Cerebrovascular malformation causing sudden death. Analysis of three cases and review of the literature

Three unusual cases of sudden death resulting from cerebrovascular malformation (CVM) are presented. CVMs are highly variable in location and morphology, and may be difficult to detect. Two of the patients discussed here had CVMs that involved the circle of Willis directly, and produced rapidly fatal subarachnoid hemorrhage at the base of the brain; both of these subjects were in their late 30s. One had a history of epilepsy; the other had been completely asymptomatic prior to the catastrophic event. The third was an asymptomatic 6 year old with a cerebellar CVM, who survived long enough for inconclusive neurosurgical intervention. In all three cases, the diagnosis was not made prior to autopsy; in one case, the circumstances of death were initially misleading. The relevant literature is reviewed and discussed, with emphasis on differential diagnosis, anatomic examination, and background investigation.     

Intracranial arteriovenous malformations presenting as sudden unexpected death: a report of 3 cases and review of the literature

Intracranial arteriovenous malformations (AVMs) are cerebrovascular abnormalities due to maldevelopment of the regional capillary bed, producing lesions with arteriovenous shunting. AVMs may account for as many as 1% of all sudden deaths; however, case reports in the literature are exceedingly rare. We present 3 cases of sudden death due to hemorrhage of AVM and discuss the literature and the differential diagnosis in cases of sudden death due to intracranial hemorrhage.     

Sudden unexpected death due to Taxus poisoning. A report of five cases, with review of the literature.

The toxicity of yew (Taxus) has been known since antiquity. However, in the past 31 years, to our knowledge only six cases of Taxus poisoning have been reported in the literature. In the present paper we add five cases. From a forensic point of view, intoxication with Taxus has three important aspects: (i) the clinical presentation, which among other causes should suggest Taxus intoxication; (ii) the fact that the diagnosis may often be easily made by examination of the contents of stomach, duodenum and small bowel and (iii) the widespread availability in the near future of Taxol, an anti-neoplastic drug which is an alkaloid extracted from Taxus. The clinical and autopsy findings are summarized, the diagnostic aspects are discussed and the literature concerning Taxus is reviewed.     

Human herpesvirus-6 and sudden death in infancy: report of a case and review of the literature

Investigation of sudden death in infancy is a vital function of the medical examiner's office. Surveillance of these cases may lead to recognition of new diseases or new manifestations of previously described diseases. Human herpesvirus-6 (HHV-6) is a relatively newly described virus that has been recognized as a cause of acute febrile illness in early childhood. While most cases are apparently self-limited, seven fatal cases have been reported. We present a case of a seven-month-old Latin American male with recent otitis media and vomiting who was found dead in bed. Autopsy revealed interstitial pneumonitis with an atypical polymorphous lymphocytic infiltrate in the liver, kidney, heart, spleen, lymph nodes, and bone marrow, associated with erythrophagocytosis. Polymerase chain reaction (PCR) analysis of formalin-fixed paraffin-embedded tissue was positive for HHV-6 and negative for Epstein-Barr virus (EBV) and cytomegalovirus (CMV). HHV-6 was also detected in the atypical lymphoid infiltrate by in-situ hybridization.     

Sudden death in toddlers caused by influenza B infection: a report of two cases and a review of the literature

Sudden fatal cases of influenza B infection in a 4-year-old girl and a 2-year-old boy are presented. Both children complained of abdominal pain without respiratory, neurologic or cardiac symptoms; additionally the girl had vomiting within 2 days of death. Autopsy revealed histological changes in the respiratory system consistent with a viral infection. Influenza B infection was identified by immunohistochemistry in the girl and real-time polymerase chain reaction in the boy. Additional testing including cultures, toxicology, and screening for metabolic disorders were negative. These cases illustrate the usefulness of viral testing, especially for influenza, in the medical legal autopsy of children even when the classic respiratory symptoms of flu are lacking.     

Unexpected death in persons with symptomatic epilepsy due to glial brain tumors: a report of two cases and review of the literature.

Two cases of unexpected death in persons with epileptic seizures due to a brain tumor are presented which encompassed an astrocytoma WHO grade II and an anaplastic astrocytoma WHO grade III. A 35-year-old man was found somnolent and disoriented at home. A computed tomography (CT) scan revealed a tumor of the right frontal lobe suggestive for an oligodendroglioma. During an angiographic examination the patient experienced an epileptic seizure. Some weeks later, the man was found dead in front of his house with a fresh bite mark of the tongue. Neuropathological examination revealed an astrocytoma WHO grade II of the right frontal lobe. A 47-year-old man plunged into a swimming-pool and was found submerged some minutes later. After resuscitation he survived comatose for 8 days but finally died due to severe hypoxic brain damage. He had been operated on a brain tumor of the temporal lobe 1 year before the accident. Neuropathological examination revealed residual tumor tissue at the operation site corresponding to an anaplastic astrocytoma WHO grade III. Although rare, death in persons with epileptic seizures due to brain tumors is an important mechanism of death encountered by the forensic pathologist.     

A pathological study of sudden coronary death in China: report of 89 autopsy cases.

This paper reports the results of a forensic pathological study of 89 autopsy cases of Sudden Coronary Death (SCD). Of 89 cases, 63 (52 male, 11 female) were narrowed by 76-100% in cross-sectional area (XSA) of the coronary artery (CA) and 26 (22 male, 4 female), by 51-75%. Atherosclerotic plaques in the CA were serious and extensive, especially in the left anterior descending and often involved several branches of CA at the same time. Recent thrombosis was found in 18 cases, haemorrhage in plaques in 17 cases. Only 2 cases had visible acute myocardial infarction. Inflammatory cell infiltration was found in coronary plaques in 36 cases. Myocardial fibrosis or small scar formation was detected in 51 cases. It is suggested that although the incidence of coronary heart disease (CHD) is low in China, SCD is the commonest mode of Sudden Unexpected Death. The majority of SCD (52%) were middle aged males (30-49 years old). Most of the cases died suddenly during sleep without any clear precipitating factors. The characteristics of occurrence and pathological changes in the CA and myocardium and the pathological diagnosis of SCD are also analysed and discussed.     

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.     

Delayed sudden death in an infant following an accidental fall: a case report with review of the literature

Several controversies exist regarding ultimately lethal head injuries in small children. Death from short falls, timing of head injury, lucid intervals, presence of diffuse axonal injury (DAI), and subdural hematoma (SDH) as marker of DAI are the most recent controversial topics of debate in this evolving field of study. In this area of debate, we present a case of delayed death from a witnessed fall backwards off a bed in a 9-month-old black male child who struck his head on a concrete floor and was independently witnessed as "healthy" postfall for 72 hours until he was discovered dead in bed. Grandmother, babysitter, and mother all independently corroborated under police investigation that the child "acted and behaved normally" after the fall until death. Autopsy showed a linear nondisplaced parietal skull fracture, diastasis of adjacent occipital suture, subgaleal hemorrhage with evidence of aging, small posterior clotting SDH, marked cerebral edema, and a small tear of the midsuperior body of the corpus callosum consistent with focal axonal injury (FAI). No DAI was seen, and there were no retinal hemorrhages. All other causes of death were excluded upon thorough police and medical examiner investigation. Although this seems to be a rare phenomenon, a delayed, seemingly symptom-free interval can occur between a clinically apparent mild head injury and accidental death in a young child.     

急性混苯中毒死亡2例报道

在法医学实践中,高浓度混苯中毒引起死亡者少见,尚未见文献报道,本文报道2例.     

19例原发性心肌病猝死案例的病理学研究

本文对19例原发性心肌病猝死的尸检案例的发病年龄、职业特点及病理学改变进行了分析和讨论，其中扩张性心肌病11例,肥厚性心肌病8例．     

医疗纠纷中135例猝死分析

目的为探讨引起医疗纠纷案例中猝死发生的特点，特别是其年龄、性别、科室、疾病的分布和发生纠纷的原因，为有关单位调处医疗纠纷和制定有关法规提供科学依据。方法自本教研室1955～1996年42a间受理的法医病理学尸检资料中挑选各种医疗纠纷案例；制定统一表格，将其中猝死者逐一登记，并进行统计分析。结果42a中涉及医疗纠纷的淬死135例。其中男87例、女48例。年龄自新生儿～67岁。以新生儿和婴儿居多（67例），男明显多于女；其次为25～34岁的青壮年组（21例），女多于男。近12a发生的猝死（94例）是过去30a（41例）的2．3倍。猝死疾病以呼吸系统最常见（46％），次为心血管系统疾病（25％）；但54例成人猝死者心血管系统疾病占首位（26例），次为泌尿生殖系统疾病（12例）。发生的科室多见于产科和儿科（74例）。结论认为近10年来医疗纠纷中猝死案例明显增多；医疗纠纷中非医疗事故远多于医疗事故；法医病理尸检对正确、合理地调处医疗纠纷，并对探讨猝死的发生机制，反馈、丰富和发展相关临床学科的内容，以及提高诊治水平均具有重要意义。     

Simultaneous sudden infant death syndrome: a proposed definition and worldwide review of cases.

Epidemiologic studies of sudden infant death syndrome (SIDS), the leading cause of death of infants during the postperinatal period (7-365 days), have mainly focused on the deaths of single infants. Simultaneous sudden infant death syndrome (SSIDS), the death of a pair of twins occurring at the same time, has received limited attention within the medical community. To the authors' knowledge, this article is the first to describe the 41 SSIDS cases cited in the world literature from 1900 to 1998 by the location of death, a summary of the circumstances surrounding the deaths, and evaluation of these cases in terms of a proposed definition of SSIDS. This evaluation critiques whether the 41 pairs of SSIDS cases adhere to a newly proposed definition of SSIDS. Twin infant deaths must meet all three criteria to be considered SSIDS. The study found that only 12 pairs of twins met all three criteria (29.2%), nine pairs met two criteria (21.9%), alternative cause of death was offered in five pairs of twins (12.1%) and in the remaining 15 pairs (36.6%), only limited information was available; therefore, no conclusions could be reached.     

Sickle cell lung disease and sudden death: a retrospective/prospective study of 21 autopsy cases and literature review

Sudden death in the setting of sickle cell lung disease (SCLD), is periodically seen in the practice of medical examiners. The goal of the present study was to identify the most common pathologic findings of SCLD associated with sudden or unexpected death. A retrospective/prospective review of 21 autopsy cases from sickle cell patients between 1990 and 2004 was performed. Review of medical records, autopsy reports, and H&E-stained slides of lung tissue was performed. Oil-Red-O and elastic staining of lung tissue were evaluated. All cases were screened for both acute and chronic forms of SCLD. Patients admitted for sickle cell pain crisis ranged in age from 8 months to 65 years. Fifteen out of 21 cases (71.4%) showed significant pulmonary pathology. The most frequent lung findings included pulmonary edema (47.6%), pulmonary thromboembolism (38.1%), fat emboli (33.3%), pulmonary hypertension, grades I-IV (33.3%), and microvascular occlusive thrombi (28.5%). Our study demonstrates higher-than-expected percentages of acute and chronic sickle cell-related lung injury such as fat embolism (33.3%) and pulmonary hypertension (33.3%), with right ventricular hypertrophy (33.3%). Therefore, we propose a simple and high-yield autopsy algorithm of ancillary procedures that should be applied on all known and suspected autopsy cases of sickle cell disease.     

Trophoblastic microemboli as a marker for preeclampsia-eclampsia in sudden unexpected maternal death: a case report and review of the literature

The authors report the case of a 25-year-old white woman at 7 months' gestation who died suddenly and unexpectedly at home. Anatomic findings at autopsy included a tongue contusion, glomerulonephritis, changes indicative of systemic hypertension, and trophoblastic microemboli in the lungs. Review of the prenatal care record disclosed 3+ proteinuria 2 days before death. The features of the postmortem examination were consistent with clinically undiagnosed preeclampsia-eclampsia and glomerulonephritis. The authors discuss the rarity of fatal preeclampsia-eclampsia, the contribution of concomitant glomerulonephritis, and the significance of trophoblastic microemboli in the lungs.     

TB-related sudden death (TBRSD) due to myocarditis complicating miliary TB: a case report and review of the literature

TB-related sudden death (TBRSD) is rarely reported in the literature and in the majority of cases is due to bronchopneumonia and hemoptysis. Cardiac complications of tuberculosis causing sudden death can take many forms and are rarer still, with only a handful of cases reported. We describe a case of a previously fit and healthy 20-year-old Asian female who, after returning from a holiday in India, collapsed while getting off a bus. At postmortem, the only macroscopic finding of note was a localized area of fibrosis on the anterior wall of the left ventricle. Microscopic examination of this area showed Langhans giant cells; noncaseating epithelioid granulomas and acid-fast bacilli were demonstrated on Ziehl Nielsen staining. In addition, the lungs, liver, and kidneys contained multiple noncaseating granulomas. The case serves to highlight the protean nature in the presentation of this disease and the importance of postmortem histology in autopsy work.     

316例急死的法医学分析

对重庆地区316例急死进行分析。结果表明:男性多于女性,中青年及小于10岁的婴幼儿居多,第三季度增多,呼吸系统疾病居首位,其次为循环系统疾病,死亡场所是医院占多数。     

Supravalvular aortic stenosis, Williams syndrome and sudden death. A case report

Supravalvular aortic stenosis (SVAS) is an uncommon but well characterized congenital narrowing of the ascending aorta above the level of the coronary arteries. It can be a familial disorder, can occur sporadically, or associated with Williams syndrome (WS) which is a neurodevelopmental disorder affecting connective tissue and the central nervous system. Sudden death is a well-known complication of non-syndromic SVAS but few cases have been reported associated with WS. We present a case of sudden death in a woman with the diagnosis of SVAS and WS since the age of 3 years who refused surgical correction and died at the age of 27 years. At autopsy, the aorta and pulmonary trunk were narrowed and the walls showed peculiar microscopical characteristics. In the cardiac conduction system the His bundle was small and intramyocardial. The incidence, pathology, pathogenesis and prognosis of both conditions (SVAS and WS) are reviewed.     

Sudden unexpected death following exercise and congenital anomalies of coronary arteries. A report of two cases

Two cases of anomalous origin of the left coronary artery from the pulmonary trunk with unusually prolonged post-childhood survival are presented. In both cases, death was associated with physical exertion. The pathological findings included enlarged right coronary ostium, myocardial hypertrophy, endocardial fibrosis, and focal myocardial scarring.