Rupture of a giant splenic artery aneurysm. Report of an autopsy case.

We describe an autopsy case of a 61-year-old woman with von Recklinghausen's disease, who died suddenly following intraperitoneal hemorrhage due to the rupture of a giant splenic artery aneurysm. The aneurysm measured 16 x 13 x 5.5 cm--much larger than those in most previous reports. The pancreatic body, which was pressed by the aneurysm, was widely atrophic. In general, splenic artery aneurysms are more frequent in pregnant women or patients with portal hypertension. The pathogenesis of this aneurysm is presumed to be arterial dysplasia, focal arterial inflammation, or portal hypertension, unlike other aneurysms due to arteriosclerosis or syphilis. Since the patient had not been pregnant and had not had liver cirrhosis or arteriosclerosis, the pathogenic factor could not be determined in this case. The relationship between the genesis of the aneurysm and von Recklinghausen's disease was not clear either.     

Sudden and unexpected death resulting from splenic artery aneurysm rupture: two case reports of pregnancy-related fatal rupture of splenic artery aneurysm

Rupture of a splenic artery aneurysm is a rare and usually catastrophic event, most commonly associated with pregnancy. In spite of increasingly common reliance on abdominal angiography, magnetic resonance imaging, and computerized tomography during the past quarter century, clinicians uncommonly recognize any of the various splanchnic arterial aneurysms absent premonitory signs or symptoms. Accordingly, rupture of a visceral aneurysm, including splenic artery aneurysm, typically presents as sudden, unexpected obtundation or death. As a consequence, the initial recognition and diagnosis of splenic artery aneurysm rupture take place only at autopsy. This report presents two such cases of sudden death resulting from splenic artery aneurysm in a pregnant woman and a postpartum woman, respectively.     

Sudden, unexpected death due to splenic artery aneurysm rupture

Splenic artery aneurysms are an uncommon form of vascular disease that have a significant potential for rupture, resulting in life-threatening intraperitoneal hemorrhage. We describe the case of a 33-year-old man who died suddenly and unexpectedly due to the rupture of a splenic artery aneurysm. At medicolegal autopsy, 3000 mL of fluid blood were recovered from the peritoneal cavity. The source of bleeding was a sack-like aneurysm of the splenic artery, measuring 2 cm in diameter. Histologic examination of the splenic artery aneurysm revealed fibromuscular dysplasia. No atherosclerotic lesions or any inflammatory changes were apparent within the wall of the splenic artery. Portal hypertension and pancreatitis, previously described as important factors promoting splenic artery aneurysm formation, were excluded by autopsy and histology. From the forensic pathologist's viewpoint, this rare case underlines the importance of splenic artery aneurysm rupture as a relevant differential diagnosis of intraperitoneal hemorrhage and sudden death, respectively, since such cases may be misinterpreted as a result of blunt-force trauma.     

Fatal hemothorax from mycotic celiac artery aneurysm.

We present two cases of ruptured mycotic aneurysms infected with Staphylococcus aureus. Each patient had hemoptysis and in each case there was hemothorax caused by a ruptured mycotic aneurysm of the celiac artery. In case 1, the pathogenesis was transient Staphylococcus aureus septicemia infecting an atherosclerotic plaque with subsequent aneurysm formation and rupture. In case 2, the septicemia arose from an infected knee. The presentation of a celiac artery aneurysm as hemoptysis and as the cause of hemothorax is rare.     

Homicidal cerebral artery aneurysm rupture

When a normally natural mechanism of death is induced by physical injury or intense emotional stress, it is appropriate to rule the manner of death as something other than natural. When the case-specific circumstances are such that the death occurs as a result of the criminal activity of another person, it is acceptable to rule such deaths as homicides. Presented herein is a case of homicidal cerebral artery aneurysm rupture occuring in an intoxicated, 46-year-old man who was punched in the face by another individual. The details of the case are presented, followed by a discussion of the controversies that exist when dealing with such cases. Guidelines for investigating similar deaths are presented, with emphasis on the timing of the trauma in relation to onset of symptoms due to aneurysm rupture.     

Dissecting aneurysm of the hepatic artery

Aneurysms of the hepatic artery are rare and frequently diagnosed only at autopsy. First described by Wilson over 250 years ago, less than 400 cases have been reported in the literature (1,2). Dissection of these aneurysms is documented even less frequently, with only 11 cases reported in a review by Larson et al. (3). A case of sudden death from dissection and rupture of such an aneurysm was seen at the Westchester County Medical Examiner's Office, New York.     

Rupture of the major artery in incomplete desmogenesis

A pathomorphological examination of a congenital disease - incomplete desmogenesis (ID) - was made in 5 women aged 19-34 years. They had spontaneous ruptures of the major arteries (subclavial, brachial, splenic, gastric). Microscopically, the wall of the ruptured artery contained no or minimal collagenic structures which looked homogeously, like a mixomatous edema. Content of acid mucopolysaccharides and hyperelastoses was elevated. The rupture was provoked by infections, additional loads, such as pregnancy, etc. Vascular surgery in ID is difficult as arteries often break at suturing while vascular walls are amputated at ligation. In one patient tamponade stopped hemorrhage and saved her.     

Diagnostic postmortem angiography of fatal splenic artery haemorrhage

The site of fatal haemorrhage from the splenic artery, caused in one case by a ruptured aneurysm and in another case by an intracystic haemorrhage of a postoperative pancreatic pseudocyst, was revealed by postmortem angiography. Radiopaque silicone rubber vulcanizing at room temperature was used as contrast medium. In the latter case, the dissection was seriously hampered by tight postoperative intestinal adhesions following four abdominal operations to control bleeding into the gastrointestinal tract. The results indicate the usefulness of postmortem angiography with contrast medium vulcanizing at room temperature for postmortem diagnosis of rare causes of gastrointestinal haemorrhage.     

Rupture of the spleen or splenic vessels (splenic emergency syndrome) in late pregnancy: a report of two autopsy cases

During the years 2004-2006, seven divers, who had deadly accidents, underwent post-mortem examination at the Institute of Legal Medicine of the University of Munich. The cause of death in all divers was drowning with typical pathomorphological findings. This should be regarded as separated to the triggering reason for drowning. The trigger for accident was established in four of seven cases by technical analysis and police investigation. High risk-taking, lack of technical service, and deficiency of dive equipment care were main reasons for death. We present two of these cases which showed several problems occurring concurrently. Autopsy always is necessary to look for indices for application of force or to exclude competitive reasons for death.     

Sudden death in an infant caused by rupture of a basilar artery aneurysm.

Ruptured aneurysms of the cerebrovasculature in infancy and early childhood, except for "giant" aneurysms and arteriovenous malformations, are rare. Seizures, loss of consciousness, and apnea are the usual presenting signs in infancy; symptoms such as headache or visual disturbances and signs such as cranial nerve compression or meningeal irritation commonly found in older children or adults are absent in infants. However, the morphologic findings (i.e., subarachnoid and retinal hemorrhage, and occasionally subdural hemorrhage) may be mistaken for inflicted trauma, especially if the aneurysm is not identified. Sudden death caused by rupture of a cerebral aneurysm has not been previously described in an infant. This report outlines the investigation and autopsy findings in a 7-month-old infant who died unexpectedly as a result of rupture of a complex basilar artery aneurysm.     

Sudden death due to ruptured pancreaticoduodenal artery aneurysm

Superior pancreaticoduodenal artery aneurysms are rare; their rupture often leads to sudden death. We report a case of a 59-year-old hypertensive man who died of a massive retroperitoneal hemorrhage following rupture of an aneurysm of the superior pancreaticoduodenal artery. We also discuss this unusual vascular lesion and review the pertinent literature.     

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.     

Dissecting coronary artery aneurysm: a report of two cases

Two cases of sudden, unexpected death resulting from coronary artery dissection have been reported. Since sudden and unexpected death falls within medical examiners' jurisdiction, the systematic autopsy examination of such cases offers an opportunity to evaluate this entity as well as other rare causes of natural death. A review of the literature concerning the subject has been presented.     

Sudden unexpected death due to atherosclerotic coronary artery aneurysm

The case of a 34-year-old white male who died suddenly and unexpectedly of a thrombosed coronary artery aneurysm is presented. Coronary artery aneurysms have a prevalence of approximately 2%; over half of these are caused by atherosclerosis with the remainder due to syphilis, infections, trauma, congenital malformations, vasculitis, neoplasms, and connective tissue disorders (Ehlers-Danlos and Marfan's syndromes). Replacement of the media by atherosclerotic debris is the cause of atherosclerotic aneurysms. Complications include rupture and thrombosis. Sudden death has been reported in eight other cases of atherosclerotic aneurysms; sudden unexpected death as the presenting symptom of atherosclerotic coronary artery aneurysm, as in our case, is rare.     

Death related to coronary artery fistula after rupture of an aneurysm to the coronary sinus.

Large coronary fistulas are considered to cause myocardial ischemia due to diversion of the coronary blood flow. In this case the authors report the reverse effect--the spontaneous closure of a large fistulation between the left circumflex artery and the coronary sinus evoked angina pectoris in a middle aged man, who died several years later. Postmortem examination revealed a coronary aneurysm that had ruptured and dissected into the coronary sinus and finally thrombosed. The origin of the aneurysm could be congenital but perhaps also represents a healed stage of Kawasaki disease.     

Death resulting from ruptured cerebral artery aneurysm: 219 cases

To characterize the demographics of ruptured cerebral artery aneurysm as a cause of death and to examine the effect of improved diagnostic and therapeutic techniques on the incidence of sudden death associated with the condition, the authors reviewed 219 autopsies performed at the Dallas County Medical Examiner's Office between 1977 and 1997 in which the cause of death was ruptured cerebral artery aneurysm. Ruptured cerebral artery aneurysms accounted for 1.5% of 15,033 natural deaths and 0.4% of all deaths (45,492) followed by autopsy during this period. The majority (56%) of cases occurred in females, with Caucasian females composing the largest group (38%). Seventy-seven percent of cases occurred in individuals between the ages of 31 and 70 years, with the highest concentration in the 41- to 50-year decade (29%). The most common location for ruptured aneurysms was the middle cerebral artery distribution (39%). Multiple aneurysms occurred in 22 (9.1%) cases. Other factors, such as medical history, coexisting disease, symptoms, activity at onset of symptoms, survival time, and toxicology results are also presented. Compared with literature reports before 1980, when ruptured cerebral artery aneurysms were reported as the cause of death in approximately 4% to 5% of sudden natural deaths, the results of this study suggest that despite improved diagnostic and therapeutic techniques during the past two decades, morbidity and mortality from ruptured aneurysms remain a significant health problem.     

Rapidly growing internal carotid artery aneurysm after amphetamine abuse: case report

Amphetamine is one of the most common illicitly abused drugs in certain countries. It is a potent sympathomimetic that may lead to vascular events, including stroke and myocardial infarction. Most reports of stroke after amphetamine abuse are of intracerebral hemorrhage. In this report, the authors describe a ruptured aneurysm of the right internal carotid artery in a young man with amphetamine abuse. It grew rapidly within 2 weeks. Surgery revealed fibrosis and fibrinoid necrosis around the aneurysm. The aneurysm was successfully embolized with Guglielmi detachable coil. A rapidly growing aneurysm in the major intracranial vessels resulting from amphetamine abuse is very rare.     

Sudden death in an infant caused by rupture of a basilar artery aneurysm

Ruptured aneurysms of the cerebrovasculature in infancy and early childhood, except for "giant" aneurysms and arteriovenous malformations, are rare. Seizures, loss of consciousness, and apnea are the usual presenting signs in infancy; symptoms such as headache or visual disturbances and signs such as cranial nerve compression or meningeal irritation commonly found in older children or adults are absent in infants. However, the morphologic findings (i.e., subarachnoid and retinal hemorrhage, and occasionally subdural hemorrhage) may be mistaken for inflicted trauma, especially if the aneurysm is not identified. Sudden death caused by rupture of a cerebral aneurysm has not been previously described in an infant. This report outlines the investigation and autopsy findings in a 7-month-old infant who died unexpectedly as a result of rupture of a complex basilar artery aneurysm.     

Strategies of Rupture

The paper is an exploration in critical legal theory, and argues for a return to thinking of critical legal intervention in political-strategic terms. If the insistence is on strategies of rupture it is because the attention is on what registers as resistant, neither reducible to—nor co-optable by—the order it seeks to resist. It is argued that if law is to offer redress to injustice it has to offer terms that can break incongruently, irreducibly so, with the order of capital, and its economy of representation, not couching critique within its terms, taking flight into the mysticism and escapism of the ‘ethical turn’, or entrusting critique unconditionally to the deconstructive energies of the law. The paper explores how difficult the task facing critical legal theory is in view of law’s power of ‘homology’ and its ‘mechanisms of deadlock’. Both within the courtroom (the focus here is on the tactics of rupture of the lawyer Vergès) and outside it, a return to a strategic understanding of law underlies its deployment as means of critique (‘simple’ or ‘immanent’) or object of confrontation rather than horizon of communicative exchange.