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.     

Traumatic subarachnoid hemorrhage and extracranial vertebral artery injury: a case report and review of the literature

The case is presented of a 19-year-old man who was assaulted and died shortly afterward from a large traumatic basal subarachnoid hemorrhage (TBSAH) that arose from rupture of the left vertebral artery, proximal to the point at which the artery penetrated the dura. The literature regarding TBSAH and vertebral artery rupture is reviewed, and a number of points are highlighted: patients with TBSAH may remain conscious for a period of hours after injury, subcutaneous or muscular bruising may be contralateral to the ruptured vessel, fractures of the transverse processes of the cervical vertebrae and significant pathology of the vertebral artery are not typically associated with TBSAH, and rupture of the vertebral artery may be intracranial, junctional, or extracranial.     

Traumatic rupture of intracranial vertebral artery due to hyperextension of the head: reports on three cases

In three cases of fatal basal subarachnoid hemorrhage due to rupture of the normal intracranial vertebral artery, the ruptures appeared to have been caused by overstretching of the vertebral artery from traumatic hyperextension of the head. In the first case, that of a 31-year-old male pedestrian who, while intoxicated, had been hit from behind by a car, symmetrically located bilateral complete and incomplete tearing of the vertebral arteries was found. In both of the other two cases, involving women aged 37 and 51 found dead after receiving fist blows to the face while intoxicated, complete rupture of the vertebral artery was found. The blood alcohol concentrations of the three cases ranged from 1.6 to 1.7 mg/g at autopsy.     

Injury of the vertebral artery in suicidal hanging

The vertebral artery was investigated in suicidal hanging for specific forensic, but also general traumatological reasons. The objective was to establish the extent to which the vertebral artery in its relatively protected position is injured at all and if so, in what form. For this purpose, cervical spine preparations with the posterior space of the skull were fixed in formalin and detached in the sagittal plane in 36 unselected cases of suicidal hanging after angiographic visualization of the vertebral artery. Afterwards, both vertebral arteries were visualized, and vascular injuries were compared with injuries of the soft tissues of the neck, of the cervical spine, and of the external types of hanging. The vertebral artery was shown to be injured quite frequently (rupture, intimal tear, sub-intimal hemorrhage), namely in one quarter of all cases, and indeed in more than half taking into account the perivascular bleeding. In this way, frequencies were found which were far in excess of those of the common carotid artery. The different mechanical behavior of these two paired neck arteries in traction are dealt with and the form of injury explained.     

A proposed dissection procedure for vertebral arteries in forensic pathology

Vertebral artery removing constitutes a significant forensic pathology challenge. Dissection techniques during head-neck autopsy are based on anterior approach, a difficult method, which is unable to assess the transverse part of the artery. This work presents an original and simple method for dissecting vertebral arteries by a posterior approach, opening the vertebroarterial canal through the spinal canal without any special equipment. Once the spinal cord is removed, the transversarium foramens are opened by an internal cut at the pedicle and an external cut at the transverse process. This enables us to visualize vertebral arteries in its entirety. The method improves both the examination of the upper extracranial segment of the vertebral artery and the neuropathological study when arterial injury is suspected. Applying this method routinely is both feasible and useful in suspected cases of vertebral artery trauma and could contribute to assess more precisely the actual incidence of this injury.     

Periadventitial extracranial vertebral artery hemorrhage in a case of shaken baby syndrome

We report a case of a two-month-old boy who became unresponsive in the sole custody of his father. Resuscitation efforts on route to the hospital were able to restore the infant's heart beat. However, neurologic function never recovered. Autopsy revealed massive cerebral edema, recent subdural, and subarachnoid hemorrhages, bilateral retinal hemorrhages, and cervical spine ligament hemorrhages. Separation of individual cervical vertebrae showed extensive, bilateral, periadventitial vertebral artery hemorrhages between C1 and C4, with corresponding luminal compression of the vertebral arteries. The importance of this previously unreported phenomena of periadventitial vertebral artery hemorrhage in the setting of shaken baby syndrome is discussed.     

Death from spontaneous coronary artery dissection in a healthy postmenopausal woman

Spontaneous dissection of the coronary arteries, in the absence of trauma, is an unusual but well-documented entity that occurs usually in middle-aged women. It is a rare cause of sudden death and myocardial infarction. Coronary eosinophilic arteritis is suggested to result in a predisposition to intimal disruption and dissection. We present the case of the sudden death of a previous healthy, 53-year-old postmenopausal female, while working, in a town of Thessalia in Greece. The cause of death was left anterior descending coronary dissection with histologic findings of eosinophilic arteritis and autoimmune thyroiditis.     

Morphometric studies of the vertebral artery in infants and small children

The internal circumference of the vertebral artery and the cross-sectional area of its tunica media were measured planimetrically at three different topographical sites in 48 cases of sudden infant death syndrome (SIDS) and 18 reference cases. Based on preliminary determination of the error of measurement, both groups studied showed significant differences between sides. As the degree of differences is often marked, impressive haemodynamic consequences can be expected. The findings are discussed with regard to SIDS.     

A gastric artery aneurysm complicated by a dissection of gastric and hepatic arteries: possible role of adventitial inflammation and disruption of internal elastic lamina in splanchnic artery dissection

A 77-year-old woman was found deceased at home. An autopsy examination revealed a hemoperitoneum due to a ruptured false aneurysm of a branch of the left gastric artery. A long dissection extending from the aneurysm involved splanchnic arteries including the left gastric, common hepatic, right and left branches of proper hepatic, and intrahepatic arteries. An intimal tear was identified in the common hepatic artery. Neutrophils infiltrating in the adventitia may have been reactive and may have triggered the adventitial rupture of aneurysm or development of the dissection. Disruption of the internal elastic lamina, which has been proposed to cause dissection of intracranial arteries, was seen in the dissected arteries. Little is currently known about aneurysms or dissections of splanchnic arteries; however, observation of adventitial inflammation and internal elastic lamina may help disclose the etiology and pathogenesis.     

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.     

Spontaneous dissection of the distal obtuse marginal coronary artery: a rare cause of sudden death

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction and sudden death. It typically, but not always, occurs in healthy postpartum women without traditional risk factors for atherosclerosis. Moreover, the site of dissection usually involves the proximal, major coronary arteries: left main coronary artery and/or the left anterior descending artery, and in men, more often the right coronary artery. We report a case of sudden death caused by dissection of the obtuse marginal branch of the left circumflex artery, in a 49-year-old man, a very rare site of fatal coronary dissection.     

Carotid and vertebral artery circulation in forearm choke holds in Doppler sonography

By means of continuous wave doppler the effect of two choke holds (Carotid sleeper, Nami-juji-jime) on the carotid and vertebral arteries was investigated. For both choke holds, which are characterized by pressure on lateral parts of the neck, we found an obstruction up to a complete stop of flow. The degree of obstruction depended on the direction of force. The vertebral artery can be compressed between the subclavian artery and the foramina transversaria, therefore it was most effective to press on the lower neck. Tensing the neck muscles can reduce the effect of choking.     

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.     

A biomechanical study of the human vertebral artery with implications for fatal arterial injury

We studied the biomechanical behaviour of ring and strip specimens from along the length of 18 vertebral arteries taken from 16 subjects aged 28-90 years, in order to consider some of the factors which may play a role in vertebral artery rupture. The method was chosen to allow a comparison between circumferential distension (ring samples) and longitudinal extension, (strip samples). The samples were extended between the jaws of a tensile testing apparatus until the specimen broke and a number of biomechanical parameters were derived. These were the percentage extension to break, the tensile strength, Young's modulus and the peak load. There were a number of important findings. The vertebral artery was shown to be susceptible to longitudinal stretching with a number of strip samples breaking when extended by as little as 16-20%. The tensile strength and load at peak of the strip specimens were correspondingly lower than for the ring samples. Marked intersubject variations were shown for all these parameters and prominent changes in behaviour occurred along the vertebral artery. This study indicates that the artery may be susceptible to head and neck movements which cause the vessel to stretch, and intersubject variations in behaviour may be one important explanation for the marked differences in outcome which appear to exist in subjects who suffer broadly similar head and neck insults.     

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.     

Transmesenteric hernia due to double-loop formation in the small intestine: a fatal case involving a toddler

We report a unique case of transmesenteric hernia resulting in death, which went undiagnosed during a recent hospital visit. The victim was a 2.5-year-old girl who - with the exception of chronic constipation - had no medical history. One night she complained of abdominal pains and was taken to a pediatric hospital where doctors performed an abdominal X-ray and echography. No significant findings suggesting bowel obstruction (e.g. air-fluid levels or dilation of the bowel) were obtained on examinations and bloody feces were not observed in this particular episode. As her abdominal pain gradually attenuated, the doctor allowed her to return home. A few hours later, she lost consciousness and expired despite resuscitation efforts attempted at an emergency hospital. A subsequent autopsy revealed that the small bowel had herniated through a defect in the mesentery resulting in two consecutive and inversely forming loops, in which each loop protruded on either side of the mesentery. This rare morphological anatomy seems to have progressed in a two-step process. The girl's mild abdominal pain was likely induced by herniation and formation of the first intestinal loop, followed by severe shock occurring when the subsequent intestinal segment invaginated into the same defect forming the second loop on the opposite side of the mesentery. This case illustrates the difficulty of diagnosing transmesenteric hernia due to the presentation of unspecific symptoms; especially in infants and toddlers. Furthermore, this report demonstrates the value of a complete autopsy in cases of sudden and unexpected deaths involving children.     

Traumatic rupture of the basilar artery: report of two cases and review of the literature

Two cases of traumatic rupture of the basilar artery are reported. In the first case, severe basal subarachnoid hemorrhage (SAH) due to a complete transverse tear of the basilar artery was observed in a 53-year-old restrained male driver who was involved in a head-on collision while intoxicated and drowsy. He lost consciousness shortly after the accident and was admitted to hospital in cardiopulmonary arrest. Intensive resuscitative therapies produced cardiac response, but he died 50 minutes after the accident. The ethanol concentration in his blood and urine was 0.35 and 0.55 mg/ml, respectively. In the second case, SAH due to a similar tear of the basilar artery was observed in a 47-year-old man who received several fist blows to the face while intoxicated. He suddenly lost consciousness after the final blow and was admitted to hospital in cardiopulmonary arrest. Intensive resuscitative therapies produced cardiac response, but he died 6 hours after the event. In these cases, the mechanism of the traumatic rupture of the basilar artery is thought to be overstretching due to hyperextension of the head, and intoxication, drowsiness, or both may have interfered with the decedents' ability to protect themselves; thus, the hyperextension of the head may have been rather forceful.     

"Spontaneous" coronary artery dissection. The challenge of detection, the enigma of cause

Sudden death secondary to acute dissection of a coronary artery is a rare, but increasingly recognized, cause of sudden, unexpected death in apparently healthy persons. It has been reported more frequently in women and has been associated with sudden death during the puerperium. It has also been reported that these involved coronary vessels contain increased numbers of eosinophils and often show areas of cystic medial necrosis. In this article, we report a case of sudden death in a 47-year-old white woman due to dissection of the distal segment of her left anterior descending coronary artery. There was marked involvement of the coronary arterial walls with cystic degeneration of the media with accumulation of glycosaminoglycans as demonstrated by Alcian blue staining. There was no eosinophilic infiltrate within the arterial walls. This case is unusual in that this woman's mother and brother both have had aneurysms, which stresses the importance of not only searching carefully for these lesions, but also of obtaining family history in such cases.