Primary intimal sarcoma of the pulmonary artery misdiagnosed as pulmonary thromboembolism: A case confirmed at medicolegal autopsy

Misdiagnosed PAS confirmed at medicolegal autopsy Pulmonary artery sarcoma (PAS) is a rare disease and usually indistinguishable from acute or chronic thromboembolic disease of the pulmonary arteries. We present a case of pulmonary artery sarcoma in a 54‐year‐old male, who was clinically misdiagnosed as pulmonary thromboembolism. The patient died of disease; however, the actual diagnosis of PAS was made after a medicolegal autopsy. PAS can be a diagnostic challenge for both clinicians and pathologists. In an autopsy case with a clinical suspicion of pulmonary thromboembolism, if there is an abnormal gross appearance in the pulmonary artery, the forensic pathologist should have a high index of suspicion of PAS, which should be ruled out by a histopathologic examination.     

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.     

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.     

Sudden, unexpected death due to splenic artery aneurysm rupture

Splenic artery aneurysms are an uncommon form of vascular disease that have a significant potential for rupture, resulting in life-threatening intraperitoneal hemorrhage. We describe the case of a 33-year-old man who died suddenly and unexpectedly due to the rupture of a splenic artery aneurysm. At medicolegal autopsy, 3000 mL of fluid blood were recovered from the peritoneal cavity. The source of bleeding was a sack-like aneurysm of the splenic artery, measuring 2 cm in diameter. Histologic examination of the splenic artery aneurysm revealed fibromuscular dysplasia. No atherosclerotic lesions or any inflammatory changes were apparent within the wall of the splenic artery. Portal hypertension and pancreatitis, previously described as important factors promoting splenic artery aneurysm formation, were excluded by autopsy and histology. From the forensic pathologist's viewpoint, this rare case underlines the importance of splenic artery aneurysm rupture as a relevant differential diagnosis of intraperitoneal hemorrhage and sudden death, respectively, since such cases may be misinterpreted as a result of blunt-force trauma.     

Uncertainty of determining mode of death in medicolegal material without autopsy — A systematic autopsy study

Systematic autopsy was performed in 807 medicolegal deaths where the police had not requested autopsy. In all cases both the cause of death and the mode of death had been reported at the medicolegal external examination. The autopsy revealed differences in the mode of death in about 4% of all cases. This was due in particular to the problems associated with distinguishing presumed natural deaths from accidents and suicide. The cases of “concealed” suicide were found in particular among the higher age groups. However, no characteristic relationship was found between the proportion of differing modes of death and the age groups. All cases of homicide were recognized at the medicolegal external examination.Malignant disease that had not been diagnosed previously was found in about 4% of the cases, the reason being the large proportion of elderly subjects in the material. Syphilitic aortitis that had not been previously diagnosed was demonstrated in about 1% of all cases, and pulmonary tuberculosis that had not been previously diagnosed was demonstrated in 0.7% of the cases.The conclusion is that the results provide no support for replacing the medicolegal autopsy by medicolegal external examination alone, but rather suggest that the proportion of medicolegal autopsies should be increased.     

Technical and interpretive pitfalls of postmortem CT: Five examples of errors revealed by autopsy

Image acquisition of dead bodies, particularly using postmortem computed tomography (PMCT), has become common in forensic investigations worldwide. Meanwhile, in countries such as Japan which have an extremely low rate of autopsy, PMCT is being increasingly used in the clinical field to certify the cause of death (COD) without performing an autopsy or toxicological tests, even in cases of unnatural death. Additionally, these PMCT images are predominantly interpreted by clinical personnel such as emergency physicians or clinicians who are not trained in PMCT interpretation and who work for the police, that is, the so-called police doctors. Many potential pitfalls associated with the use of PMCT have been previously described in textbooks and published papers, including the pitfalls of not performing a complete forensic pathology investigation, and the use of physicians without appropriate PMCT training to interpret PMCT and direct death investigation and certification. We describe five examples in which apparent misdiagnosis of COD based on PMCT misinterpretation was revealed by autopsy. Here are the five examples of errors: (1) Postmortem changes were misinterpreted as COD, (2) resuscitation effects were misinterpreted as COD, (3) COD was determined after an incomplete examination, (4) fatal findings caused by external origin were wrongly interpreted as ‘of internal origin’ based on PMCT, and (5) non-fatal findings on PMCT were wrongly interpreted as fatal. Interpretation of PMCT by appropriately trained physicians and an accompanying complete forensic investigation, including autopsy when indicated, is necessary to prevent significant errors in COD determination and related potential adverse medicolegal consequences.     

Medicolegal death investigator workplace safety hazards: A scoping review of the literature

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on-scene and follow-up activities, a scoping review was conducted to document known occupational safety risks and health-related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty-five articles met inclusion criteria, which included seventeen survey-mixed method designs, two systematic reviews, five quasi-experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies.     

Uncertainty of determining cause of death in a medicolegal material without autopsy. An autopsy study

In constrast to other studies, this investigation was made on cases of medicolegal deaths that would not normally be autopsied. 223 females and 322 males, whose deaths were found to be natural before as well as after autopsy, were studied. The cause of death was estimated by external medicolegal examination, and after autopsy.In 79 females and 109 males, i.e. 35% and 34% respectively, estimated cause of death was found to be different after the autopsy. This was mostly because ischaemic heart disease as a cause of death was overestimated at the external medicolegal examination. No constant relationship between differing causes of death and age group could be demonstrated. Underdiagnoses and overdiagnoses tended to outweigh each other. Pneumonia, pulmonary embolism, cor pulmonale and aortic stenosis were clearly underestimated before autopsy. In addition, a variety of diseases that were not even mentioned at the medicolegal examination was found (subarachnoid haemorrhage, uraemia, perforated and bleeding gastric ulcers, tuberculosis).The same unreliability in the estimated cause of death therefore exists among cases not normally autopsied as found in retrospective studies of cases where autopsy is performed under all circumstances at the request of the police.False information will thus be given to the mortality statistics among the approximately 5000 cases of medicolegal deaths not autopsied in Denmark per year, most of these being natural deaths. Besides, contagious and inherited diseases could be overlooked, relatives given false information and the value of scientific studies in causes of death diminished.The conclusion is that autopsy is still essential to ensure continuous control and correction of causes of death.     

Significance of hemorrhages at the origin of the sternocleidomastoid muscles in hanging

Hemorrhages at the periostal-clavicular origin of the sternocleidomastoid muscles are part of the indirectly induced autopsy findings in death by hanging. In a prospective study of 178 cases of hanging, clavicular hemorrhages were found in 110 cases (a relative frequency of 62%). A statistically significant association between occurrence of hemorrhages and completeness of the victim's body suspension was discovered (P = 0.046) as well as a significant association between the occurrence of hemorrhages and the location of the ligature knot on the neck (P = 0.008). The occurrence of hemorrhages at the clavicular origin of the sternocleidomastoid muscles was independent of age, sex, and weight. This article renews the knowledge of this important vital sign described mainly in the German medicolegal literature.     

全面系统的法医学尸体检验及常见失误的防范

法医学尸体检验是法医学检案鉴定工作中的重要环节,是保证鉴定质量的基础和前提。虽然各人所做方法、步骤略有不同,每一案例又各有特殊性,但力求全面系统和规范是其基本要求。狭义的全面系统尸体检验是指尸体解剖时不仅应剖验颅、胸、腹腔这“三大腔”,还应剖验脊髓腔及其它应解剖的部位。如脊髓腔、关节腔、骨骼、眼球、周围神经和软组织等。而广义上的全面系统法医学尸体检验则应包括上述尸解和提取并保存适当、足量、可靠的检材标本这两方面。其常见的失误有:①案情不清,致尸检方案错误;②准备不足,盲目尸检;③仅作局解,片面不全;④尸解不规范,操作不标准;⑤观察不仔细,遗漏损伤或病变;⑥描述不准,记录不明,图照不清;⑦取材不适当,不能反映事实。     

Old pulmonary embolus of the distal part of a Pudenz low-pressure ventriculoatrial shunt

At the autopsy of a man, aged 21 years, who had suffered from spastic tetraplegia for 10 years, the distal 25 cm of the Pudenz low-pressure ventriculoatrial shunt was found in the pulmonary artery, partly adherent to and partly covered with intima. The site of the detachment was the connection at the entrance to the facial vein. It is mentioned in the literature that the entrance of the venous system is, indeed, the most common site of detachment. An x-ray film of the chest, taken 3 1/2 years previously, retrospectively disclosed the catheter at the same location as demonstrated at the autopsy, but it had been overlooked at the time. On the non-intima-coated parts of the catheter, fresh thrombotic material was found, and there was cor pulmonale. The cause of detachment may have been the long-standing spastic tension in the neck muscles.     

Popliteal artery bullet embolism in a case of homicide: a case report and review of the tangible literature

Bullet embolism is a well known but a relatively rare phenomenon in common medicolegal autopsy practice. We present a homicide case of a bullet embolism to the left popliteal artery with interesting trajectory of projectile through the chest wall and right heart ventricle into the aortic lumen. Since in our presented case obvious homicidal manner of death was in question, discovery of bullet was an obligatory part of investigation in order to positively identify the responsible firearm. Detection of the missile transported through the circulation requires very thorough autopsy examination, especially if X-ray equipment is not available. As in all other cases in which initial bullet trajectory is changed in the body, the very important part of the medicolegal autopsy in cases accompanied with missile embolism, is to determine direction of the first part of the bullet's trajectory, because this indicates the position of the axis of the weapon barrel in the moment of firing (if there was no external ricochet), taking into consideration the posture of the victim and the location of the shooting person in the same moment. A review of the tangible literature is given.     

医疗纠纷法医学鉴定质量评价模型的建立

目的建立医疗纠纷法医学鉴定质量评价模型。方法收集同济医学院法医学系近10年410例涉及医疗纠纷的法医学鉴定的案例,对影响医疗纠纷法医学鉴定质量的10个关键指标,运用SAS软件进行了主成分分析。结果通过统计学分析,筛选出6个能反映所有原指标变量主要信息的主成分,并依此结果推算出评价法医学系医疗纠纷的鉴定质量评价模型。结论在建立“医疗纠纷鉴定质量管理体系”时,应按影响鉴定质量的主成分设计相应的对策。     

Recent status of the medical examiner system in Japan: demographic variation of medicolegal deaths in Hyogo Prefecture and uncertainty in medicolegal investigations conducted by medical practitioners.

The medical examiner system has been steadily abolished in Japan. Instead, medicolegal investigations are entrusted by the police to medical practitioners, who are not permitted to perform autopsies. The necessity for the medical examiner system was assessed through inquest records in Hyogo, one of the three prefectures which still have medical examiner systems. Standardized mortality ratios (SMRs) for accidents and suicides were negatively associated with population density, being high in rural areas with a large proportion of elderly citizens, while the SMR for natural deaths was high in urbanized areas and associated with the proportion of inquests to total resident deaths. The high proportion of inquests, however, did not always mean that inquest records were of good quality. Significant differences in the quality of medicolegal investigations seemed to exist between medical examiners and medical practitioners. That is, in order to certify the cause-of-death, medical examiners performed autopsies in about half of their cases, while only 2% of medical practitioner cases were subjected to autopsies. Medical practitioners, who certified the cause-of-death as "heart failure" without advising an autopsy, were regularly entrusted with inquests. It is likely that the causes-of-death for medicolegal cases may be questionable since more than 85% of all medicolegal deaths were investigated by medical practitioners, which may cause inaccuracy in at least 3-7% of mortality statistics. It is necessary to educate medical practitioners concerning the importance of mortality statistics and ICD and on the validity of autopsies, in order to obtain accurate mortality statistics from medicolegal cases.     

Dissecting intramural haematoma of the coronary artery with intimal tears.

A dissecting intramural haematoma of the coronary artery is an infrequent cause of sudden and unexpected death. Most cases are women and in a significant number of these women, the haematoma occurred at term to 80 days postpartum. Because the intimal rupture and communication with the lumen were not found in most of the cases, the site of rupture has been considered to be a vasa vasorum. The authors report on a case of one woman who was at a later postpartum period (106 days). The microscopic finding of the dissected coronary artery revealed two intimal tears in a section. The case showed that the dissecting intramural haematoma of the coronary artery is caused not only by the rupture of the vasa vasorum but also by the rupture of the intima.     

Is routine histopathologic examination beneficial in all medicolegal autopsies?

Postmortem examinations are performed for a number of reasons. Medical autopsies are performed at the request of and with the consent of the next of kin of a decedent and are often requested to determine the extent of a disease process or to evaluate therapy. In contrast, medicolegal autopsies are performed by a forensic pathologist primarily to determine cause and manner of death but also to document trauma, diagnose potentially infectious diseases and report them to the appropriate agencies, provide information to families about potentially inheritable diseases, provide information to family members and investigative agencies, and testify in court. As medicolegal and hospital autopsies differ in their purpose, so do they differ in procedure. Medicolegal autopsies often include histologic analysis, but not always, as with medical autopsies. We designed a prospective study to address the question of whether or not routine histologic examination is useful in medicolegal cases, defining a routine case as one where histology would not normally be performed and where the cause and manner of death were readily apparent during the gross autopsy. We reviewed brain, heart, liver, kidney, and lung sections on 189 routine forensic cases and compared the results to the gross anatomic findings. Of the 189 cases, in only 1 case did microscopic examination affect the cause of death and in no case did microscopic examination affect the manner of death. Thus, we feel that routine microscopic examination (performing histologic examination in all cases regardless of cause and manner of death) in forensic autopsy is unnecessary. Microscopic examination should be used, as needed, in certain circumstances but is not necessary as a matter of routine.     

Hemolytic staining of the intima of the aortic root in freshwater drowning: a retrospective study

A retrospective study was conducted of files at the Institute of Legal Medicine in Hamburg, Germany from 1998 to 2003 of all cases of drowning where there was no putrefaction, to document the rate of recording of hemolytic staining of the intima of the great vessels. All cases had full police investigations with reviews of previous histories, circumstantial evidence, and autopsy findings. A series of control subjects who had died of various natural and nonnatural, nondrowning deaths, matched for age, sex, and postmortem interval, was also reviewed. One hundred twenty cases of freshwater drowning were identified. Drowning occurred in a garden pool in 1 case, in a bath in 2, and in the river Elbe in 117. The age range was from 2 to 91 years (mean = 55 years; M:F = 1:1.8). Hemolytic intimal staining of the aortic root was documented in 6 cases (6 of 120; 5%). This consisted of reddened discoloration of the proximal portion of the aortic root, without any significant staining of the proximal pulmonary artery. No significant hemolytic staining of the intima of the great vessels was recorded in any of the 120 control cases. Although under-reporting of findings may occur in retrospective analyses, this study has shown that at least 5% of freshwater drowning cases showed differential staining of the pulmonary trunk and aorta, with hemolytic discoloration of the aortic intima. When present, hemolytic staining of the aortic root intima may be a useful and possibly under-recognized corroborative sign of freshwater drowning.     

Unusual death of a farmer.

A farmer was found dead, in a pool of blood on his farm. Evidence indicated that the farmer had dragged himself or been dragged from the stable to the point where his body was found. With the exception of abrasions in the face, there were no other signs of injury. An autopsy revealed a depressed fracture of the skull and showed a venous air embolism to be the cause of death. The medicolegal interpretation of the findings left no doubt that the farmer was killed by a cow.     

Sudden death in an infant caused by rupture of a basilar artery aneurysm.

Ruptured aneurysms of the cerebrovasculature in infancy and early childhood, except for "giant" aneurysms and arteriovenous malformations, are rare. Seizures, loss of consciousness, and apnea are the usual presenting signs in infancy; symptoms such as headache or visual disturbances and signs such as cranial nerve compression or meningeal irritation commonly found in older children or adults are absent in infants. However, the morphologic findings (i.e., subarachnoid and retinal hemorrhage, and occasionally subdural hemorrhage) may be mistaken for inflicted trauma, especially if the aneurysm is not identified. Sudden death caused by rupture of a cerebral aneurysm has not been previously described in an infant. This report outlines the investigation and autopsy findings in a 7-month-old infant who died unexpectedly as a result of rupture of a complex basilar artery aneurysm.     

Sudden death in an infant caused by rupture of a basilar artery aneurysm

Ruptured aneurysms of the cerebrovasculature in infancy and early childhood, except for "giant" aneurysms and arteriovenous malformations, are rare. Seizures, loss of consciousness, and apnea are the usual presenting signs in infancy; symptoms such as headache or visual disturbances and signs such as cranial nerve compression or meningeal irritation commonly found in older children or adults are absent in infants. However, the morphologic findings (i.e., subarachnoid and retinal hemorrhage, and occasionally subdural hemorrhage) may be mistaken for inflicted trauma, especially if the aneurysm is not identified. Sudden death caused by rupture of a cerebral aneurysm has not been previously described in an infant. This report outlines the investigation and autopsy findings in a 7-month-old infant who died unexpectedly as a result of rupture of a complex basilar artery aneurysm.