posterior) in relation to diameter of vertebral body. In normal cases the quotient is over 1 - in pathological narrowing under 1. Clinical symptoms mainly appear from 45th year onwards, when reactive-degenerative changes increase the space problem. In wiplash injuries or other adequate cervical trauma 7 cases were seen and described with acute incomplete tetraplegia or/and multilocular lesions of cervical roots, resulting from cervical stenosis combined with degenerative changes in 6 patients. Myelography revealed multilocular deformities of the spinal subarachnoidal space in the abnormal narrow cervical canal. The referred cases were not complicated with forensic aspects. The prognosis quod sanationem was poor. A chronic cervical myelopathy results. Pretraumatic clinical alterations of cervical roots and/or the myelon in the referred cases were absent, existing in other patients. Predominantly men and hard working people with narrow cervical canal became ill. Early symptoms were pain in extremities. Dysesthesia and loss of sensation combined with signs of pyramidal lesion occured later. Defects in nerve roots sometimes overlayed the myelon symptoms. Unspecific CSF-Alterations were common. The EMG showed abnormalities in cases of root involvement. Operative treatment was tried to remove the reactive processes, but could not alter the constitutional anomaly. The resulting immobilisation of myelon and nerve roots involves in the case of trauma a direct mechanical lesion and secondary vascular complications via Arteria vertebralis, spinalis anterior and radicularis, namely in patients with degenerative alterations of the cervical spine, these including a further narrowing behind the constitutional anomaly. Our experience seems to recommend that more attention should be paid a cervical narrow spinal canal in medicolegal implications.     

Retropharyngeal Hematoma Secondary to Cervical Spine Surgery: Report of One Fatal Case

A 53‐year‐old woman suffering from radicular pain due to cervical herniation underwent a spinal surgery consisting of anterior cervical discectomy and fusion with an implantable titanium cage. Five hours after the procedure, the patient developed cervical swelling and dyspnea. An emergency surgery permitted evacuation of a deep cervical hematoma and intubation of the patient, who died some minutes later. The family of the deceased lodged a complaint with the public prosecutor because of unclear circumstances of death. After analysis of the medical records by two forensic pathologists, a medicolegal autopsy was ordered. Massive retropharyngeal and mediastinal hematomas were diagnosed. Pathological study confirmed acute cervical hemorrhage, but failed to detect the source of bleeding. The forensic pathologists concluded that death was due to mechanical asphyxia secondary to pharyngeal compression by the cervical hematoma. To the best of our knowledge, death secondary to retropharyngeal hematoma in this neurosurgical context is rarely encountered.     

An unusual case of sudden unexpected death: postmortem investigation and biomechanical analysis of the cervical spine

A naked man died under peculiar circumstances and the postmortem examination revealed unexpected lesions in the cervical spine. Investigations of the cervical spine (computed tomography, magnetic resonance imaging, and histological examination) showed that a piece of bone was torn of the anterior part of vertebra C6 and that there was fresh bleeding in the surrounding tissue. The cause of death remained unclear but was most likely cardiac arrhythmia initiated by beta-2 agonist inhalation due to an acute asthmatic attack. Data from biomechanical investigation using finite element analysis supported the conclusion that the cervical spine injury was secondary to impact during falling as a consequence of the cardiac arrhythmia.     

Fatal high cervical spinal cord injury in an automobile accident complicating os odontoideum

We report a case where spinal instability from incomplete fusion of the dens of C2 (os odontoideum) allowed anterior displacement of the skull and first cervical vertebra following right frontal impact against the A pillar in an automobile accident. Resultant crushing and laceration of the spinal cord occurred at the level of C1 and C2. Without either radiographic investigation or detailed examination of the spine, the fatal injury might have been overlooked and death attributed to acute alcoholic poisoning because the blood alcohol level was .613%.     

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.     

Spontaneous Coronary Artery Dissection: Case Report and Literature Review

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction and sudden cardiac death. It occurs most commonly in otherwise healthy women during pregnancy or the postpartum period. The true incidence of SCAD is underestimated, as most cases are diagnosed at autopsy. The pathophysiology of SCAD is still not fully understood, and its management can be challenging. This report describes a 35‐year‐old pregnant female who presented with an acute antero‐lateral ST elevation secondary to spontaneous dissection of the left anterior descending artery and the circumflex artery. The diagnosis was established by coronary artery angiography. However, the patient died following cardiac tamponade. The examination of this case represented a starting point for the reviewing of the diagnosis, clinical course, and management of SCAD, and for the placing of this in context with the existing literature. This study highlights the importance of prompt diagnosis and subsequent lifesaving treatment.     

多层螺旋CT冠状动脉钙化积分在评价冠心病猝死中的应用

目的通过运用多层螺旋CT（multi—slicespiralcomputedtomography,MSCT）冠状动脉钙化积分（coronaryarterycalciumscoring．CACS）的方法．评价其在冠心痛（coronaryarterydisease,CAD）猝死案例中的法医学应用价值,为虚拟解剖鉴定CAD猝死探索有效手段。方法收集9例进行法医学鉴定的心源性猝死案例．尸体解剖前均进行MSCT扫描。通过Agatston’s法对每例冠状动脉钙化程度进行定量分析,并计算CACS,钙化积分〉400作为存在CAD的评判标准,并与尸体解剖结果比较。结果经尸体解剖证实CAD猝死的9例案例中仅有2例钙化积分〉400,CACS对CAD的预测率仅为22．2％。MSCT检查与系统尸体解剖均发现CAD猝死案例中普遍存在不同程度肺水肿改变,冠状动脉左前降支较其他分支发生管腔狭窄的发病率高。结论运用MSCT并结合计算CACS可对CAD猝死案例中冠状动脉钙化明显的进行检测,而钙化不明显的需要辅以如尸体血管造影等其他技术。     

Sudden Unexpected Death Due to Left Subclavian Artery‐esophageal Fistula Caused by Fish Bone

A 53‐year‐old woman was admitted to the hospital due to unexpected dizziness and died the following morning. To investigate the cause of death, a forensic autopsy along with histological examination was performed 3 days after her death. The major findings of the autopsy were that a fish bone had pierced the left subclavian artery after perforating the esophagus with 680 mL of blood in the stomach and bloody and tarry contents were present in the intestines, and the cause of death was confirmed to be subsequent hemorrhagic shock. Unfortunately, none of her family realized that she had eaten a fish 4 days before the tragedy until the fish bone was found. The present case is rare and instructive. The histopathological findings of left subclavian artery‐esophageal fistula induced by a fish bone can be used as a reference in forensic practice.     

Death during percutaneous transluminal coronary angioplasty (PTCA) and the medicolegal aspects

Coronary embolisation is a very rare complication of the clinically widespread method of percutaneous transluminal coronary angioplasty (PTCA). The well-documented case of a 64-year-old male patient is presented comparing angiographic and morphological findings. The occluded left anterior descending artery (LAD) was successfully dilated during PTCA. Simultaneously the circumflex artery showed acute occlusion. The patient fell into cardiac shock and died after attempted resuscitation and agonal installation of extracorporeal circulation. The autopsy revealed severe residual stenosis of the proximal LAD by parietal thrombosis and occlusion of the proximal circumflex artery by an unattached intraluminal thrombus (0.8 x 0.3 x 0.2 cm) which had been dislocated during PTCA. Autopsy thus confirmed the clinical presumption of coronary embolism and, in addition, disclosed a previously unknown perforation of the femoral artery which had occurred during agonal installation of extracorporeal circulation and contributed to death via severe retroperitoneal hemorrhage. The case is discussed under the aspects of clinical quality control by forensic pathological investigations.     

Sudden unexpected death due to papillary fibroma of the aortic valve. Report of a case and review of the literature

The case of the sudden unexpected death of a 21-year-old man due to embolization of segments of an aortic valve papillary fibroma to the left main and anterior descending coronary artery is presented. The literature regarding cardiac papillary fibroma is reviewed with particular reference to those cases associated with sudden death.     

Dissecting Thoracic Aortic Hematoma Masquerading as Blunt Force Injury of the Neck

Discoloration of the skin of the anterior and lateral neck may raise suspicion for blunt force injury, particularly cervical compression, in an unwitnessed death. We present a case of an elderly woman with an unwitnessed death at home which highlights an external examination finding of blue/purple discoloration of the skin of the neck and links this finding with those from internal examination at autopsy. Pertinent negatives include absence of conjunctival and mucosal petechiae, absence of cutaneous abrasions of the neck, and absence of contusions of the anterior neck musculature. This case illustrates a natural disease entity, spontaneous dissection of a thoracic aortic hematoma, masquerading as blunt force injury externally and highlights the importance of having an appropriate index of suspicion when triaging jurisdictional cases for postmortem examination to accurately determine cause and manner of death.     

The importance of Simon's symptom in cases of hanging (author's transl)

Radiological and patho-anatomical investigations of the spines of 32 corpses of persons who had committed suicide by hanging revealed spine damage in 81% of the cases. The cervical spine was damaged in 69%, the lumbar spine in 56% of the cases. The typical damage of the cervical spine is a loosening of the discs at the dorsal side, usually at the level of C 4/5 to C 6/7. In the region of the lumbar spine, bleeding between the (anterior) ventral ligament and the discs is the most frequently observed damage (Simon's sy;mtpom). Simon bleeding is brought about by traction force and is not dependent on the age at death or on any existing degenerative changes of the spine.     

Extra- and intracranial injuries of the cerebral arteries as a sequela of assault

The case of an 47-year-old man is reported, who was injured in a fight while under the influence of alcohol. The culprit knocked him down and stamped several times on the left side of his head. The victim became unconscious. At the hospital, subarachnoid hemorrhage and massive ventricular bleeding was diagnosed via CT. Despite the implantation of a ventricular shunt, there was repeated massive cerebral pressure and arterial bleeding. Brain death occurred after 8 days. The main finding at autopsy was nearly complete disruption of the left inferior posterior cerebellar artery as the source of the lethal bleeding. The histological examination showed some additional, incomplete ruptures of this vessel and of the left intracranial vertebral artery. This is a typical result of "minor head injuries" sustained in fights: arterial rupture (ipsilateral) as a result of overstretching. Fracture of the left zygomatic arch and maxilla; no skull fracture; no primary traumatic brain damage. The extracranial carotid arteries were intact. When the vertebral arteries were examined (in the undamaged cervical spine), there was a surprising finding: distant dissection of the right vertebral artery between C1 and C2, which perhaps occurred as a result of compression (contralateral to the impact) of this region.     

Cardiac rupture due to severe fatty infiltration in the right ventricular wall

An extremely rare case of sudden death caused by cardiac rupture due to severe fatty infiltration in the right ventricular myocardium is presented. The patient, a 74-year-old woman, had no history of chest trauma, hypertension, or pulmonary disease. The autopsy showed a small tear in the right ventricle and cardiac tamponade, but no coronary artery lesion. In the right ventricular myocardium, muscle fibers were definitely atrophic or absent, with massive fatty replacement. Fatty infiltration of the myocardium, if severe, can be a cause of serious cardiac dysfunction or, occasionally, sudden death.     

Coronary thrombus and peracute myocardial infarction visualized by unenhanced postmortem MRI prior to autopsy

Sudden cardiac deaths are common within the community. They also constitute a substantial part of daily pathologic and forensic case work. However, macroscopic myocardial findings indicating acute ischemia are often absent. Then, diagnosis is based on coronary status in combination with indirect signs of acute cardiac failure. We present a case of sudden cardiac death where diagnosis was based on cardiac postmortem magnetic resonance imaging (pmMRI) findings already prior to autopsy: the heart's anterior basal ventricular septum showed hypointensities in T2-weighted images that raised suspicion of peracute ischemia. The lumen of the left anterior descending artery (LAD) exhibited a lack of otherwise discernible postmortem sedimentation of cellular blood components. Instead of a sharp border between serum and erythrocytes a homogeneous signal was seen within the narrowed lumen of the beginning LAD over a length of 1cm. Based on this, a thrombotic occlusion was assumed. Subsequent autopsy confirmed peracute septal myocardial ischemia secondary to a thrombotic occlusion of the LAD as concluded from the pmMRI.     

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.     

房室结纤维和脂肪增多与房室结动脉狭窄的关系

目的探讨房室结纤维、脂肪含量与房室结动脉狭窄之间的关系,分析房室结内病理性纤维化和病理性脂肪浸润的原因。方法选取119例心源性猝死案例,用Image-pro plus图像分析软件检测组织切片,计算房室结面积,房室结动脉内径、房室结动脉管腔面积(lumen area,LA)、外周横截面积(perimeterarea,PA),纤维组织面积和脂肪组织面积。将所有案例分为动脉狭窄组和正常对照组组,观察房室结动脉PA/LA值及房室结纤维及脂肪含量的改变。结果狭窄组房室结动脉PA/LA值在21～40岁最大,40岁以下两组房室结脂肪含量和总间质含量差异有统计学意义。结论房室结动脉狭窄与房室结间质含量增多有一定关系。     

A case of sudden death due to spontaneous coronary artery dissection

Spontaneous dissection of the coronary arteries is an extremely rare event that occurs usually in middle-aged women and is mostly recognized at postmortem examination in victims of sudden death. It is a rare coronary pathologic finding whose precise incidence, etiology, pathogenesis, treatment, and evolution have not been clearly established. We present a sudden death case of a 53-year-old woman with spontaneous dissection of the left anterior descending coronary artery with eosinophilic coronary arteritis.     

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.     

Sudden death in a neonate as a result of herpes simplex infection

This paper describes a case of a neonate with disseminated herpes simplex born to a 14-year-old asymptomatic mother. The infant's physical examination was normal at birth, and subsequent abnormalities were so subtle that infection was not recognized during life. Postmortem cultures of liver and spleen grew herpes simplex virus, and immunofluorescent direct antibody typing revealed Type 2. A cervical culture of the mother obtained after the infant's death was negative.