Giant berry aneurysms in a forensic setting: a series of 14 cases

This is a series reviewing 14 cases of giant saccular aneurysms diagnosed at the Office of the Chief Medical Examiner of New York City collected over an 11-year period. Data collected on all 14 cases included neuropathological findings, comorbidities, and toxicological findings. Of these 14 cases, 8 were in women, and the ages ranged from 3 to 79 years, with a mean and a median of 50 years. Women were overrepresented in the sixth through eighth decades. Of the 14 cases described, 11 presented with a subarachnoid hemorrhage; 3, no hemorrhage; 2, subdural hemorrhage; 8, intraventricular hemorrhage; 2, intracerebral hemorrhage; and 8, more than 1 hemorrhage type. Location of the aneurysms varied with 6 in the left side of the brain, 6 present in the right side of the brain, and 2 at the midline. We described the clinical, pathological, and toxicological findings associated with these giant aneurysms.     

Post-traumatic left ventricular false aneurysm

Most false aneurysms of the heart represent contained ventricular free wall ruptures after myocardial infarction. Post-traumatic aneurysms also may follow penetrating or non-penetrating trauma to the chest. Regardless of the origin of the false aneurysm there is a propensity for aneurysm rupture. We report a patient who developed a false aneurysm of her left ventricle that developed post-motor vehicle accident. Her orthopedic problems were the clinical problems identified and after a hospital admission of 10 days she was discharged home. Four weeks later she died suddenly from anterior left ventricle false aneurysm rupture and tamponaide. Patients with significant chest wall trauma should be assessed for cardiac pathology prior to discharge. Presentation may be delayed and be overshadowed by more evident pathology. Trauma-related aneurysms may cause sudden death, and this may occur some later time after the trauma. Attributing the cause of death to the trauma, which may be remote, is important for the forensic investigator to remember.     

Sudden death associated with a cardiac diverticulum.

We describe the unusual case of a 20-year-old Aboriginal man who was admitted to hospital with chest pain. He died 1 day later. Necropsy showed extensive anterior myocardial infarction in the left ventricle. An isolated diverticulum arising from the subaortic valve region of the left ventricle had compressed the left main coronary artery.     

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.     

Arrhythmogenesis and diagnosis of cardiac sarcoidosis. An immunohistochemical study in a sudden cardiac death

We present an uncommon case of sudden cardiac death in a 34-year-old white woman. She was found lifeless at home by her parents. Three months before death she was recovered at the Emergency Room for chest pain, palpitation and loss of consciousness. Subsequent cardiological evaluation with ECG showed sinusal rhythm, QRS deviation to the left, QS aspect, asymmetric and rounded T waves and slight length of QT. During hospitalization she presented some episodes of supraventricular paroxysmal tachycardia and non-sustained ventricular tachycardia. No echocardiography alterations were found. An anti-arrhythmic treatment was prescribed. Autopsy revealed some fibrotic scarring in the myocardium of left ventricle. The histological examination of the heart revealed diffuse and extensive fibrosis with non-caseating sarcoid granulomas. The lungs, kidneys and lymph node also showed the same non-caseating granulomas. The diagnosis of sarcoidosis with massive and extensive cardiac involvement was established as cause of death.     

The relationship of closed-head trauma to rupture of saccular intracranial aneurysms

It is often asserted, especially in worker's compensation cases, that blunt trauma or work-related physical exertion can be responsible for the rupture of a preexisting saccular intracranial aneurysm. However, a critical review of the literature and extensive personal experience indicates no or at best a very weak relationship between blunt closed-head trauma and the rupture of a preexisting saccular intracranial aneurysm. This report is based on a 19-year study of the effects of trauma on aneurysms in a clinical and autopsy-derived population.     

Sudden death in an adolescent four years after recovery from mucocutaneous lymph node syndrome (Kawasaki disease)

A case is presented of sudden death during physical activity in a 15-year-old boy with clinically inactive mucocutaneous lymph node syndrome (Kawasaki disease). At autopsy, the coronary arteries were involved by multiple aneurysms and obstructive thrombi, and the left ventricular myocardium was extensively scarred. Although Kawasaki disease most commonly occurs in infants and young children, it may be a cause of sudden death in adolescents.     

Exsanguination by subclavian-esophageal fistula associated with a left subclavian aneurysm

Aortic aneurysms are a common autopsy finding, but aneurysms confined exclusively to the subclavian arteries are rare. When found, they are typically associated with trauma, surgery, or aberrant vessel distribution. Subclavian-esophageal fistula formation is also rare, with the vast majority being related to aberrant vessel distribution or esophageal foreign bodies. Dicle et al. first reported a subclavian-esophageal fistula associated with a non-aberrant subclavian artery aneurysm in 1999 (1). The following case would mark the second report of that phenomenon, and the first in the setting of a forensic autopsy.     

Singular case of shooting a football fan with a signal rocket

The authors present a very rare case of fatal injuries resulting from shooting a parachute signal rocket with a hand operated launcher of signal pistol kind by pseudo-football fans. A 16-year-old football fan sustained extensive thermal burn of his lower extremities and abdomen, lacerated wound of his left thigh with a deep signal rocket-shot canal which caused injuries in subcutaneous tissue, fascia and both medial and posterior muscles of the thigh as well as injured both femoral vein and artery with subsequent hemorrhagic, burn and traumatic shocks. In spite of specialistic surgical treatment, the victim was not rescued. Analysis of medical documentation and our autopsy results were supplemented with an expert's opinion on physicochemical examinations supported by photographic documentation.     

Coronary artery aneurysms in a young adult

Coronary artery aneurysms are an extremely rare cause of death at any age, but particularly so in young adults. A case is described of a young and previously fit man who died suddenly following thrombosis within one of multiple coronary artery aneurysms. He had had a childhood illness with symptoms consistent with an episode of unrecognized infantile polyarteritis nodosa. It is suggested that many cases of aneurysm of the coronary arteries in young adults, where atherosclerosis has been excluded, may in fact be due to previous polyarteritis, rather than of congenital origin as is usually claimed.     

Vital animal predation of the genital region caused by a mongrel dog

A 79-year-old man, who was in a helpless situation due to cardiac decompensation, suffered dog bite injuries on the left thigh and in the genital region while still alive. Two extensive soft-tissue defects with contused and bruised wound edges were surrounded by multiple slit-like skin lesions. The outer genitals were almost completely missing. Because of surgical emergency treatment, molecular biological investigations were no longer possible. Therefore, the cause of the bite injuries had to be determined solely on the basis of the documented morphology of the wounds.     

Perforating gunshot to the head with a power-actuated tool

The article describes a shortly survived suicide with a powder-actuated tool. A 51-year-old man shot all through his head from the right to the left temple. The pin produced an extensive area of destruction in the brain tissue, but neither in the hospital nor during the autopsy was any projectile found. Finally the pin was detected in a metal fitting of the bed in which the man had killed himself. The suicide instrument was a powder-actuated tool firing a metal pin after igniting a cartridge. Unlike a nail gun using compressed air, pins fired by means of a propellant reach a velocity of up to 150 m/s thus developing a higher destructive potential.     

Ruptured cerebral artery aneurysm and bacterial meningitis in a man with osteogenesis imperfecta

This report describes a 38-year-old man with osteogenesis imperfecta who died of a ruptured cerebral artery aneurysm and bacterial meningitis. He had multiple long bone fractures in the past, and approximately 4 months before death, he had surgery to relieve symptoms of basilar impression. The surgery was complicated by a postoperative wound infection. For the next 4 months, he had intermittent headaches and vomiting. He was found dead in his bed at home. At autopsy, he had a ruptured anterior communicating artery aneurysm and bacterial meningitis. Cerebrospinal fluid and blood cultures had growth of Staphylococcus aureus. Osteogenesis imperfecta is a disorder of type I collagen. Type I collagen is present in many tissues, including blood vessels. The etiology of cerebral artery aneurysm formation is multifactorial. Some patients with cerebral artery aneurysms have been shown to have abnormalities in type III collagen. There has not been a reported relationship made between abnormalities in type I collagen and aneurysms. Meningitis can also result in cerebral artery aneurysms, but they are usually due to Aspergillus or Mycobacterium species. The case we report is unique; cerebral artery aneurysm formation may have been due to osteogenesis imperfecta and/or bacterial meningitis.     

The forensic description of torn cerebral aneurysms

103 studies of torn aneurysms in the cerebral vessels are described. Localizations, morphological peculiarities of aneurysms as well as the nature of intracranial hemorrhages caused by torn aneurysms are presented. The authors have a critical attitude to the "acquired" theory of aneurysm development.     

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Multiple Giant Coronary Artery Aneurysms: A Rare Cause of Sudden Cardiac Death

Multiple giant aneurysms involving the coronary arteries are uncommon and rarely reported. In the presented case, a 63‐year‐old man with poorly controlled hypertension died suddenly. Gross autopsy examination showed multiple giant thrombus‐filled coronary artery aneurysms, atherosclerotic coronary artery disease, and cardiomegaly. Histological sections of the coronary aneurysms showed atherosclerotic changes with both organized and fresh thrombus. Giant coronary aneurysm is defined as a segmental enlargement of a coronary artery with a diameter exceeding 20 mm or more. The main etiology of this nebulous entity is attributed to atherosclerosis and inflammatory or inherited connective tissue disorders with the remainder being congenital, infectious, or idiopathic. Before its cataclysmic presentation, when ruptured or thrombosed, giant coronary aneurysm usually has a silent clinical course. Sudden death owing to giant multiple coronary aneurysms is rare and mandates careful classification of the aneurysms and prudent search for autoimmune‐mediated or genetically based factors for subsequent ancillary autopsy studies.     

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.     

Papillary fibroelastoma of the aortic valve: a sudden death case of coronary embolism with myocardial infarction

Papillary fibroelastoma is a rare benign tumor, occasionally causing angina or sudden death. We report an autopsy case of an aortic valve papillary fibroelastoma with coronary artery embolism. The patient was a 68-year-old Japanese man who had collapsed suddenly in his house. He was a heavy drinker and had a history of liver disease but no notable cardiac event. The autopsy revealed extensive transmural infarction of the inferior wall of the left and right cardiac ventricles. The distal portion of the right coronary artery (segment 4, NYHA) was completely occluded by tumor emboli of the fibroelastoma. At the site of closure of the aortic non-coronary cusp, there was a typical papillary fibroelastoma, which was considered to have originated the coronary embolization.     

Autoamputation of the left arm--a bizarre suicide

A 24-year-old woman committed suicide by amputating her left arm immediately below the shoulder joint with a small kitchen knife. No references to such a suicide were found in an extensive literature search.     

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.