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.     

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.     

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 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.     

Homicidal hanging

We report a case of homicide by hanging of a 29-year-old woman that was committed by her husband, who nearly escaped from justice. We offer some reflections on the rarity of this method of mechanical asphyxia in cases of homicide, and on the difficulties in the diagnosis of the medico-legal etiology of these situations. We also offer a short review of similar cases in the medico-legal literature.     

Homicidal asphyxia

Homicides due to asphyxia are relatively uncommon. To better understand the presentation of such cases, the files of the Bexar County Medical Examiner's Office were reviewed from January 1, 1985, through December 31, 1998, for all such homicides. A total of 133 cases were found. The largest category was ligature strangulation with 48 deaths (21 male, 27 female). Petechiae were present in the conjunctivae and/or sclerae in 86% of the cases; fractures of the hyoid and/or thyroid cartilage were present in 12.5%. There were a total of 41 deaths from manual strangulation (27 female, 14 male). Petechiae were present in 89% of the cases. In cases of manual strangulation, fractures of the hyoid, thyroid, or cricoid cartilage were found in all the male victims and slightly more than one half of the female victims. Twenty-six cases of suffocation were found; 20 of the victims were < or =2 years of age. Only 1 of these children had petechiae and/or scleral hemorrhage. Five deaths were due to choking. Three of the deaths involved adults who were gagged; 2 deaths involved infants with foreign material pushed into the mouth. Other categories of asphyxia were as follows: 9 deaths due to more than one form of asphyxia; 1 death due to hanging, and 3 deaths due to drowning. Rape was the motive in 66% of the female victims of ligature strangulation and 52% of those due to manual strangulation.     

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.     

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.     

Fatal salmonella aortitis with mycotic aneurysm rupture

Salmonellae most commonly cause uncomplicated cases of gastroenteritis but have a predilection for damaged blood vessels, especially those damaged by atherosclerosis. The abdominal aorta is most frequently affected. The most serious complication of aortitis is mycotic aneurysm formation with subsequent rupture. The authors present the case of a 61-year-old man who was found unresponsive at home 3 days after discharge from the hospital for treatment of gastroenteritis with bacteremia. Postmortem examination revealed a ruptured mycotic aneurysm with a large retroperitoneal hematoma. Numerous gram-negative rods were embedded in the wall of the aorta and surrounding inflammatory infiltrate, compatible with the patient's previously isolated. Whereas abdominal aortic aneurysm rupture is most commonly associated with atherosclerosis, the isolation of from blood cultures, coupled with radiographic evidence of gas surrounding the aorta, should raise the suspicion of infectious aortitis. Whereas fatal rupture of an aortic aneurysm secondary to atherosclerosis alone or in conjunction with aortitis will not have an impact on the manner of death, infections are reportable and thus have public health implications.     

Homicidal behavior in schizophrenics

This paper emphasizes that homicidal behavior may be part of the clinical manifestation of schizophrenia. The failure to hospitalize potentially violent schizophrenics contributes to the incidence of psychotic homicide. The tendency to diagnose homicidal schizophrenics as personality disorders combined with legal changes brought about a shift of this population from the mental health system to the criminal justice system.     

Descending thoracic aortic aneurysm rupture during postpartum period

Aortic aneurysm refers to the pathological dilatation of the normal aortic lumen involving one or several segments. Thoracic aortic aneurysms are much less common than aneurysms of the abdominal aorta. Descending thoracic aortic aneurysm leading to dissection and spontaneous rupture is a potentially catastrophic illness. Although rare, dissection and rupture of a preexisting aortic aneurysm have been reported during pregnancy and early puerperium. To the best of our knowledge, such cases among young pregnant women are rarely reported in literature. Herein, an autopsy case of spontaneous rupture of a clinically undiagnosed descending thoracic aortic aneurysm during early puerperium in a young woman is presented along with the review of relevant literature. The victim was found dead on her hospital bed on the seventh day of puerperium. Autopsy with ancillary investigations revealed that the young woman died because of hemothorax from a ruptured dissecting descending thoracic aortic aneurysm secondary to chronic aortitis.     

Homicidal asphyxia by pepper aspiration

As punishment for lying, the foster mother of a five-year-old white male poured pepper into his throat. He immediately became dyspneic, then apneic, and was pronounced dead about 1 h later. At autopsy, the main stem and several smaller bronchi were occluded with pepper. Mechanisms of asphyxia by pepper include mechanical obstruction of the tracheobronchial tree and mucosal edema caused by the irritant effect of volatile oils in pepper. This rare circumstance represents the second reported fatal case of pepper aspiration and the third reported case overall.     

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 splenic artery aneurysm.

Three cases of death from splenic artery aneurysm rupture were encountered from 1988 to 1991 at the Philadelphia Medical Examiner's Office. In two cases, cocaine was detected in the blood and was believed to have precipitated the rupture. Toxicologic testing for cocaine should be performed in all cases of splenic artery aneurysm rupture and its presence should be interpreted properly as contributory rather than incidental to death.     

主动脉夹层破裂与非破裂管壁的病理学对比观察

目的探讨炎性细胞和金属基质蛋白酶(MMPs)与主动脉夹层病变的关系。方法对本教研室1999年~2001年尸检14例主动脉夹层破裂致死(破裂组)和8例主动脉夹层因其它疾病死亡(未破裂组)的尸检案例资料,应用W e igert弹性纤维染色和免疫组化染色对两组主动脉夹层的动脉壁结构,CD68着色及MMP-9活性进行对比观察,并对免疫组化阳性染色进行图像分析。结果W e igert染色显示,两组管壁弹力纤维和胶原纤维均有较明显的分离、断裂或消失,但破裂组病变程度比未破裂组更重。免疫组化与图像分析结果显示,CD68阳性细胞的平均光密度值在破裂组为0.933±0.750,未破裂组为0.617±0.674;MMP-9活性的平均光密度值在破裂组为0.924±0.541,未破裂组为(0.651±0.988);两组间存在显著性差异(P<0.01)。结论炎性细胞浸润程度和MMP-9活性与主动脉夹层动脉管壁的病变程度及破裂紧密相关。     

Homicidal commotio cordis in two children

This paper's objective is to describe two cases of fatal commotio cordis resulting from the deliberate striking of children's chests by adults with their fists. These deaths involve two male children, ages 3 years and 14 months. The clinical histories, events in the households prior to the deaths, behaviors of the children, autopsy findings, and investigation results are all similar. In both cases, fatal blows were delivered to the anterior chest with a closed fist. Both children collapsed immediately, unable to be resuscitated. Confessions were obtained in both cases by investigators soon after the children's deaths. Autopsies showed chest contusions in only one child, presumably due to knuckle impact. The cardiac rhythms noted by paramedics were ventricular fibrillation and asystole. Due to the lack of physical findings, an immediate and thorough investigation is critical. An accurate history of events preceding death must be obtained.     

Homicidal hanging in a dyadic death

Homicide by hanging is rare. In this case report, a young man stabbed his wife, hanged his son, and then hanged himself. He was assumed to be mentally ill, consistent with some other studies of family murder-suicide.     

产后孤立性髂动脉瘤破裂致死1例

孤立性髂动脉瘤指仅发生于髂动脉的瘤样扩张性病变，单发或多发性，亦可双侧均受累。     

产后孤立性髂动脉瘤破裂致死1例

孤立性髂动脉瘤指仅发生于髂动脉的瘤样扩张性病变,单发或多发性,亦可双侧均受累,以管径大于2.5cm为诊断标准,其破裂率可高达75%,临床上较少见,并与死亡密切相关。[1]发生于年轻女性剖宫产后的孤立性髂动脉瘤破裂致死者尤为罕见,尚未见有报道,笔者在检案中遇到1例,现报告如下。案例资料某女,27岁,职员。孕1产0,末次月经1999年9月18日,平时月经规律,预产期2000年6月25日,孕期常规产检未发现明显异常。2000年6月9日出现阴道流水,无腹痛及阴道出血,以“孕37+4周待产,胎膜早破”收入院。于当日下午6点30分行剖宫产术,以LO P顺利助娩一女活婴,1…