Age‐Related Vulnerability to Lethal Craniocerebral Crush Injuries from Electrical Beds/Tables

Vulnerability to accidents characterizes the extremes of life for reasons that may be similar in each age group. Two cases are reported to demonstrate increased risks of entrapment and crushing injury involving the use of electrically controlled beds/tables. Case 1: A frail 98‐year‐old woman with a history of dementia suffered a lethal crush injury to her head when she fell out of bed and accidentally activated its lowering mechanism. Case 2: An 18‐month‐old girl suffered a lethal crush injury to her head when she became trapped under a lowered electric massage table. Common devices may be dangerous if individuals do not have the mental or physical capabilities to deal with them. The forensic assessment of such deaths involves an evaluation of the neurocognitive level and physical strength of the decedent as documented in previous clinical assessments, in addition to a careful examination of the structure and function of the bed/table.     

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 unexpected death resulting from hypothalamic sarcoidosis

The authors report a case of sudden death in a 23-year-old woman in whom autopsy by the medical examiner revealed hypothalamic sarcoidosis. The decedent had experienced 6 months of amenorrhea and a 50-pound weight gain. She sought medical attention when she experienced headache, and after imaging and laboratory studies, she was suspected of having neurosarcoidosis. She appeared to respond well to corticosteroid therapy. However, 6 weeks after the beginning of therapy, she was found dead on the floor of her residence. Autopsy showed extensive granulomatous inflammation of the hypothalamus and adjacent structures. Previously reported cases of hypothalamic sarcoidosis are reviewed. A hypothesis for the mechanism of sudden death is presented.     

Fatal thrombosis of the basilar artery due to a minor head injury

A case is reported where a 20-year-old alcohol-intoxicated man was admitted to the hospital after a minor head injury. Initially there was no neurologic disturbances or complaints but after a few hours he became comatose, and he died 4 days later without regaining consciousness. The autopsy revealed no lesions of the upper cervical spine or the vertebral arteries, but the basilar artery was occluded in its entire length. No traumatic lesions could be seen by naked eye examination of the artery, and there was no accompanying subarachnoid haemorrhage. A thorough microscopic examination, however, using step-sectioning technique revealed a significant incomplete arterial rupture with an occluding luminal thrombosis superimposed, consisting predominantly of aggregated platelets. Only the very thin adventitia separated the vascular lumen from the subarachnoid space preventing the more well known fatal complication to a minor head injury: A subarachnoid haemorrhage. To the best of our knowledge, fatal thrombosis of the basilar artery due to a minor head injury has not previously been reported. The pathogenetic mechanism seems to be identical to that underlying fatal subarachnoid haemorrhage following a similar trauma apart from the resulting arterial rupture being incomplete instead of complete.     

Acute poisoning involving the pyrrolidinophenone-type designer drug 4'-methyl-alpha-pyrrolidinohexanophenone (MPHP)

A 36-year-old woman consulted the medical emergency unit of a private health center for abdominal pain and gastroenteritis of 5 days duration. Acute right pyelonephritis was diagnosed. Five hours after admission she became unconscious in a state of clinical shock. She was transferred to an intensive care unit but resuscitation attempts were unsuccessful and she died 3 h later. Three days after death, she was buried in the family vault. Five days after the burial, her husband lodged a complaint with the public prosecutor because he had not received a clear explanation from the physicians concerning the cause of his wife's death. After analysis of the medical records of the deceased by two forensic pathologists, a medicolegal autopsy was ordered by the public prosecutor. The corpse was exhumed and autopsy performed 9 days after death. Massive hemoperitoneum was diagnosed with a macroscopically ruptured subcapsular hematoma. Pathological study confirmed acute right pyelonephritis and demonstrated the precise cause of the hemorrhage: rupture of the hepatic artery at the hilar part, following infectious arteritis which was probably secondary to the acute pyelonephritis. To the best of our knowledge, this is the first published report of such a case.     

Fatal postpartum spontaneous liver rupture: case report and literature review

Maternal hepatic rupture is a rare complication of pregnancy that can be fatal to both mother and child. This phenomenon is most often associated with preeclampsia/eclampsia and/or HELLP syndrome, which is defined by a collection of clinical features including hemolysis (H), elevated liver enzymes (EL), and a low platelet count (LP). These disease processes are typically identified and treated during pregnancy, often in the last trimester. The described case is unusual in that the decedent had no known history of preeclampsia/eclampsia or HELLP syndrome during this pregnancy, and she died suddenly several days postpartum of liver rupture with massive intraperitoneal hemorrhage following a routine cesarean section delivery and an uneventful hospital course. Similar cases are infrequent in the literature, which is reviewed in this report.     

A case of aortic dissection caused by blunt chest trauma

A 74-year-old woman was struck by a car travelling at about 50 km/h. On arrival at hospital, a CT scan showed dissection of the ascending and descending aorta. She collapsed and died suddenly 8h later. At autopsy, there was massive bleeding into the left pleural cavity, ruptures of the pericardium and right ventricle, and a type A thoracic aortic dissection. The cause of death was haemorrhagic shock due to rupture of the pericardium and delayed rupture of the right ventricle following trauma to the chest. The thoracic aortic dissection was not the direct cause of death although histological examination did reveal that it occurred in the accident. Traumatic aortic dissection is rare although traumatic aortic rupture is a major cause of death after blunt chest trauma. This paper discusses the mechanisms, and factors involved in aortic dissection caused by blunt trauma.     

Vertebral artery laceration mimicking elder abuse

Elder abuse was first described almost 30 years ago. Today, approximately 1 in 25 elders is abused each year in the United States. A newly described form of domestic violence, the incidence of elder abuse will surely increase as the elderly population grows. Physical abuse/inflicted trauma is generally considered the most extreme form of elder mistreatment and includes blunt trauma, sexual assault, traumatic alopecia, and burns. Elder homicide is usually due to gunshot wounds, blunt trauma, stab wounds, or asphyxia. However, the difficult aspect of assessing the possible elder abuse homicide victim is delineating such inflicted trauma from accidental trauma. We report the case of a 94-year-old "demented" male, who reportedly fell out of his wheelchair. He was transported to a local emergency room, where he became unresponsive during examination. He experienced respiratory distress and was pronounced dead shortly thereafter. At autopsy, he had periorbital contusions and a midline abrasion between the eyes, with underlying supraorbital contusion. The skull, brain, and spinal cord were unremarkable for signs of trauma. The major traumatic finding was in the neck region. Neck dissection revealed hemorrhage extending from the base of the skull to the level of T-1 and anteriorly about the soft tissues, strap muscles, and vasculature. The strap muscles were individually examined and were free of hemorrhage. The carotid arteries and jugular veins were unremarkable. The larynx, hyoid, and thyroid were intact, with only surrounding hemorrhage. Further examination revealed a horizontal fracture of the C5 vertebral body and a medial laceration of the left vertebral artery at the C5 level; subarachnoid hemorrhage was absent. What initially appeared to be trauma to the neck, worrisome for strangulation or blunt force trauma, was a large retropharyngeal hematoma from the left vertebral artery laceration. Traumatic rupture of the vertebral artery usually occurs at the C1 and C2 levels, with resultant subarachnoid hemorrhage. This is an especially vulnerable location since it is where the artery turns and then enters the skull. Associated injuries include spinal cord transection or contusion, brachial plexus injury, pharyngoesophageal injury, and vertebral fractures. Retropharyngeal hemorrhage may result from deep neck infection, tumor, and trauma. Hemorrhage associated with trauma often involves flexion of the cervical spine, followed by hyperextension. The accumulation of blood slowly impinges on the pharynx/larynx and vasculature structures. The exact injuries and etiology of the hemorrhage must be determined to distinguish strangulation from blunt force trauma. The presentation of signs and symptoms can be helpful in assessing the decedent; however, in the practice of forensic pathology such a history is more often lacking.     

Metastatic cancer of the urinary bladder: can it be a nonnatural death?

Deaths from metastatic carcinoma are almost exclusively viewed as wholly natural deaths. However, if it can be shown that a cancer has arisen as a result of a prior traumatic injury and the body's healing response to the injury, or treatment thereof, then in select cases, the manner of death shall reflect that of the precipitating injury. This case report is that of a woman who was rendered quadriplegic from spinal cord injury sustained in a motor vehicle crash when she was 22 years old. She died at the age of 49 years from widely metastatic squamous cell carcinoma of the urinary bladder. Her bladder cancer most likely arose from decades-long chronic irritation of the bladder epithelium by physical contact with an indwelling Foley catheter and urinary infections. Over the years, the chronic bladder irritation likely precipitated metaplastic, dysplastic, and finally neoplastic changes of the bladder epithelium, providing a link between her spinal cord injury, the indwelling Foley catheter, and her bladder cancer, engendering an accidental manner of death. The manner of death reflected the circumstances of her injury that predisposed her to the cancer that eventually caused her death.     

The High Court's lost chance in medical negligence: Tabet v Gett (2010) 240 CLR 537

In 2010 the High Court of Australia in Tabet v Gett (2010) 240 CLR 537 determined an appeal in a medical negligence case concerning a six-year-old girl who had presented to a major paediatric hospital with symptoms over several weeks of headaches and vomiting after a recent history of chicken pox. The differential diagnosis was varicella, meningitis or encephalitis and two days later, after she deteriorated neurologically, she received a lumbar puncture. Three days later she suffered a seizure and irreversible brain damage. A CT scan performed at that point showed a brain tumour. As Australia does not have a no-fault system providing compensation to cover the long-term care required for such a condition, the girl (through her parents and lawyers) sued her treating physician. She alleged that, because a cerebral CT scan was not performed when clinically indicated after the diagnosis of meningitis or encephalitis and before the lumbar puncture, she had "lost the chance" to have her brain tumour treated before she sustained permanent brain damage. She succeeded at first instance, but lost on appeal. The High Court also rejected her claim, holding unanimously that there were no policy reasons to allow recovery of damages based on possible (less than 50%) "loss of a chance" of a better medical outcome. The court held that the law of torts in Australia required "all or nothing" proof that physical injury was caused or contributed to by a negligent party. The High Court, however, did not exclude loss of chance as forming the substance of a probable (greater than 50%) claim in medical negligence in some future case. In the meantime, patients injured in Australia as a result of possible medical negligence (particularly in the intractable difficult instances of late diagnosis) must face the injustice of the significant day-to-day care needs of victims being carried by family members and the taxpayer-funded public hospital system. The High Court in Tabet v Gett again provides evidence that, as currently constituted, it remains deaf to the injustice caused by State legislation excessively restricting the access to reasonable compensation by victims of medical negligence.     

A fatal overdose of the ergot derivative cabergoline

A 79-year-old woman, with Parkinson's disease treated with cabergoline, was admitted to a hospital due to jaundice and weakness. She was found confused, absent minded, and died after 2 weeks. Autopsy showed an extrahepatic bile duct adenocarcinoma with spread to the gall bladder, the liver, and regional lymphnodes. While cleaning the hospital bed after her death, the nurses found several tablets hidden in the bed. Biological samples obtained at the autopsy were screened for common drugs and narcotics. Several drugs such as buprenorphine, codeine, paracetamol, and propranolol were detected in the blood at therapeutic levels. A method to determine cabergoline in whole blood and other forensic matrices was developed, and further investigations determined cabergoline concentrations in whole blood and liver tissue of 94 and 3100 microg/kg, respectively. The blood concentration was 100 times above the therapeutic level reported on cabergoline in plasma and in combination with her symptoms, suggest she took a fatal overdose of cabergoline.     

Fatal Ischemic Enteritis with Hemorrhage—A Late Complication of Treated Wilms Tumor

A 35‐year‐old man with a history of childhood Wilms tumor successfully treated with radiotherapy, chemotherapy, and surgery, collapsed and died unexpectedly in hospital following admission for abdominal pain. At autopsy, there was ischemic necrosis of the small intestine with altered blood within the stomach and small intestine. Within the upper abdominal aorta, there was patchy confluent calcific atherosclerosis with extension into the proximal superior mesenteric artery which was occluded by thrombus. Death was attributed to ischemic enteritis of the small intestine caused by mesenteric artery thrombosis complicated by gastrointestinal hemorrhage with aspiration. Localization of atherosclerosis to the radiation field with no significant atherosclerosis elsewhere and the young age of the decedent were supportive of radiation‐induced atherogenesis. Geographically, localized atherosclerosis at autopsy in a tumor survivor should raise the possibility of a treatment‐related side effect that may directly contribute to death many years after the original therapeutic intervention.     

Traumatic dissection of the vertebral artery in a toddler following a short fall

Spontaneous subarachnoid haemorrhage (SAH) in children is uncommon, but is sometimes seen after rupture of aneurysms, and in different disorders. Traumatic SAH is common after serious accidental head injury, but is also reported after child abuse with vigorous shaking. To avoid unnecessary accusations of innocent care givers, it is important not to misinterpret the findings as abusive head trauma in small children with SAH. In the presented case, a nearly two-year-old girl was brought to the hospital after a fall witnessed by her father. The girl was unconscious, with elevated intracranial pressure, SAH and bilateral retinal haemorrhage (RH). She was pronounced dead after 9h. Premortem angiography revealed a dissection of the right vertebral artery, and postmortem examination revealed a traumatic lesion deep in the neck, at the base of the skull. Cerebral edema, in combination with SAH and RH, is highly suggestive of abusive head trauma. However, no external lesions, no skeletal lesions, especially no long bone metaphyseal lesions, or subdural haematomas occurring at the same time as SAH, were found. There was no report of previous child abuse in the family. Based on the radiological and postmortem findings, we believe that an accidental fall caused a blunt force trauma with a subsequent dissection of the right vertebral artery. To our knowledge, accidental tear of one of the vertebral arteries, leading to SAH in a toddler, has previously not been described. Child abuse is an important exclusion diagnosis with serious legal implications.     

Disseminated neonatal herpetic infection simulating abusive anal trauma

Potential simulators of premortem trauma present problems of misinterpretation and possible false accusations of caregivers. A case of unsuspected neonatal herpes is reported with associated perianal ecchymosis that raises the possibility of sexual abuse. The decedent was an 8-day-old newborn infant who was born by Cesarean section and treated for 5 days postdelivery for sepsis. The newborn infant was discharged home but returned 2 days later with probable sepsis and new onset of perianal hemorrhage. She died 1 day later with autopsy, revealing neonatal disseminated herpetic infection with early anal involvement consisting of microscopic ulcerations with leukocytoclastic-like vasculitis and rare viral cytopathic changes. These histological changes produced grossly appearing anal ecchymosis with an absence of typical herpetic vesiculopapular lesions, which simulated abusive trauma. This case highlights the importance of considering occult neonatal herpes with associated perianal ecchymosis when presented with possible abusive anal trauma in a newborn infant.     

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.     

输血与丙型肝炎因果关系鉴定及相关法律问题探讨

丙型肝炎病毒（ＨＣＶ）已成为输血后非甲非乙型肝炎的主要致病因子，但是要确定患者所感染的丙型肝炎与某次输血有必然的因果关系仍很困难。本文通过对一个案例进行研究，提出鉴定方法，即收集病人的所有住院病历，查阅病人输血前、输血后或者以后一段时间转氨酶的变化情况，尤其是伤后近期查出的转氨酶水平，基本上可代表伤前的水平。结合抗－ＨＣＶ抗体的变化，确定输血与肝炎间的因果关系。作者还结合我国法律，提出输血后感染丙型肝炎的患者可以“严格责任原则”起诉医院或者血库，医院或者血库承担举证责任，举证的内容包括其所提供血液的献血员来源合法，已作了法定的筛选检测，同时提供所有法定的记录档案，否则血库或者医院将承担败诉的民事责任。     

Vertebral artery dissection complicating occipital injection of heparin for treatment of thoracic outlet syndrome

A 38-year-old woman with a 2-year history of chronic neck pain radiating down her right arm underwent radiological and neurological evaluations, which revealed no anatomical cause for her pain. She sought alternative therapies including intramuscular heparin injections. Following a right occipital injection of heparin, cyanocobalamin, and lidocaine, she had a sudden cardiorespiratory arrest and was successfully resuscitated, but did not regain consciousness.Computed tomography of the head and neck and subsequent autopsy revealed a right vertebral artery dissection, but at autopsy, no significant subarachnoid hemorrhage was noted at the base of the brain. This is the first case report where heparin (a potent anticoagulant) used in an occipital injection was documented to cause a vertebral artery dissection. It is also the first reported case where radiographically and histologically documented vertebral artery dissection did not present with overwhelming subarachnoid hemorrhage at the base of the brain. The subtle gross anatomical findings in this case highlight the importance of evaluating the cervical spinal cord in any case of sudden cardiorespiratory arrest following even apparently minor neck injury.     

Fatal virus-associated hemophagocytic syndrome in a young adult producing nontraumatic splenic rupture.

A 24-year-old man with no previous medical history was admitted to a local hospital with pancytopenia after a recent "viral illness." During his hospitalization, he developed sudden abdominal distension and hypotension. Surgical exploration of his abdomen revealed a ruptured spleen. The spleen was removed, but the patient did not survive the operation. We investigated this unexpected and unexplained hospital death for any traumatic or iatrogenic injury. The cause of death after review of the clinical history, autopsy, and microscopic sections was virus-associated hemophagocytic syndrome (VAHS). VAHS consists of a generalized histiocytic proliferation and marked hemophagocytosis associated with a systemic viral infection. Clinically it presents as pancytopenia and organomegaly. This recently described entity is often confused with malignant histiocytosis. This is the first case report of VAHS producing nontraumatic splenic rupture, thus adding to the differential diagnosis of spontaneous splenic rupture and sudden natural death.