Travel, time zones, and sudden cardiac death. Emporiatric pathology

In an 11-year retrospective study of coroner's autopsies on the Hawaiian island of Kauai, it was found that an unusual and apparently unique subset of travelers died suddenly. Death was caused by coronary arteriosclerosis, was characterized by acute coronary changes, and occurred in a group younger than the usual age for sudden cardiac death. Visitors with two-vessel disease had an incidence of sudden death nearly four times that of Kauaians (p less than 0.02), with a ninefold increase of coronary thrombosis (p less than 0.001), a sixfold prevalence of old myocardial infarcts (p less than 0.001), and three times the prevalence of cardiomegaly (p less than 0.001). The circadian pattern of these deaths was different from that previously described in acute myocardial infarction or sudden death, with the number of incidents rising steadily through the day in contrast to the morning peak described in previously published series. The syndrome was expressed in decedents with two-vessel coronary disease either with acute coronary artery lesions--thrombosis, hemorrhage in a plaque, or ruptured coronary artery--or no lesions, presumably spasm. Underlying chronic processes included enlarged heart or old myocardial infarct, which both occurred with a significantly greater incidence in travelers than in local residents, and in a totally different pattern from that occurring in subjects with three-vessel disease. It is postulated that the syndrome is caused by stress related to travel and time zone changes.     

Sudden and unexpected death of a 6-month-old baby with silent heart failure due to anomalous origin of the left coronary artery from the pulmonary artery.

A 6-month-old girl died suddenly without any previous symptoms of heart failure. Autopsy examination showed cardiomegaly (97 g) with a severely fibrotized myocardium. The left coronary artery was originating from the pulmonary artery. Histologically, the myocardium showed myocardial infarcts of different ages, as well as grossly thickened arterial branches due to increased flow in left-right shunt. We suggest that rare anomalies of the coronary arteries should be considered in the autopsies of suspected sudden infant death syndrome cases.     

Pathologic Findings of Coronary Stents: A Comparison of Sudden Coronary Death Versus Non‐cardiac Death

There are few histologic studies of intracoronary stents found at autopsy. We studied histologic findings of 87 intracoronary stents from 45 autopsy hearts. There were 40 patients with chronically implanted stents and five shorter than 30 days. Of five patients with recent stent placement, the cause of death was related to the stent (in‐stent thrombosis) in one case. Of the 40 patients with chronic stents, there were 16 sudden coronary deaths and 24 noncoronary deaths (controls). There were no late stent thromboses in the coronary deaths. In the coronary deaths, 26% of stents showed restenosis versus 11% in controls (p = 0.1). The rate of healed infarcts and cardiomegaly was similar in the coronary and noncoronary groups, and acute thrombi in native arteries were seen only in three hearts in the coronary group. We conclude that the cause of death is rarely impacted by in‐stent findings at autopsy, especially in chronically implanted stents.     

早期心肌梗死bFGF的免疫组化研究

采用免疫组化和图像分析与统计学处理方法,对人体早期心肌梗死猝死者心肌中碱性成纤维细胞生长因子 (basic fibroblast growth factor,bFGF)的表达进行了研究。结果发现 :心肌梗死组 24例的心肌细胞核以及血管内皮细胞核均为强阳性染色,有些细胞浆也有阳性染色,尤以心肌梗死灶周围区域心肌细胞为甚。可疑梗死组 21例中 17例见心肌细胞核以及血管内皮细胞核为强阳性染色, 4例为弱阳性染色,未见阴性染色。而正常心脏对照组 16例中 3例呈弱阳性染色,其余均为阴性。图像分析与统计学处理结果显示对照组 bFGF阳性指数明显低于心肌梗死组和可疑心肌梗死组（ P< 0.001）,而后两组无显著性差异（ P >0.05）。结果表明 bFGF免疫组化染色可望为早期心肌缺血致猝死的死后诊断提供客观的形态学依据。     

VEGF在早期心肌梗死死后诊断中的应用

运用免疫组化方法和图像分析与统计学处理系统 ,对人体心脏标本VEGF的表达进行定量研究。结果显示 :心肌梗死组 2 4例心脏标本心肌细胞膜及血管内皮细胞膜均可见棕黄色VEGF强阳性染色 ,有些胞浆也呈阳性 ,尤以心肌梗死灶周围区域心肌细胞为甚 ;在可疑梗死组 2 1例中 ,19例心肌细胞膜及血管内皮细胞膜VEGF强阳性 ,2例为弱阳性 ,未见阴性 ;在正常心脏对照组 16例中 ,仅 1例见心肌细胞膜及血管内皮细胞膜散在棕黄色VEGF弱阳性 ,其余均为阴性。图像分析与统计学处理结果表明 ,对照组VEGF阳性指数 ( 0 3 0± 0 10 )明显低于心肌梗死组 ( 12 46± 3 2 6,P<0 0 1)和可疑梗死组 ( 11 70± 3 5 6,P <0 0 1) ,后两组之间阳性指数无明显差异 (P >0 0 5 )。提示运用免疫组化染色方法结合图像分析处理技术定量检测心肌局部VEGF的表达可望作为因早期心肌缺血导致心脏性猝死死后诊断较为客观的病理形态学指标之一。     

Sudden cardiac death following psychoemotional stress

Sudden death from cardiac arrest is described, which occurred after a minor accident. Morphologically, a coronary change was found in the sense of "juvenile coronary atherosclerosis" in connection with intramural bleeding postmortem. As there were no injuries in connection with the accident but psychoemotional stress had occurred, it is concluded that affective resonance resulting from the accident initiated the death. The pathological and pathophysiological relationships are discussed.     

Hypoxic/ischaemic brain damage, especially pallidal lesions, in heroin addicts.

The occurrence of pallidal lesions with or without other hypoxic/ischaemic brain injuries was evaluated in 100 intravenous (i.v.) heroin addicts. The brains were collected consecutively from forensic autopsies during the period from January 1995 to June 1996. The autopsies were required by the police and performed at The Institute of Forensic Medicine, The National Hospital, Oslo. There were 21 women and 79 men, median age 32 (range 21-47) and 34 (19-60) years, respectively. Of 38 brains with abnormalities, twenty-five cases showed isolated or combined lesions of hypoxic/ischaemic origin. Pallidal lesions were found in nine brains; six lesions were old, one was subacute (a couple of weeks), and two were part of recent, generalized hypoxia/ischaemia. Six persons had old infarcts in the hippocampal formation, and one of them in combination with old pallidal infarcts. In seven brains small and old infarcts were found in watershed areas in the cerebellum. Between five and ten percent of i.v. heroin addicts might have pallidal infarcts, either as the sole lesion, or combined with other manifestations of hypoxic/ischaemic brain injury. This might give severe mental disturbances in the affected persons.     

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.     

Stressful events as a trigger of sudden death: a study of 43 medico-legal autopsy cases

The reports relating emotional stress to sudden death are largely anecdotal. In addition to experimental and electrophysiological studies, an opportunity for a better understanding of possible stress-related sudden death (SSD) may be provided by medico-legal autopsies. The goal of our autopsy study was to analyze cardiovascular pathologic findings in cases of SSD and if possible identify mechanisms by which the stressful event (SE) could be the cause. Forty three cases were studied (29 males and 14 females). In all cases, the SE and the death were witnessed. The age range was 22 to 90 years in males (mean, 52) and 30 to 92 years in females (mean, 64). Death occurred in all cases without premonitory symptoms. In 20 cases, death occurred during the SE and in the other 23 cases occurred within 2 h of the event. SE included fear, 15 cases; altercation, 21 cases; sexual activity, 3 cases; police questioning or arrest, 4 cases. According to police reports, in 40 cases (90%), the victims had no previous clinical history of cardiovascular disease. At autopsy, the heart weight in males ranged from 255 to 1000 g with a mean of 517 g and in females the range was 250–700 g with a mean of 417 g. In only 3 cases, gross and microscopic examination of the heart was normal. In 2 of the remaining 40 cases the subjects died of subarachnoid hemorrhage. In 38 cases, a cardiac cause of death was found as follows: coronary heart disease, 27 cases; cardiomyopathy, 6 cases; aortic valvular stenosis, 2 cases and right ventricular dysplasia, 3 cases. A coronary artery thrombosis was found in 8 cases of sudden coronary death. Post myocardial infarction fibrosis was present in 25 cases (92%) of sudden coronary death. In conclusion, it appears from our autopsy study that SSD occurs primarily in those individuals with severe heart disease, especially coronary heart disease.     

Asthmatic deaths in the medical examiner's population

A study of people who die from asthma was performed. The case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida, U.S.A., were examined during the 5-year period 1979-1983, and all autopsied cases in which bronchial asthma was the primary or contributory cause of death were collected. These 39 cases were then analyzed as to the age, race, sex, and cause of death of the victim. Additionally, the medication list of the victim, the location of the terminal incident, the scene circumstances, the presence of hospitalization at the terminal incident, and the histopathology of the lungs at autopsy were additionally observed. Essentially, the asthma victim the medical examiner sees at autopsy is an adult white male commonly dying in an acute asthmatic attack. Ninety percent (90%) of the deaths had medications noted with 20% having three or more medicines, one of which was a steroid. The terminal incident occurred at home most frequently with an acute attack or being found dead noted. Most victims received some form of terminal hospitalization. Histopathologically, classical "asthma findings" were noted approximately one half of the time.     

Death as a result of asthma in Wayne County Medical Examiner cases, 1975-1987

All deaths ascribed to asthma in the 5-to-40-year age group at the Wayne County Medical Examiners' Office were reviewed from 1975 to 1987 inclusive. Fifty-eight deaths were attributed solely to asthma, and the annual number increased fivefold in the 1980s to a rate of approximately 0.5 per 100,000 per year when extrapolated to the Wayne County population. Blacks were overrepresented to double their proportion in the general population. Almost all cases were known asthmatics, and many had received previous emergency care. Most fatalities occurred at night and did not demonstrate any seasonal variation. The onset of the fatal attack was apparently very rapid in most cases, with many engaged in routine activities and few surviving any length of time in hospital or having sought treatment earlier. Our data reveal a significant increase in sudden death in previously well asthmatics in Wayne County in the 1980s. Similar increases in deaths as a result of asthma have been noted previously in other countries for reasons that remain unclear.     

Determination of potassium/sodium ratio in heart tissue. Evaluation of its use as an index of myocardial ischaemic damage. Comparison with the nitro-BT test

The succinate dehydrogenase method of staining and the determination of the K⁺/Na⁺ ratio of heart tissue have been applied to forensic material as a tool for demonstrating early signs of myocardial infarctions. Both methods are controlled by a series of forensic cases dying from causes other than arteriosclerosis of the coronary arteries. Based on an analysis of normal material some factors influencing the K⁺/Na⁺ ratio are defined. It is concluded that the determination of the K⁺/Na⁺ ratio shows more infarcts than the formazan method; however, the evaluation of the K⁺/Na⁺ ratio is difficult. The K⁺/Na⁺ determination is not recommended for routine use. A possible indication for the use of the K⁺/Na⁺ determination together with the formazan test could be cases of instantaneous death by accidents suspected to have been provoked by a fatal heart attack.     

Unexpected sudden death from coronary sinus thrombosis. An unusual complication of central venous catheterization

Coronary sinus thrombosis is an unusual but potentially serious complication of the use of central venous devices. We report a fatal case of coronary sinus thrombosis in relation to a malpositioned central venous catheter. The death occurred very soon following the beginning of symptoms and the cause could not be suspected. Direct trauma of the catheter on the coronary sinus endothelium seems the most probable cause of the thrombosis.     

Kinking of a coronary artery as a rare complication in mitral valve replacement

We present the case of a 70-year old woman who had elective mitral and aortic valve surgery. She underwent surgery without complications for about 4h until 4 pm. Approx. 3h after surgery her condition deteriorated. 1500ml of blood were collected in the chest drainage until 11 pm. An emergency thoracotomy in the patient's bed showed a ventricular rupture. Death occurred around 11:30 pm. At autopsy, the implants of the biological mitral and aortic valves were found to be sewn tightly. There was no vascular injury and no unusual bleedings to the mediastinum. In the left ventricular wall, a rupture of 1cm and a surrounding fresh myocardial infarction area of 10cm×6cm was noted. Preparation of the coronary arteries showed moderate coronary atherossclerosis without stenosis or clots. The left circumflex coronary artery (LCX) showed a sharp, obviously stenosing kink which had been caused by the mitral valve surgery. Exsanguination due to ventricular rupture following myocardial infarction caused by implant-related "kinking" of a coronary artery, was found to be the cause of death.     

冠心病猝死心肌mcl-1蛋白检测及其意义

目的观察冠心病猝死(SCD)心肌mcl-1蛋白产物,探讨其免疫组化检测及其对SCD诊断的意义。方法运用免疫组织化学SABC法,对46例SCD和40例非猝死心肌(有冠心病和无冠心病)中mcl-1蛋白产物进行检测和观察,并比较其差异。结果(1)自症状出现至死亡,时间超过30min的SCD(36例),其心肌组织均出现mcl-1蛋白阳性染色;(2)自症状出现至死亡,时间短于30min的SCD(10例),其心肌组织mcl-1蛋白呈弱阳性染色;(3)冠心病非猝死样本(20例),4例心肌出现微弱的mcl-1蛋白阳性染色,无冠心病非猝死样本(20例)几乎没有出现阳性染色。结论心肌mcl-1蛋白的免疫组化检测可诊断自症状出现至死亡时间超过30min的SCD。     

Death during percutaneous transluminal coronary angioplasty (PTCA) and the medicolegal aspects

Coronary embolisation is a very rare complication of the clinically widespread method of percutaneous transluminal coronary angioplasty (PTCA). The well-documented case of a 64-year-old male patient is presented comparing angiographic and morphological findings. The occluded left anterior descending artery (LAD) was successfully dilated during PTCA. Simultaneously the circumflex artery showed acute occlusion. The patient fell into cardiac shock and died after attempted resuscitation and agonal installation of extracorporeal circulation. The autopsy revealed severe residual stenosis of the proximal LAD by parietal thrombosis and occlusion of the proximal circumflex artery by an unattached intraluminal thrombus (0.8 x 0.3 x 0.2 cm) which had been dislocated during PTCA. Autopsy thus confirmed the clinical presumption of coronary embolism and, in addition, disclosed a previously unknown perforation of the femoral artery which had occurred during agonal installation of extracorporeal circulation and contributed to death via severe retroperitoneal hemorrhage. The case is discussed under the aspects of clinical quality control by forensic pathological investigations.     

Repeat Coronary Artery Dissection in Pregnancy: A Case Report and Review of the Literature

Non‐atherosclerotic spontaneous coronary artery dissection (NA‐SCAD) is a rare cause of morbidity and mortality with a propensity for young, healthy, and often peripartum women. NA‐SCAD etiology is poorly understood, with possible hormonal and hereditary mechanisms. Current treatment strategies range from conservative management (often showing resolution on angiographic follow‐up) to invasive angiographic procedures. Rarely, NA‐SCAD has recurred in another coronary artery, ranging hours to years later. We report NA‐SCAD of the right coronary artery (RCA) in a 30‐year old, 3‐month postpartum female with an additional autopsy finding of remote myocardial infarction (MI) in the left anterior descending (LAD) coronary artery territory. The remote MI is consistent with prior NA‐SCAD of the LAD and, given the medical history, may have occurred in the peripartum period of the decedent first pregnancy 3 years earlier. As such, to the best of our knowledge, this may represent the first reported case of NA‐SCAD recurrence in a subsequent pregnancy.     

冠心病心肌线粒体DNA5.0kb缺失的检测

目的探讨冠心病心肌线粒体DNA5.0kb缺失的检测。方法120例心脏的左、右心室肌各1份,分为正常对照组、病例相关组和病例组,每组40例80个样本。用断裂点连接PCR分别扩增样本含线粒体DNA5.0kb缺失的片段,巢式PCR检测含5.0kb缺失片段的扩增产物的准确性,半定量PCR对该产物进行定量,聚丙稀酰胺凝胶电泳检测PCR产物。结果在对照片段扩增成功的样本中,正常对照组未检出线粒体DNA5.0kb缺失;病例相关组检出2例,占6.07%(2/33);病例组检出29例,占85.29%(29/34);左、右心室肌线粒体DNA5.0kb缺失量分别为0.0015%~0.7813%和0.0008%~0.3906%。病例组与其他两组缺失率经χ2检验,其差异具有极显著性意义(P<0.001);左、右心室肌的缺失量经t检验,其差异具有极显著性意义(P<0.001)。结论冠心病心肌多有线粒体DNA5.0kb缺失,缺血明显的区域其缺失量也较高。     

Delayed left anterior and middle cerebral artery hemorrhagic infarctions after attempted strangulation: a case report

The 2 common carotid arteries bifurcate in the neck into the internal and external carotid arteries. The internal carotid artery enters the skull and further divides into the anterior and middle cerebral artery. During its short course in the neck, the carotid artery travels encased in the carotid sheath along with the vagus nerve and the internal jugular vein. During its course in the neck, the carotid artery is quite superficial, making it vulnerable to both penetrating and blunt traumatic injuries. We report here a case of a 40-year-old man who presented to the emergency department after sudden collapse and loss of consciousness a day after an attempted strangulation. Imaging revealed large hemorrhagic infarcts in the left anterior cerebral artery and middle cerebral artery territories as well as a smaller infarcts in the right anterior cerebral artery territory necessitating emergency decompressive hemicraniectomy. Our case report adds to the existing literature on nervous system injury due to strangulation. Physicians should be aware of the possibility of delayed presentation of neurological deficit after attempted strangulation.