头颈外伤致椎动脉破裂伴颅底蛛网膜下腔出血1例尸检分析

头颈外伤致椎动脉破裂伴颅底蛛网膜下腔出血１例尸检分析易旭夫，刘敏，吴家Ｓｕｂａｒａｃｈｎｏｉｄｈａｅｍｏｒｒｈａｇｅｄｕｅｔｏｒｕｐｔｕｒｅｏｆｔｈｅｖｅｒｔｅｂｒａｌａｒｔｅｒｙａｓｓｏｃｉａｔｅｄｗｉｔｈｈｅａｄｔｒａｕｍａ：ｒｅｐｏｒｔｏｆｏｎ...     

Blunt basal head trauma: rupture of posterior inferior cerebellar artery.

Two cases are reported of rupture of posterior inferior cerebellar artery (PICA) from blunt basal head trauma. The anatomy at the site of rupture is discussed as a prerequisite for rupture. The rapid fatal course is also discussed. The authors propose that the forensic term "traumatic subarachnoid haemorrhage" ought to be abandoned and replaced by the nature and localization the source of bleeding, analogous to clinical practice at the spontaneous haemorrhage from rupture of aneurysm.     

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.     

Medicolegal diagnostic value and clinical significance of traumatic incomplete tears of the basilar artery

Ruptures of arteries of the vertebrobasilary system are relatively frequent in medicolegal practice, and their origin may be both natural and violent. Tears that affects the whole thickness of the basilar artery cause subarachnoid hemorrhage (SAH), with an often rapid fatal outcome. 1-3 However, in some situations, arterial tears may be incomplete, involving the intima or both the intima and the media, but with preserved adventitia. 1, 4 Although such incomplete tears are not the source of immediate subarachnoid bleeding, their presence may be important from both a medicolegal and a clinical point of view.The aim of this article is to point out the significance of incomplete tears of basilar artery as a possible diagnostic sign of traumatic origin of SAH as well as a certain mechanism of injury, which involves forcible hyperextension and rotational movements of the head. The authors also describe their method of performing longitudinal section of the basilar artery, both at autopsy and for histologic examination, which is convenient for identifying multiple transversal incomplete tears of this blood vessel. The article is based on the analysis of three cases from the autopsy material of the Institute of Forensic Medicine in Belgrade.     

Extra- and intracranial injuries of the cerebral arteries as a sequela of assault

The case of an 47-year-old man is reported, who was injured in a fight while under the influence of alcohol. The culprit knocked him down and stamped several times on the left side of his head. The victim became unconscious. At the hospital, subarachnoid hemorrhage and massive ventricular bleeding was diagnosed via CT. Despite the implantation of a ventricular shunt, there was repeated massive cerebral pressure and arterial bleeding. Brain death occurred after 8 days. The main finding at autopsy was nearly complete disruption of the left inferior posterior cerebellar artery as the source of the lethal bleeding. The histological examination showed some additional, incomplete ruptures of this vessel and of the left intracranial vertebral artery. This is a typical result of "minor head injuries" sustained in fights: arterial rupture (ipsilateral) as a result of overstretching. Fracture of the left zygomatic arch and maxilla; no skull fracture; no primary traumatic brain damage. The extracranial carotid arteries were intact. When the vertebral arteries were examined (in the undamaged cervical spine), there was a surprising finding: distant dissection of the right vertebral artery between C1 and C2, which perhaps occurred as a result of compression (contralateral to the impact) of this region.     

Fatal subarachnoid hemorrhage complicating actinomycotic meningitis

Actinomycosis is caused by Gram-positive Actinomyces species that are part of the normal oral flora with low virulence. We describe a rare case of sudden death of a 48-year-old man with actinomycotic basilar meningitis that was complicated by fatal subarachnoid hemorrhage. Autopsy revealed meningitis at the basilar region of the brain, and histological examination revealed characteristic bacterial aggregates with extensive leukocyte infiltration and severe vasculitis of arteries of this region. Rupture of an artery by severe arteritis was thought to be the cause of the subarachnoid hemorrhage. The probable primary source of infection was found in the left lung. To the best of our knowledge, the complication of subarachnoid hemorrhage has not been reported previously in actinomycotic meningitis.     

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.     

Vertebral artery rupture in traumatic subarachnoid haemorrhage detected by postmortem angiography

A fatal subarachnoid haemorrhage from a ruptured normal intracranial vertebral artery in a 49-year-old male, following a blow to the head, was revealed by a postmortem angiographic technique using radiopaque silicone rubber as a contrast medium vulcanizing at room temperature. No fracture of the atlas or connection between intracranial vessels and extracranial soft tissue haematoma could be visualized. We advocate the use of postmortem angiography in the diagnosis of suspected head trauma sustained in fights.     

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.     

Fibromuscular dysplasia of the basilar artery: an unusual case with medico-legal implications

A 28-year-old male car driver was reported to suddenly loose the control over his vehicle, to hit the right and middle crash barrier, and to be unconscious as the car came to a halt in a position at right angles to the road. The car was hit in its left side by an automobile with high velocity, and the 28-year-old driver died. Examination of the brain revealed a massive isolated basal subarachnoid hemorrhage and a complete tearing of the basilar artery. A macroscopically detectable aneurysm was not found. However, histological examination of the large arteries at the base of the brain showed (i) fibromuscular dysplasia (FMD) mostly involving the basilar artery (ii) with a ruptured micro-aneurysm in its upper third part. The observations of the eye witnesses that the driver initially lost control over his car were judged in favour of the accused to be due to that rupture of the micro-aneurysm, while complete transverse tearing of the basilar artery occurred during the car crash due to hyperextension and rotation of his neck. Intracranial FMD is a rare cause in the differential diagnosis of isolated basal subarachnoid hemorrhage. The medico-legal implications of this entity are described in the presented case.     

Traumatic rupture of intracranial vertebral artery due to hyperextension of the head: reports on three cases

In three cases of fatal basal subarachnoid hemorrhage due to rupture of the normal intracranial vertebral artery, the ruptures appeared to have been caused by overstretching of the vertebral artery from traumatic hyperextension of the head. In the first case, that of a 31-year-old male pedestrian who, while intoxicated, had been hit from behind by a car, symmetrically located bilateral complete and incomplete tearing of the vertebral arteries was found. In both of the other two cases, involving women aged 37 and 51 found dead after receiving fist blows to the face while intoxicated, complete rupture of the vertebral artery was found. The blood alcohol concentrations of the three cases ranged from 1.6 to 1.7 mg/g at autopsy.     

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 thrombosis of internal carotid artery following minor blunt trauma to the neck

Fatal traumatic thrombosis of the left internal carotid artery occurred in a 38-year-old man following minor blunt cervical trauma during an altercation. There was no external injury observed on the head, face, or neck. Neurologic deficit developed soon after the injury, which progressed to right hemiplegia. His condition deteriorated and he expired on the sixth hospital day. The gross and microscopic findings of the internal carotid artery are presented and the significance of minor cervical blunt trauma and the possible mechanism for the vascular lesion are discussed.     

Posttraumatic thrombosis of the middle cerebral artery

Posttraumatic cerebral infarction resulting from carotid or cerebral artery occlusion is rare. Traumatic dissection of the carotid artery is the most frequent cause of infarction, whereas posttraumatic thrombosis of the cerebral artery is very rare. The authors describe a case of posttraumatic thrombosis of the left middle cerebral artery. Early in the morning, a 16-year-old boy was found unconscious in the parking lot of a supermarket. He had received fist blows and kicks to the head, face, body, back, and hip during the night. Computed tomography 10 hours after the violence revealed a gross cerebral infarction in the area of the left middle cerebral artery. He died 9 days after the violence. The autopsy revealed a thrombosis in the left middle cerebral artery. Microscopically, granulation tissue in the intima and a rupture of the internal elastic lamina were observed near the beginning of the artery. It was concluded that the blows to the head and face caused a partial rupture in the arterial wall, leading to thrombosis and cerebral infarction.     

Vertebral artery rupture in a sudden death case after mild trauma

We report a case of subarachnoid hemorrhage at the skull base with possible rupture of a vertebral artery, and we present a new method to investigate rupture of this artery. In this method, the brain stem and cerebrum are divided with ligation of the internal carotid artery and basilar artery, and milk is injected from the original part of the vessel to find the rupture. We show that this method is particularly useful for cases of subarachnoid hemorrhage at the skull base in which there may be rupture of a vertebral artery.     

Fatal traumatic rupture of an aortic aneurysm of the sinus of Valsalva: an autopsy case

This report describes an autopsy case of a rare type of aortic sinus of Valsalva aneurysm, which caused fatal rupture from a blunt chest impact. A 51-year-old male was hit in the chest with a fist, lost consciousness after about 15min and died after approximately 7h. The postmortem examination revealed a large saccular aneurysm of the right coronary sinus bulging on the right atrium, which had a full laceration causing pericardial hematoma (cardiac tamponade). A related chest wall injury was observed in the right outer mammary region. A rare type of bulging onto the right atrium and subsequent sclerosis of the right coronary artery appeared to have greatly contributed to the fatal rupture.     

A Case of Fatal Spontaneous Varicose Vein Rupture—An Example of Incorrect First Aid

Abstract:  Severe external bleeding due to varicose vein rupture is a rare complication of this frequent venous pathology. Venous bleeding can be very intensive and can be mistaken for arterial hemorrhage. A rare case of fatal varicose vein rupture with an example of an incorrect and ineffective first-aid technique in a 43-year-old man is reported here with a review of the recent literature. The victim was found on a sand stack, not far from his domicile in a large pool of blood. The external examination revealed a flat ulcer on the internal surface of the right shank. On dissection, the lesion contained a perforation that was continuous with superficial veins arising from a varicosed saphenous vein. The man tried to give himself first aid, due to the massive bleeding that he probably predicted arterial bleeding and applied the ligature closer to the heart above the bleeding defect, thereby not stopping the venous bleeding but exacerbating it. Death was caused by a hypovolemic shock because of external hemorrhage from a varicose vein.     

Traumatic subarachnoid haemorrhage: a 10-year case study and review

Fourteen cases of traumatic subarachnoid haemorrhage (TSAH) from the years 1985-1995 are described. Two of these cases, one paediatric and one involving controlled substances, are considered separately. All 14 cases are then discussed together with the current literature with respect to: typical subject, the circumstances and aetiology of injury, time interval between injury and collapse; time of survival, the role of alcohol, the site of arterial rupture, and the methods recommended by other authors for the location of such an injury. We conclude that TSAH is a poorly understood cause of sudden death; fuller research is needed to clarify aetiology.     

Subarachnoid hemorrhage during sexual activity after sildenafil intake: an accidental association?

We report and describe an autopsy case of a man dead for rupture of cerebral artery aneurysm with subsequent subarachnoid hemorrhage after sexual intercourse. Toxicologic analysis demonstrated that he had consumed sildenafil (Viagra). Although subarachnoid hemorrhage has been reported to be associated with sexual intercourse, it is not among the known adverse effects of sildenafil. However, sildenafil has been found to interact with vascular physiology via multiple mechanisms and in most of the vascular districts of the human body. This case provides an example of a very rare association between this drug and a fatal pathologic event and deserves to be added to the existing clinical knowledge about sildenafil and the pathophysiology of the events involved. This knowledge may be helpful in orienting further investigation into the mechanisms of action of sildenafil and their clinical implications.     

Cardiac Ventricular Laceration Due to Child Abuse: Abusive Ventricular Laceration

Traumatic cardiac ventricular ruptures in children are rare. Only a single case of left ventricular rupture due to child abuse has been reported. We report a child who sustained a fatal left ventricular apical rupture. It appeared to have resulted from hydrostatic forces resulting from abusive blunt thoracic injury. That he was being abused was previously missed when he was presented to the emergency department with facial pyoderma. It was not noted that he also had lip and oral mucosal injury, sites not affected by staph toxins. As a result, his underlying, abusive and secondarily infected, facial flow type scald burn was not appreciated. Within a week thereafter his fatal injury occurred, accompanied by extensive and obvious associated abusive injuries. Postmortem high‐detail whole body computed tomography scanning aided the autopsy. Although rare, ventricular rupture from abusive blunt thoracic injury can occur.