Cardiac Inhibitory Reflex as a Cause/Mechanism of Death

The role of cardiac inhibitory reflex as a potential cause of death is still a matter of debate. This study reports two cases of death under unusual circumstances. Case 1 corresponds to a man found hanging where the role of ligature compression of the carotid sinus became relevant as a possible explanation of death. In Case 2, the participation of a vasovagal syncope was clearly triggered by the laryngoscopic procedure. It is proposed that cardiac inhibitory reflex should be taken into account in those cases of unexpected death, which fulfills the following three criteria: (i) The investigation of the circumstances of the death is consistent with a hypothesis of cardiac arrest. (ii) A typical triggering peripheral stimulus is present. (iii) The performance of a complete autopsy cannot rule out the participation of a cardiac inhibitory reflex in the cause of death.     

Histological examination of the carotid bifurcation in case of violence against the neck

The carotid body and carotid sinus are localized in the area of the carotid bifurcation and respond to pressure fluctuations in the arterial blood vessel system. In case of irritation or stimulation, nervous impulses can reflexively increase the ventilation or slow down the heart rate and blood pressure, respectively. The external stimulation of the carotid sinus by neck compression with subsequent bradycardia or asystolia, especially in pre-existing heart-disease, is discussed controversially in the literature. Histological examination of the tissue of the carotid bifurcation, particularly with regard to haemorrhage as an indication of tissue trauma, should be carried out in terms of simple and easy feasibility in routine diagnostics. In 20 cases of violence against the neck and additionally 82 cases of a control group without neck trauma and variable causes of death, the carotid bifurcations were examined histologically. Only in one case of violence against the neck haemorrhage was found, which suggested a direct trauma to the tissue of the carotid bifurcation, but evidence of lethal cardiac reflex was not found in any case.     

The deadly broomstick: an unusual missile injury to the neck

A 51-year-old man was struck by the tip of a broomstick weighing 1000 g at the left side of the neck, upon which he collapsed. Intense but delayed cardiopulmonary resuscitation restored the circulation roughly 30 minutes after the incident. Upon admittance to a nearby hospital, an extensive hypoxic cerebral damage was diagnosed. Death due to the severe cerebral damage occurred 5 hours after the incident. An autopsy demonstrated a severe subcutaneous traumatization of the left side of the neck, with a hemorrhage compressing the carotid bifurcation. A prolonged excitation due to this ongoing compression of the baroreceptors in the carotid sinus was assumed to have led to a cardiac arrest. In this case report, the authors discuss the underlying pathophysiology of this potentially lethal and rare reflexogenic incident also known as the Hering reflex and discuss possible therapeutic measures.     

Trigemino‐Cardiac Reflex as Lethal Mechanism in a Suicidal Fire Death Case

In the vast majority of immediate fire deaths, the mechanism of death is inhalation of toxic gases (especially carbon monoxide), direct thermal injury, or neurogenic shock due to the redistribution of the body's blood volume produced by surface heat on the skin. We present a suicidal case that is unusual because the mechanism of immediate fire death could arguably be explained in terms of a primitive autonomic reflex/the trigemino‐cardiac reflex. Although this reflex is well known to surgeons and anesthetists, with possible lethal consequences in the course of invasive surgical procedures on the head and neck region, it is much less familiar to forensic pathologists.     

Morphometrische Untersuchungen bei stenosierender Koronarsklerose und ihre Bedeutung für die Bewertung konkurrierender Todesursachen

Coronary sclerosis is generally supposed to be the most important factor for coronary thrombosis, myocardial infarction and coronary heart death. Stenosing coronary sclerosis may be postmortally documented by angiography and morphometry. It is possible to obtain sufficient morphological data to suggest acute cardiac insufficiency, if the maximum grade of stenoses as a functional parameter and the heart weight are regarded in addition to the quantitative results of the three main branches of the coronary arteries (lumen and intima areas).Generally the cardiac results of autopsy are used individually and subjectively for the explanation of the cause of death. The conclusiveness of these results of autopsy depends on the circumstances of death and the existence of further pathological findings. Competing causes of death may exist in the form of illnesses, injuries, alcoholic and drug effects, physical strain and emotional stress or medical provisions. The quantitative valuation of the cardiac findings with a critical limit for an acute coronary death permits a more exact interpretation of such competing causes of death. This method of examination may also reveal an unpresumed competing cause of death, for example an intoxication. This was demonstrated by four autopsy cases.     

Apparent partial hanging

A careful analysis of circumstances and investigations of death scene are required before commenting on the manner of death in a case of hanging. Hanging may result from either complete or incomplete suspension of the body. Two cases of hanging are reported where discrimination in eyewitness's account and death scene investigation report was evident regarding type of hanging (complete/partial). The use of term apparent partial hanging is proposed in such cases. Body position in hanging is one of the numerous factors that determine the strength of the neck compression by the ligature and thus should be considered in the evaluation of dying process and pathomorphologic feature of hanging. The cases also put a probable explanation to the higher incidence of partial hangings in different studies. We believe that incidence of true partial hangings may be much lower than that reported in the literature.     

Sudden death after a cold drink: case report

We report a case of sudden cardiac death in a 12-year-old boy after rapid ingestion of a frozen slurry drink. The cause of death was determined to be a cardiac arrhythmia secondary to a previously undiagnosed cardiac rhabdomyoma with associated myocardial scarring. Ingestion of cold liquids has been associated with syncope, but not sudden cardiac death. In this case, bradycardia induced by cold-induced vasovagal reflex may have precipitated the terminal arrhythmia. Ingestion of cold liquids should be considered a potential trigger for fatal cardiac arrhythmias in patients with underlying heart disease.     

Reenactment of circumstances in deaths related to restraint

Reenactment of the circumstances in deaths associated with restraint, utilizing participants and witnesses while memories are fresh, may help death investigators more accurately determine the cause of death. Two recent deaths in Ventura County that occurred during restraint are discussed. Within a day of the autopsies the restrainers agreed to participate in reenactments of the restraint process, utilizing live volunteers as subjects. They allowed videotaping. Deaths associated with restraint often have nonspecific autopsy findings. Timely reenactment of the circumstances of deaths associated with restraint can help death investigators more accurately determine the probable cause of death in these difficult cases.     

Sudden unexpected death from cardiac concussion (commotio cordis) with unusual legal complications

Sudden and unexpected death may result from cardiac concussion following blunt force trauma to the thorax. Undiagnosed pathologic disease must be carefully evaluated as a possible contributory element. Legal complications may arise from any autopsy. It is recommended that a photograph be taken upon completion of the autopsy. This photograph and adequate records can be used to refute any charges against the pathologist or assistants for the poor condition of a body after its release.     

Sniffing-associated deaths in Denmark

An account is given of 20 deaths, which occurred in association with sniffing during the period 1959 – 1978. The annual number of deaths was almost constant during the period. Most of the deaths occurred in males. Ether and trichloroethylene were the predominant toxic substances. The material was divided into two groups. Group A, 14 cases, included real sniffing deaths, the cause of death being poisoning by the substance inhaled. In group B, 6 cases, sniffing was a contributory factor to death: 2 cases of suffocation by obstruction, one case of carbon monoxide poisoning during fire, one case of septicemia/severe anemia caused by bone marrow depression, and one case of bleeding to death from stab wounds inflicted by a sniffer against a non-sniffer. The circumstances before and at the time of death are reported, together with the autopsy and toxicological findings when these were performed.     

Evaluation of certifier practices regarding alcohol-related deaths: Fulton County Medical Examiner's Center, Atlanta, Georgia, 2004

CONTEXT: Alcohol can contribute to various manners of death by acute intoxication that places a person at risk for fatal injury, acute fatal alcohol poisoning, or the various fatal complications of chronic abuse with or without superimposed acute intoxication. The reporting of alcohol use on the death certificate may vary with office policy or procedure, certifier judgment, and the timing of information received during investigation. OBJECTIVE: To determine the number of deaths including mention of alcohol use in the investigative case file, the number of death certificates on which alcohol use is reported, the number of discrepancies between the 2, and the possible reasons for observed discrepancies. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case review of all deaths where alcohol use was mentioned in the investigative case file and/or on the death certificate for deaths investigated by the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between January 1, 2004, and December 31, 2004. MAIN OUTCOME MEASURES: Percentage of deaths with alcohol use reported on the death certificate, tabulation of where and how alcohol use is reported on the death certificate, and tabulation of the differences between the investigative case file and death certificate regarding alcohol's possible role in causing death. RESULTS: Among the 1324 deaths certified by the office, 105 (8%) had alcohol use reported on the death certificate. The majority (67%) of these cases were natural deaths. Sixty-nine (5%) deaths had mention of alcohol use in the investigative case notes but did not include it on the death certificate. Twenty-five (2%) deaths had mention of alcohol on the death certificate but did not have mention of it in the investigative case file based on our search criteria. However, subsequent review of additional case follow-up information disclosed a history of alcohol use or acute intoxication in each case. CONCLUSIONS: The data show that more natural deaths are considered to be directly caused by alcohol than other manners of death. For the unnatural manners of death (excluding acute alcohol poisoning), alcohol use is often viewed by medical examiners as an incidental, associated finding or risk factor surrounding the circumstances of death rather than being an actual cause of death. In such cases, alcohol use is often omitted from the death certificate. For deaths directly caused by alcohol, the proportion of cases involving possible underreporting or overreporting of alcohol involvement was relatively small and usually involved the omission of chronic alcohol use from the death certificate. Researchers need to be aware of potential limitations of death certificate data for studying alcohol-related deaths.     

Impact of Myocardial Infarction and Abnormalities of Cardiac Conduction System on Sudden Cardiac DeathCSCD

Sudden cardiac death (SCD), most commonly seen in coronary heart disease, is a kind of sudden death caused by series of cardiac parameters, which usually combines with myocardial infarction. However, some SCDs (including early myocardial infarction) happen suddenly and cause death in a very short time. In these circumstances, typical morphological changes are lack in macroscopic or microscopic fields, which make such SCDs become the emphasis and difficulty in the present research. SCD caused by myocardial infarction and abnormalities of cardiac conduction system (CCS) is related to atherosclerosis of coronary artery closely. This paper reviews cardiac dysfunction caused by myocardial infarction and diseases of CCS from morphology and molecular biology, and explores potential relationship between them. This paper aims to provide clues to the mechanism of myocardial infarction related sudden death and possible assistance for forensic diagnosis of SCD. © 2017 by the Editorial Department of Journal of Forensic Medicine.     

Forensic Considerations in Cases of Myotonic Dystrophy at Autopsy

Myotonic dystrophy (DM) is a chronic, slowly progressive, autosomal‐dominant disorder with delayed muscle relaxation after contraction, distal skeletal muscle weakness, and atrophy. It has a reduced life expectancy due predominantly to respiratory failure or sudden cardiac death. The mortality rate is approximately 7.3 times greater than the general population with a mean age at death of 53 years. Degeneration of the cardiac conduction system causes atrioventricular block, arrhythmias, and ventricular failure. A case of sudden death in a 44‐year‐old woman with DM type 1 is reported to demonstrate an alternative lethal mechanism. At autopsy, there was extensive infiltration of skeletal muscles with adipose tissue. The heart was structurally normal. A deep venous thrombosis of the right calf was identified with a large saddle pulmonary thromboembolus and bilateral peripheral thromboemboli. DM1‐related thrombosis had most likely occurred because of the decedent's impaired mobility, possible hypercoagulable state, and serum changes from muscle necrosis.     

Sudden death in the alcoholic

A study of victims of alcohol abuse was performed on the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida. During the year 1983, all cases in which alcoholism, either acute or chronic, was the cause of death primarily or contributory in a natural or accidental manner of death were collected. These 118 cases were then analyzed as to the age, race, sex, and cause of death of the victim along with the blood alcohol content, the drugs detected at autopsy, the scene circumstances, the geographic location of the terminal incident, noting whether or not there was a history of drinking prior to the terminal incident, the average weights of key target organs, and the histopathology of the liver. The most common victim is an older (greater than 50 years) white male who dies from "chronic alcoholism" with a terminal negative blood alcohol. This victim is usually "found dead" at home with a past history of drinking, and histopathologically the liver depicts fatty metamorphosis rather than cirrhosis.     

Fatal Drowning Accident and Undiagnosed Hydrocephalus

Abstract: Bodies found in water present several diagnostic challenges for the forensic examiner, such as the identification of the time and mechanism of death, the postmortem submersion time, and above all the circumstances of drowning. We report the case of a 33‐year‐old security guard found dead in Venice, in the water of the lagoon, who at autopsy presented a previously undiagnosed hydrocephalus with macrocephaly. The victim remained asymptomatic until 2 months before death and had never undergone a neurological or radiological examination. In the article, we emphasize the need to perform a thorough autopsy in all suspected drownings, discuss the etiopathogenesis of the neurological disease and hypothesize a possible relationship between the hydrocephalus and the drowning accident. Finally, we discuss the major clinical and forensic implications of macrocephaly and hydrocephalus in adults.     

Comparing Known and Reconstructed Circumstances of Death Involving a Blunt Force Trauma Mechanism through a Retrospective Analysis of 21 Skeletonized Individuals

Little is known about to what extent the events surrounding death can be reliably reconstructed from blunt force trauma analysis alone. In this study, we reconstruct circumstances of death from a blind blunt force trauma analysis using a sample of 21 individuals of known death circumstances, obtained from two identified skeletal collections in Portugal. Fresh versus dry bone trauma and probable mechanism of fracture production were identified. The overall pattern of injuries was then used to reconstruct the most likely circumstances of death. Results show an agreement between the proposed and the reported circumstances for 13 individuals (68.4%), disagreement for 3 (15.8%), and similarity in 3 cases (15.8%). Although the significant amount of agreement highlights the potential of trauma analysis, the cases with disagreement draw attention to the pitfalls and shortcomings of attempting to reconstruct the death circumstances from skeletal trauma analysis alone.     

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.     

An unusual case of sudden unexpected death: postmortem investigation and biomechanical analysis of the cervical spine

A naked man died under peculiar circumstances and the postmortem examination revealed unexpected lesions in the cervical spine. Investigations of the cervical spine (computed tomography, magnetic resonance imaging, and histological examination) showed that a piece of bone was torn of the anterior part of vertebra C6 and that there was fresh bleeding in the surrounding tissue. The cause of death remained unclear but was most likely cardiac arrhythmia initiated by beta-2 agonist inhalation due to an acute asthmatic attack. Data from biomechanical investigation using finite element analysis supported the conclusion that the cervical spine injury was secondary to impact during falling as a consequence of the cardiac arrhythmia.     

Left Ventricular Aneurysm: Sudden Unexpected Deaths in a 29‐Year‐Old Man

Left ventricular aneurysm (LVA) is an abnormal dilated heart structure, either congenital or acquired. LVA is a rare cardiac condition with no symptoms in most cases, thus occasionally diagnosed during investigations of other diseases. Its association with certain cardiac complications and sudden cardiac deaths has been reported. However, its role as a cause of sudden unexpected death is rare. The author reported a sudden cardiac death in a 29‐year‐old man with LVA. Without a significant coronary artery disease and known etiologies of LVA, such an abnormal heart structure in the present case was considered congenital LVA. As no other possible mechanisms of death could be identified other than LVA with its associated pathologic lesions, mural thrombi, and dilated cardiomegaly, his death was attributable to fatal cardiac arrhythmia (most commonly ventricular tachycardia) secondary to LVA.