Massive pulmonary embolization by cerebral tissue after head trauma in an adult male

We report a case of an adult man who was run over by a car, suffering severe head trauma. After 3 hours in the hospital, he experienced sudden and severe hemodynamic deterioration, dying immediately. The autopsy showed massive cerebral tissue pulmonary embolization (CTPE), confirmed by immunohistochemistry. Multiple fractures of the skull, tear of the transverse sinus, and brain laceration of the occipital lobe were present. CTPE is very infrequent. In children and adults, it occurs as a complication of severe closed or penetrating head trauma. Although laceration of a large cerebral venous sinus is not always essential, in some cases (like in the present one) this laceration is the mechanism of entry of the cerebral tissue to the blood circulation. The clinical repercussion of CTPE is variable. In some cases, it could be an incidental finding of autopsy. In other cases, coagulation abnormalities and disseminated intravascular coagulation have been reported. Finally, such as in the present case, the immediate cause of death is the sudden hemodynamic failure due to the massive CTPE.     

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.     

颅脑外伤后假性癫痫的法医学鉴定

通过对2例颅脑外伤后假性癫痫的法医鉴定案例的分析,总结假性癫痫发作的临床特点及外伤后假性癫痫发作与外伤性癫痫发作的鉴别要点。其法医学鉴定应结合颅脑外伤的程度、部位、颅内有无后遗病灶及临床发作特点等综合分析。     

Nonfracture-associated fatal fat embolism in a case of child abuse

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.     

Heart embolization with the Kirschner wire without cardiac tamponade

The case of the heart embolization with the Kirschner wire that was used for shoulder trauma fixation, 2 years previously in a 67-year-old female, is reported. This case is unique; although embolization of foreign bodies to the heart is not a novel occurrence, heart embolization with non-broken Kirschner wire with a total length of 13.5 cm without cardiac tamponade was not described in medical literature so far.     

Pulmonary embolization by chorionic villi causing maternal death after a car crash

Throughout the last century, there has been a marked decline in obstetric maternal deaths, resulting in an increase in the proportion of nonobstetric deaths among pregnant women. Trauma, in particular, has become a leading cause of maternal death. We report the case of a 20-year-old primigravid woman who was involved in a motor vehicle crash at 36 weeks gestation. The woman developed abruptio placentae, followed by disseminated intravascular coagulation, adult respiratory distress syndrome, and shock, and died the day after the crash. Widespread pulmonary embolization by chorionic villi was identified at autopsy. This report discusses traumatic maternal deaths, with emphasis on the differences in injury pattern observed in pregnant trauma victims in comparison with other adults. It is important that the pathologist be aware of these problems so that an accurate cause of death can be identified in cases of maternal death after trauma. Also discussed is the relationship between trauma and placental abruption and the mechanism of death in the patient. To the authors' knowledge, this is the first reported case of extensive embolism of chorionic villi to the lungs after trauma.     

Death due to positional asphyxia under severe alcoholisation: pathophysiologic and forensic considerations

In contrary to "physical restraint", describing a fixed body position due to external devices, "positional restraint" is defined as an abnormal body position, resulting from accidental fixation under unfortunate circumstances. We report on a remarkable case of positional asphyxia of an alcoholised young man after a fall down a staircase. On external examination, the body showed petechiae of the conjunctivae and oral mucosa, abrasions on the left zygomatic region and scratch marks, respectively. Neither broken fingernails, etc. nor signs of external violence against the neck were found. Autopsy revealed haemorrhages in the praevertebral cervical musculature and Simon's sign. Haemorrhagic pulmonary edema and cerebral edema were observed; blood alcohol concentration: 2.60 g/l, urine alcohol concentration: 3.26 g/l. As cause of death, positional asphyxia after blunt head trauma has to be considered as well as lethal ethanol intoxication. To us, alcoholisation attributed to the fall and together with unconsciousness following blunt head trauma circumvented self-rescue efforts, and therefore, aggravated the potentially lethal impact of positional restraint.     

Death due to superficial soft tissue injuries.

A series of deaths due to multiple superficial injuries is reported. These cases represented 5% of a consecutive homicide series in the Northern Territory of Australia. All cases were characterized by extensive superficial injuries, particularly involving soft tissue, which were present over much of the body including the face, head, arms, legs, and trunk. Upper-limb fractures were present in some cases, as were fractured ribs. The internal organs and tissues were pale, but there was either little or no organ damage. No significant volume of free blood was found in any of the body cavities. In one case, fat emboli were identified in moderate numbers in the lung and kidney. Death due to multiple superficial soft tissue injuries has not previously been characterized in the literature.     

A case of sudden death by decidual cell embolism

A 35-year-old multipara died suddenly of a pulmonary embolism about 12 h after delivery. The morphological features and the entry site of the emboli into the circulation suggested that they were decidual cells. Intact decidual cells accounted for only a minority of the emboli: the great majority were cells that had lost their nuclei and/or had been fragmented. The presence of embolized areas, accompanied by fibroblasts and newly formed capillaries, suggested that the embolization process had started before the beginning of labor. However, no symptoms suggesting embolism had been recorded on the clinical chart.     

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.     

Fatal acute intracranial injury, subdural hematoma, and retinal hemorrhages caused by stairway fall

We describe an infant with an acute subdural hematoma, a fatal head injury, and severe hemorrhagic retinopathy caused by a stairway fall. His cerebral and ocular findings are considered diagnostic of abusive head trauma by many authors. Our literature search of serious injuries or fatalities from stairway or low-height falls involving young children yielded 19 articles of primary data. These articles are discrepant, making the classification of a young child's death following a reported short fall problematic. This case report contradicts the prevalent belief of many physicians dealing with suspected child abuse that low-height falls by young children are without exception benign occurrences and cannot cause fatal intracranial injuries and severe retinal hemorrhages. The irreparable harm to a caregiver facing an erroneous allegation of child abuse requires physicians to thoroughly investigate and correctly classify pediatric accidental head injuries.     

Suicide by blasting caps: a case study of rare cranial trauma

Suicide is a deliberate act of ending one's life. Suicide by use of any explosive device, when not involved in a terrorist act, is quite rare in occurrence when compared with other methods routinely utilized. In this paper, we present to the medicolegal community a case of an adult male who committed suicide with blasting caps and the subsequent extensive damage to the cranial hard tissue. Although the cause and manner of death were relatively straightforward, consultation with forensic anthropologists was requested for an anthropological trauma assessment of the highly fragmented skull. After the skull was cleaned and reconstructed, the analysis revealed similarities between blasting cap trauma to the head and high velocity gunshot trauma to the head. Therefore, in a case where some evidence may have been removed or destroyed, forensic analysis involving trauma of this magnitude could result in a misinterpretation of the true mechanism responsible for the osseous damage. In this case, cooperation among the law enforcement agency, coroner's investigators, the forensic pathologist, and forensic anthropologists provided a comprehensive death case analysis.     

A Rare Presentation of Sudden Death due to Pulmonary Thromboembolism Possibly as a Result of Giant Hepatic Hemangioma

Hepatic hemangiomas are usually detected incidentally when investigating for other nonrelated pathologies. When symptomatic, they are usually large and cause symptoms such as abdominal discomfort or other digestive issues. Occasionally, uncommon presentations such as bleeding with coagulopathy (Kasabach–Merritt syndrome) or even fever of unknown origin may occur. As hepatic hemangiomas are benign, they do not result in tumor emboli and pulmonary thromboembolism due to hepatic hemangiomas is extremely rare. This is a case report of a rare case of a female with no known past medical history who presented with sudden death due to pulmonary thromboembolism, possibly as a result of an underlying giant hepatic hemangioma. Incidentally, she also had three other tumors—pancreatic cystic lymphangioma, cerebral capillary telangiectasia, and papillary thyroid carcinoma, and their potential contribution to the cause of death will be discussed.     

人脑挫伤后波形蛋白表达的免疫组化染色观察

目的观察人脑挫伤后波形蛋白（vimentin,Vim）的动态变化,探讨星形胶质细胞Vim表达变化与脑损伤时间的关系。方法42例闭合性脑损伤死亡者,根据伤后死亡时间分为6组（〈2h,〈24h,〈3d,〈7d,〈14d,≤30d）;取大脑挫伤灶进行HE和Vim免疫组织化学染色,对Vim染色阳性细胞面积进行图像分析。结果HE染色显示,脑挫伤后2h挫伤灶内脑组织挫碎、出血,5．5h挫伤灶周出现反应性星形胶质细胞,3d脑水肿明显,7d反应性星形胶质细胞明显增多,14d胶质结节形成,30d出现大量泡沫细胞,胶质瘢痕增多。Vim染色结果显示,脑挫伤后5．5hVim开始表达,少量Vim阳性细胞出现在挫伤灶周围,7d阳性反应性最强,14d逐渐下降,30d胶质瘢痕增多,Vim阳性表达又增强。Vim阳性细胞主要为反应性星形胶质细胞。结论Vim在反应性星形胶质细胞内表达呈现一定波动性,其表达部位在脑挫伤周围,Vim免疫组化染色结合图像分析技术可作为推断脑挫伤时间及部位的参考指标。     

Hanging: fulminant thrombembolia as a vital reaction? (author's transl)]

Fulminant pulmonary thrombembolias were found in two suicides committed by hanging. The origin was a thrombosis of the iliac vein in one case and of femoral veins in the other. The thrombi and emboli respectively were examined histologically. It is assumed that the detachment of the emboli might have been caused mechanically during terminal muscle-cramps or hemodynamically by sudden alterations of blood pressure.     

Sudden Unexpected Death due to Chiari Type I Malformation in a Road Accident Case

This case concerns a sudden death of a patient with Chiari I malformation. A 17‐year‐old female was seen unconscious then fell off a motorbike during the vehicle acceleration. The girl was confirmed dead on the way to hospital, being previously asymptomatic and with a clean medical record. Autopsy findings showed an extremely extra‐long cerebellar tonsillar herniation in the left side and unexplained multiple small cavities in cerebral hemispheres. Microscopic findings revealed loss and abnormal migration of the Purkinje cells, as well as capillary congestion in the herniated tonsil. The cause and mechanisms of this sudden death are considered as the cardiopulmonary dysfunction and arrest resulted from compression of the medulla and cervical cord, which was induced by both the positional insult and minor head trauma. In addition, this study stresses the importance of cervical cord examination in the case of unexpected sudden death following road accidents.     

Fatal paradoxical air embolism diagnosed by postmortem imaging and autopsy

The recognition and visualization of an arterial gas embolism are difficult. We report a case of sudden death caused by paradoxical air embolism of coronary and cerebral arteries, diagnosed by the pre autopsy computed tomography (CT) scanning. A 54-year-old woman suddenly died after the self-removal of the jugular vein catheter. Postmortem imaging examination using CT scanning showed multiple gas embolisms in the cerebral arteries, pulmonary artery, right atrium and ventricle, left ventricle, aorta, and coronary arteries. These findings suggested that the occurrence of acute ischemia of the brain and heart caused by massive air inflow to the artery. Conventional autopsy revealed a patent foramen ovale of the heart. These results indicated that the patient died of paradoxical air embolization of the coronary and cerebral arteries through a patent foramen ovale because of right-to-left shunting. The use of postmortem imaging as an aid for conventional autopsy has proved to be of advantage in the case of gas embolism.     

Deaths associated with liposuction: case reports and review of the literature

Tumescent liposuction is a common cosmetic procedure that is performed as an outpatient service in physician's offices and is largely believed to be safe. The protuberant areas of the body containing the undesirable fat deposits are injected with normal saline containing lidocaine and epinephrine for pain control and hemostasis, and the waterlogged cells are suctioned out via cannula through a small incision. We recently encountered three cases in which deaths were attributed to this procedure. Two showed fat embolization in the lung and one died from fluid overload. The osmium tetroxide post-fixed lung sections showed fat emboli in the interstitial capillaries and arterioles. We reviewed the recent literature and found that pulmonary thromboemboli, fat embolization, fluid overload, and lidocaine and epinephrine intoxication are found at autopsy in many cases. Forensic pathologists responsible for determining the cause and manner of death should become familiar with the postmortem findings and risks of liposuction therapy and communicate them to their clinical colleagues and communities.     

Fat Transfer and Fatal Macroembolization

Fat embolism is usually associated with long bone fractures or other trauma. The diagnosis is usually clinical, and in most cases, emboli are not fatal and not usually seen on gross examination. At the Los Angeles County Coroner's Office, we autopsied the victim of fatal macroscopic fat embolization to the lungs. The patient died during buttock enhancement surgery when fat from liposuction was injected into her buttocks. Fat embolism from liposuction and fat injection is reportedly rare, and macroscopic embolization is rarer still. Varicose veins can occur in the area of the sciatic notch and are known to cause painful sciatica symptoms. We suggest them as a potential conduit for macroscopic fat to reach the lungs. Simple pre‐operative questioning for sciatica symptoms and possible radiologic study to rule out sciatic varices seem prudent before undertaking buttock‐enhancing surgery. Careful fat injection with pre‐aspiration is always advised.     

An application of a quantitative analytical system for the grading of pulmonary fat embolisms

The severity of pulmonary fat embolism in 5 autopsied cases has been measured using a quantitative image analytical system. With reference to the mean size of the fat emboli, the cases were divided into 2 groupings regardless of the number of the emboli. The mean sizes of the emboli in 3 cases of the first group were significantly larger (about 490-600 microns 2) than those found in the 2 cases of the other group (about 220 and 235 microns 2). An investigation into the localization of fat emboli revealed that more were lodging in the small arteries and arterioles in the first group than in the second. Our results have indicated that a reliable grading of pulmonary fat embolism can not be established without a quantitative image analysis of the size and localization of the fat emboli, and that this quantitative analytical method is useful in achieving this reliable grading.