青年人CCS脂肪超前变化致猝死

为研究心传导系统（CCS）与猝死的相互关系，对120例心性猝死者CCS作常规检查，光镜下作半定量计算其脂肪含量。结果发现：9例经一般常规尸检未找到任何致死原因的青年人（30岁以下），其房室结（AVN）与房室束（HB）的脂肪组织含量为70％，比同龄人明显增多，致使结、束肌细胞被脂肪分割中断或压迫萎缩。结内外细胞连接不足或缺失是构成心电不稳的病理基础。此外本文尚对其脂肪浸润的病因发病，猝死机理作了探讨。     

Evaluation of a simplified method of the conduction system analysis in 110 forensic cases

A simplified method of the His bundle analysis is evaluated by the study of 110 forensic cases. The atrioventricular node or its part were observed in 96 cases (87.3%), penetrating bundle in 92 cases (83.6%), branching and left bundles branch in 109 cases (99.1%) and right bundle branch in 73 cases (66.4%). The changes such as fibrosis and fatty infiltration show statistically significant differences (P<0.01) between progressive age groups confirming their degenerative and age-related nature. The study included as well nine cases of sudden unexpected death and two cases of sudden infant death syndrome (SIDS), for which the autopsy with histological examination and toxicological analysis resulted negative. For nine of these cases, pathological lesions were found which can even explain the fatal issue. Moreover, in the cases with known cause of death, potentially lethal changes were noticed. This simple, low cost technique could be proposed to forensic pathologists as easy to fit into the routine processing of autopsy material, allowing the detection of major abnormalities with minimal effort. The authors also consider the difficulties related to the interpretation of the pathological findings in the conduction system.     

Diagnostic value of post-mortem examination of the cardiac conduction system

Introduction (Aim)

Sudden unexplained death (SUD) is a common problem in forensic pathology. In many of these cases, the autopsy findings, toxicological examinations and patient history are inconclusive. Many studies suggest that in such cases, the cardiac conduction system (CCS) should be histologically examined. We decided to determine the diagnostic value of histological examination of the CCS.

Methods

We reviewed autopsy files from the period 2005–2007 and selected those cases in which the CCS had been sampled. These were divided into two groups, the first comprising cases with an obvious cardiac pathology (e.g. severe coronary disease, myocardial infarction, significant myocardial hypertrophy/dilatation, valvular disease, etc.) and the second comprising cases without obvious cardiac pathology (i.e. fatal injuries, intoxications and deaths unexplainable by routine procedures). The CCS was sampled according to a detailed protocol and examined under a light microscope. On the basis of the findings of histological examination of CCS, we formed subgroups of the aforementioned main groups.

Results

We analyzed 118 cases, of which 83 were males and 35 females. In 57% of cases, autopsy revealed gross pathological abnormalities of the heart. In 10 (15%) of them, examination of the CCS showed significant pathological changes (narrowing of the nodal artery and its branches, moderate to severe interstitial fibrosis, calcifications in the central fibrous body impinging upon CCS). In some, especially those with no acute findings, CCS disease can be considered to have been the cause of fatal arrhythmias. In 43% of cases, autopsy revealed no gross abnormalities of the heart, while histological examination of the CCS disclosed significant pathological changes in 4 (8%). Among them, CCS disease was regarded as the cause of death in one case and as a possible cause in another case.

Conclusion

As with other similar studies, our study showed that examination of the CCS can provide valuable information on the cause of death. We therefore consider that examination of the CCS should be performed in all SUD cases, especially those in which the cause of death cannot be established by routine procedures. Although we had only 1 confirmed cause of death linked to CCS disease and one possible, we had 14 cases with significant pathological CCS changes. This leads us to the conclusion that post-mortem examination of the CCS is of diagnostic value.     

Sudden death resulting from lesions of the cardiac conduction system

Sudden unexpected deaths in young persons with noncontributory histories, autopsy results, and drug screen results are a common problem in forensic pathology. As part of the evaluation of such cases, the cardiac conduction system (CCS) should be studied. To determine the type and incidence of lethal CCS lesions, the authors reviewed their files of sudden unexpected cardiac deaths with particular attention to cases with causes of death in the conduction system. Cases of sudden cardiac death in patients aged < or=40 years during a 10-year period (Michigan) and a 4 year-period (Spain) were selected from the files. From this group, cases were identified in which the cause of death was a lethal change in the CCS. The portions of the heart containing the CCS were excised, and at least one hematoxylin and eosin slide and at least one trichrome or elastic trichrome slide per block were studied. In the two centers, 381 cases of sudden cardiac death were identified. The most common causes of sudden cardiac death were arteriosclerotic narrowing of the coronary arteries, cardiomyopathy, and myocarditis. In 82 cases, there was no identifiable cause of death even after complete gross and microscopic autopsy was performed, a medical history was obtained, and a drug screen was performed. In 11 cases, the CCS contained lesions that were considered lethal: narrowing of the atrioventricular node artery by fibromuscular hyperplasia (7 cases) and atrioventricular node tumors (4 cases). The 11 cases accounted for 2.9% of the 381 cases of sudden cardiac death and 11.8% of the indeterminable cases. It was concluded that examination of the CCS in deaths in which the gross and microscopic autopsy, history, and drug screen fail to provide a cause of death can yield a cause of death in a significant percentage of cases. If heart block was not documented during life and no explanatory lesions were found during routine cardiac examination, examination of the CCS can yield valuable information.     

886例人心传导系统形态变异研究

探讨划分心传导系统 (CCS)变异与发育异常的界限。用本组建立的CCS检查法[1] ,连续切片 ,HE或Masson三色染色 ,光镜检查 ,对非心源性死亡组 (737例 )和心源性猝死组 (14 9例 )进行形态学及死因对比分析。结果显示 :(1)人CCS具有大小、位置和形态的先天性变异 ;(2 ) 4例心源性猝死者的房室结、房室束发育异常。房室束分叉部向室间隔膜部内移位、偏向于室间隔左侧、向左下侧移位 ,以及不足 1/2房室结移位至中心纤维体内、普通心肌移位至房室束或左束支内等应属变异 ;成年人胎儿型房室结及房室结全部移位至中心纤维体内或房室束完全分成 3束以上 ,房室束分叉部移位至三尖瓣根部应视为发育异常     

Mahaim纤维致猝死5例

寻找心源性猝死者的病理形态学诊断依据。采用本组建立的心传导系统检查法 ,对 16 5例无心外器官疾病猝死者的心脏 ,作心传导系统的组织学检查。发现 5例存在心传导系统Mahaim纤维 ,全部均为束室束型。本组Ma haim纤维的形态学与房室束 (HB)或左束支 (LBB)相似 ,胞体横径在 10～ 35 μm左右 ,胞浆丰富 ,色淡红染 ;来自HB的纤维胞体呈细条状 ,核居中 ;来源于LBB的则按其始发点不同自上而下逐渐变大 ,纵切细胞未见分叉 ,但部分细胞周围见有一薄层结缔组织包围。分析结果表明 ,Mahaim纤维是可致猝死的房室传导旁路。     

32例无心外原因猝死者传导系统病理学观察

在对32例无心外原因猝死者传导系统(CCS)组织学观察中,发现31例 CCS 有异常和病变,其中11例可致猝死。这些病变包括有急性炎症、出血、脂肪浸润和结内外神经病变,且与猝死有关。     

6例心脏传导系统病变致交通事故的病理学观察

检查100例交通事故死亡者的心脏传导系统（CCS），发现大部分存在着程度不同的病变。其中6例的SAN、AVN、AVB及LBB、PBB起始部见明显的出血、炎症、脂肪浸润、纤维化、神经病变和结动脉狭窄等病变。结合案情与现场勘查，6例交通事故与CCS病变导致心律失常有关。     

心脏神经病

目的 研究心源性猝死的病理形态学。方法 用本组建立的CCS检查法对179例心源性猝死者作常规CCS组织学检查。结果 发现8例心脏神经或神经节内有出血、炎症或肿瘤浸润,伴神经组织水肿、变性、坏死,而其他病变不足以解释猝死。结论 一切原发或继发性心脏神经病均可致猝死。     

20例脂肪栓塞死亡的法医学分析

目的分析脂肪栓塞综合征（fatembolismsyndrome,FES）死亡的一般情况以及法医病理学特点,为此类案件的法医病理学鉴定提供参考。方法选取某大学法医学鉴定中心1999—2012年20例FES死亡案件．对其一般情况及法医病理学特点（包括致伤方式、损伤类型、临床表现、病理学改变等方面）进行总结。结果脂肪栓塞主要见于损伤导致的长骨骨折和全身大面积软组织损伤,主要类型为肺脂肪栓塞,偶见合并脑脂肪栓塞。症状多出现在伤后和术后较短时间内,组织病理学检查可在肺小血管内检见大量脂滴并经特殊染色证实。结论FES死亡案例在损伤类型、脂肪栓塞出现症状时间及组织病理学表现等方面均有一定规律和特点。在鉴定中应注意进行特殊染色（油红0染色）处理,寻找FES的直接证据。     

颅脑损伤后心内膜下出血的病理及心电图改变

研究颅脑损伤后心内膜下出血的病理改变及其法医学意义。利用68例颅脑损伤的尸检和临床病历资料,以及相应心内膜下出血的心脏标本,以病理组织学方法观察心肌损害,分析心电图异常图形。结果显示：早期主要为左心室内膜下新鲜出血,浅层心肌出血,心肌散在灶状变性、横纹消失等心肌缺血性改变。晚期主要为以多形核白细胞为主的浸润,成纤维细胞增多,早期心肌瘢痕形成等心肌梗死样改变。21倒心电图异常以窦性心动过速和ST-T改变为主,严重的出现心律紊乱和房室传导阻滞。研究颅脑损伤后心内膜下出血的病理改变和心电图异常,在法医学实际检验鉴定和临床救治方面有重要的应用价值。     

婴幼儿猝死综合征心传导系统的免疫组化研究

作者应用ＰＧＰ９．５与抗Ｓ１００抗体和高压消毒蒸锅抗原复活技术对４例婴幼儿猝死综合征（ＳＩＤＳ）和３例非心源性死亡对照婴儿心传导系统的神经组织总量进行免疫组化研究。结果：在正常婴儿心传导系统，ＰＧＰ９．５与Ｓ１００阳性的神经纤维里不均匀分布，以窦房结最多，房室结次之，希氏束最少；４例ＳＩＤＳ心传导系统的神经组织分布同对照组无明显差异。     

房室结纤维和脂肪增多与房室结动脉狭窄的关系

目的探讨房室结纤维、脂肪含量与房室结动脉狭窄之间的关系,分析房室结内病理性纤维化和病理性脂肪浸润的原因。方法选取119例心源性猝死案例,用Image-pro plus图像分析软件检测组织切片,计算房室结面积,房室结动脉内径、房室结动脉管腔面积(lumen area,LA)、外周横截面积(perimeterarea,PA),纤维组织面积和脂肪组织面积。将所有案例分为动脉狭窄组和正常对照组组,观察房室结动脉PA/LA值及房室结纤维及脂肪含量的改变。结果狭窄组房室结动脉PA/LA值在21～40岁最大,40岁以下两组房室结脂肪含量和总间质含量差异有统计学意义。结论房室结动脉狭窄与房室结间质含量增多有一定关系。     

Age-related variation in the interstitial tissues of the cardiac conduction system; and autopsy study of 230 Han Chinese

The amount of fatty and fibrous tissues in 230 Han Chinese who died of noncardio-vascular diseases has been studied by a semi-quantitative method and analysed by chi-square test. The results have shown some consistency. Generally, in the sino-atrial node (SAN), fibrosis and fatty influtratin appear only after 40 years of age and increase one grade with every 20 years. The atrio-ventricular node (AVN) showed fatty change after 30 years of age and fibrosis appeared after 60. In the His bundle (HB), fatty infiltration and fibrosis appear after 40 years. The left bundle branch (LBB) showed similar changes. The appearance of fibrosis in the AVN seems to be later than that reported by Lev.     

青壮年猝死综合征心传导系统及心肌HHF35免疫组化研究

为了探讨青壮年猝死综合征（SMDS）的死亡原因与心性猝死之间的关系，作者对SMDS、冠心病、非心血管疾病死亡（正常对照）三组共23例心脏标本进行H．E和HHF35免疫组化观察．结果：9例SMDS中，8例心传导系统及心肌细胞出现小灶性HHF35阴性缺染区，而H．E染色未发现明显梗死灶；冠心病组7例均出现不同程度的心肌细胞缺染，呈广泛大面积分布；对照组心肌细胞、心传导系统及血管壁里均匀一致的阳性染色．表明部分SMDS死前已有早期心肌缺血或梗死等病变，其死亡原因应为急性心功能不全而致猝死．     

Virtopsy,a new imaging horizon in forensic pathology: virtual autopsy by postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)--a feasibility study

Using postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI), 40 forensic cases were examined and findings were verified by subsequent autopsy. Results were classified as follows: (I) cause of death, (II) relevant traumatological and pathological findings, (III) vital reactions, (IV) reconstruction of injuries, (V) visualization. In these 40 forensic cases, 47 partly combined causes of death were diagnosed at autopsy, 26 (55%) causes of death were found independently using only radiological image data. Radiology was superior to autopsy in revealing certain cases of cranial, skeletal, or tissue trauma. Some forensic vital reactions were diagnosed equally well or better using MSCT/MRI. Radiological imaging techniques are particularly beneficial for reconstruction and visualization of forensic cases, including the opportunity to use the data for expert witness reports, teaching, quality control, and telemedical consultation. These preliminary results, based on the concept of "virtopsy," are promising enough to introduce and evaluate these radiological techniques in forensic medicine.     

A study of 44 forensic autopsy cases of adrenal hemorrhage

44 cases of adrenal hemorrhage (AH) were analyzed. The forensic autopsy showed that AH occurred mainly in male aged from 20 to 40 years old. The traumatic AH was more often seen in young men and the pathologic AH was mostly seen in elderly persons. AH were more likely found in bilateral adrenal corticomedullary junction. The pathological grade of AH was not related to the interval time of survival. The pathologic mechanism of AH was discussed as well.     

宝鸡市358例法医送检器官的组织病理学分析

目的 分析法医尸体检验后送检器官的病理学特征,总结此类案件的特点.方法 对宝鸡市法医送检358例尸体解剖器官标本进行常规检查并进行组织病理学诊断. 结果 358例中以青壮年男性为主,死亡原因主要为创伤、猝死、中毒.组织学能明确死亡原因250例,无典型组织学病变101例,组织自溶腐败7例.病理诊断以心血管疾病为主,其次为呼吸、神经、消化系统疾病. 结论 法医解剖具有专业特点,与病理解剖不尽相同.组织病理学检验进行死亡原因诊断时,应积极与法医沟通,以充分掌握案情、死亡经过及特定的法医病理学特征.