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.     

Traumatic basal subarachnoid hemorrhage. Report of six cases and review of the literature

Basal subarachnoid hemorrhage due to rupture of normal extra- and intracranial arteries, in association with minor trauma to the face and neck and alcohol intoxication, has been well described but often goes unrecognized at autopsy. This results in the incorrect classification of the manner of death as natural. Six cases of subarachnoid hemorrhage due to mild-to-moderate blows to the head or neck are presented. All were men in the age range 28-61 years (mean, 38.8 years). Four had blood alcohol levels of 0.09-0.28 g % at autopsy, and five of six were comatose or dead within 30 min of the initiating trauma. Traumatic ruptures of otherwise normal extra- and intracranial arteries were identified in four cases. The site of rupture was not found in one case, and the final case had rupture of a fibrotic intracranial vertebral artery. Multiple sites of incomplete and complete rupture were found in four cases. Postmortem angiography was used in one case to demonstrate the site of rupture prior to removal of the brain. Postmortem angiography and careful gross and histologic examination of extra- and intracranial cerebral arteries is recommended in all cases of basal subarachnoid hemorrhage where minor trauma to the head or neck has occurred prior to collapse or death, especially if the decedent was intoxicated at the time of the trauma.     

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.     

Traumatic venous aneurysm of the popliteal vein with outcome: a case report and review of the literature.

A case of sudden death due to recurrent pulmonary thromboembolism is described. The fatality took place three and a half weeks following blunt trauma to the left popliteal region. The patient died unexpectedly. Autopsy revealed the source of the emboli as a sacciform venous aneurysm of the popliteal vein, an entity seldom described, but important to consider in cases of soft tissue popliteal masses or unexplained pulmonary embolism, especially in otherwise healthy individuals.     

Sudden death due to dissecting pulmonary artery aneurysm: a case report and review of the literature

Pulmonary artery aneurysm and pulmonary artery dissection are rare antemortem diagnoses, most often associated with sudden death. These pathologic entities are strongly associated with chronic pulmonary hypertension due to structural cardiac defects, either congenital or acquired. We report the case of a 49-year-old woman who died suddenly due to dissection and rupture of a large pulmonary trunk aneurysm, with subsequent cardiac tamponade. Key historical and physical findings are described. Additionally, we present a discussion of the incidence, clinical presentation, pathogenesis, and pathologic diagnostic features of pulmonary artery dissection.     

Fatal subarachnoid hemorrhage during sexual anal self-stimulation in a female: a case report

Sudden death after sexual activity is a well-known entity, but it is rare in females. Herein we present a case of fatal, massive subarachnoid hemorrhage from a ruptured berry-shaped aneurysm, during sexual anal self-stimulation. A 39-year-old woman was found dead on a couch, with the wooden handle of a spring twirl whisk inserted inside her anus and rectum as a dildo-like object. External examination was unremarkable with no signs of injuries. Intracranial examination showed a massive subarachnoid hemorrhage, up to 6 mm in thickness, especially around the brainstem and the inferior side of the brain. After removing the blood clots, the saccular aneurysm was found at the site of the bifurcation of the left internal carotid. In this case study, we underline the utility of forensic autopsy, as well as death scene investigation, in reconstructing the mechanism of death, as well as the dynamics of the event.     

A case of Ludwig angina: a case report and review of the literature

Ludwig angina is a rapidly progressing submaxillary, submandibular, and sublingual necrotizing cellulitis of the floor of the mouth that can have lethal consequences due to airway obstruction. Various aerobic and anaerobic microorganisms, and less often fungi, have been implicated to cause Ludwig angina, including oral flora such as streptococci and staphylococci. Early recognition and the use of parenteral antibiotics can prevent mortality and morbidity. We report a case of a 25-year-old white man who was admitted to the hospital by his dentist after being diagnosed with Ludwig angina secondary to periodontal abscesses involving teeth #17 and #32. Although antibiotics were administered, while in the hospital, the decedent had difficulty swallowing and was drooling. He suddenly began to have seizure-like activity thought to be anoxic myoclonus. The decedent was aggressively resuscitated and taken to the operating room for neck exploration and a tracheostomy. Neck exploration revealed severe necrotizing acute inflammation of the deep soft tissues and musculature of the neck. He remained on life support for 7 days until he was declared brain dead. Ludwig angina is a progressive cellulitis that often results in death by asphyxia. Ludwig angina can be complicated by subsequent deep neck infection. The underlying etiologies and common scenarios are examined, and significant autopsy findings and dissecting procedures are discussed. The pathophysiology of Ludwig angina is studied with a review of the current literature.     

Massive systemic silicone embolism: a case report and review of literature

Subcutaneous injections of inert or quasi-inert plastic material designed to smooth out wrinkled skin or to create a more esthetically sought appearance have become very popular with the American public in general, and, in particular, with certain groups highly focused on their physical image. The case of the injection procedure has attracted into the field of plastic medicine a substantial number of illegal, incompetent, and unscrupulous operators. Their ignorance of involved medical risks and procedures not uncommonly results in severe complications, disfigurement, and death of patients. We report the typical pathological and chemical findings of a systemic fatal silicone embolism in a 53-year-old heterosexual woman following illegal chronic injections of silicone in her hips and buttocks. The injected subcutaneous silicone apparently migrated rapidly from the interstitial subcutaneous tissue into the general blood stream resulting in a fatal systemic silicone embolism. An analysis of the presented case in conjunction with a review of the pertinent medical literature, including a recent article, revealed a marked similarity in the clinicopathologic findings between silicone embolism and fat embolism.     

Suicidal ligature strangulation: case report and review of the literature

An unusual case of suicidal ligature strangulation is described. The victim is a 42-year-old white male who devised a very elaborate ligature mechanism comprised of thin wire, a plastic tub filled with water, and a combination of other common objects to commit suicide while in custody. A brief review of the literature follows.     

Suicidal decapitation using a tractor loader: a case report and review of the literature

In forensic practice, decapitated bodies are predominantly associated with decapitation by wheels of trains or with postmortem dismemberment following homicide. In the suicidal context, decapitation accounts for less than 1% of total suicide. Apart from decapitation by trains, other encountered methods involve suicidal hanging and vehicle-assisted ligature suicide. Reported here is a unique case of suicidal decapitation in a 45-year-old man using a tractor loader at the foot of a silo, on his farm. The head was recovered in the loader and there were several impact spots from the loader as well as blood on the silo wall. The autopsy revealed a complete decapitation wound with the severance plane located between the third and fourth cervical vertebra. A 1.5 cm wide abrasion on the anterior part of the neck and abrasions under the chin were noted. This very unique case of intentional suicidal decapitation is the first reported case of a planned system intended to create decapitation outside the unique case of homemade guillotine and the more common decapitation by train.     

Pathologic findings in malignant hyperthermia: a case report and review of literature

Malignant hyperthermia (MH) is a rare, potentially lethal disorder of skeletal muscle calcium homeostasis characterized by muscle contracture and life-threatening hypermetabolic crisis following exposure to halogenated anesthetics and depolarizing muscle relaxants. Susceptibility to MH results from mutations in calcium channel proteins that mediate excitation-contraction coupling, with the ryanodine receptor calcium release channel (RyR1) representing the major locus. The mode of inheritance appears to be autosomal dominant with variable penetrance. The authors report the death of a 60-year-old white male with a history of low back pain. He had undergone 2 back surgeries previously, the first occurring 10 years prior to his current presentation. Both previous procedures were done under generalized anesthetic with no complications. Recently, he developed stenosis and presented for fusion of vertebrae L3 and L4. The procedure was performed under general anesthetic including sevoflurane, with no intraoperative complications. The anesthesiologist noted that, near the end of the 2-hour procedure, the decedent's CO2 levels were slightly elevated. After the procedure, the decedent was extubated, the temperature probe which had been recording normal values was removed, and he was rolled from ventral to dorsal position. He immediately became hypotensive and bradycardic. Lifesaving interventions were begun. Subsequently, he went into cardiac arrest, at which time the temperature probe was reinserted into the trachea, where it read a body temperature of 109 degrees F. Malignant hyperthermia protocol was initiated, and interventions continued for over 2 hours, at which time they failed. At autopsy, the abdomen contained 1800 mL of blood, and bilateral hematomas were present in the psoas muscles. The authors present this case of clinically apparent malignant hyperthermia, discuss how to approach such a case, the gross and microscopic findings, ancillary studies, and a review of the literature.     

Verapamil toxicity: an unusual case report and review of the literature

Verapamil blocks the rapid influx of calcium into the cardiac myocytes of the cardiac conduction system and smooth muscle of the vasculature, resulting in decreased myocardial contractility, prolonged conduction time, and vascular relaxation. A sustained-release form, verapamil SR (or ER), is available that contains higher levels of medication and requires only once-daily dosing. The majority of reported fatal cases of verapamil toxicity are due to massive, intentional overdoses. Herein, we present an unusual case of fatal verapamil SR toxicity in a 57-year-old female that resulted from accidental overdose of only 3 tablets (720 mg), as witnessed by the decedent's daughter. In spite of the low dose ingested, the postmortem cardiac blood verapamil level was clearly toxic (6000 ng/mL, or 6 mg/L). Her preexisting medical conditions included hypercholesterolemia, hypertension, iron deficiency anemia, diabetes mellitus, and associated mild chronic renal failure. Complicating factors, which likely include the decedent's preexisting renal and cardiac disease, and a review of the available literature will be discussed.     

Childhood panhypopituitarism presenting as child abuse: a case report and review of the literature

Childhood panhypopituitarism may be acquired or congenital. Children with panhypopituitarism can present clinically with diabetes, growth failure, decreased bone density, and morbid obesity. In the forensic setting without the proper history, it can be misdiagnosed as child abuse or neglect. We report a case of a 3-year-old black girl who was admitted to the emergency room with apnea and subsequently died. While at the emergency department, it was discovered that the child had a fractured left hip and was severely growth retarded for age. The coroner wanted to rule out child abuse and/or neglect and requested an autopsy based on the physical findings identified by hospital staff. Significant findings at autopsy included small for age (15th percentile for age), hypoplastic brain/pituitary gland/adrenal gland/thyroid gland, abnormally formed skull with an occipital protuberance, a fractured left hip with decreased bone density, and central adiposity. Subsequent to the autopsy, it was discovered that at 6 weeks of age the child suffered from group B streptococci meningitis that resulted in panhypopituitarism. The panhypopituitarism then resulted in seizure activity, diabetes insipidus, and growth retardation. The authors hope this case report and review of the literature will assist investigators, pathologists, and clinicians in making a distinction between neglect or inflicted injury of child abuse and panhypopituitarism that can present with similar signs and symptoms.     

Ancillary studies in amniotic fluid embolism: a case report and review of the literature

The incidence of amniotic fluid embolism during pregnancy is approximately 1/50,000 and has a mortality rate in excess of 80%. The postmortem diagnosis of amniotic fluid embolism can be challenging for forensic investigators and pathologists. At autopsy, usually signs of disseminated intravascular coagulation suggest an amniotic fluid embolism. A definitive diagnosis of amniotic fluid embolism cannot be made until ancillary studies are performed on the decedent's tissues. We report a case of a 37-year-old G3P2 white female who was 36 weeks gestation when her membranes spontaneously ruptured. She suddenly became breathless, went into cardiogenic shock, and died. The autopsy revealed gross and microscopic findings of amniotic fluid embolism, which was confirmed with ancillary studies consisting of special stains, immunohistochemistry, and a serum tryptase level. The authors hope this case report, including gross and microscopic autopsy findings with procedural and ancillary studies, and review of the literature will help investigators and pathologists in the diagnosis of amniotic fluid embolism.     

Fatal strychnine poisoning--a case report and review of the literature

A typical case of suicidal strychnine poisoning by a rodenticide is presented. The forceful muscular convulsions were accompanied by a clear sensorium. Pathological findings consisted of an early onset of postmortem rigidity and microscopic hemorrhages with minimal degenerative neuronal changes in the spinal cord. The highest tissue concentrations of strychnine were found in the bile and liver. The pathophysiology and epidemiology of strychnine poisoning is reviewed and discussed in context.