Hemorragia Intracerebral Imprevisible en un Hombre Joven: La Importancia de la Tomografía computarizada craneal post-mortem / Unpredictable Intracerebral Hemorrhage in a Young Male: The Importance of Post-Mortem Cranial Computed Tomography

La muerte súbita es aquella que ocurre dentro de las 24 horas posteriores al inicio de los síntomas y se caracteriza por ser clínicamente inexplicable, inesperada y repentina. Debido a la naturaleza de la muerte súbita, no es posible llegar a un diagnóstico preciso sin una autopsia. En esta comunicación breve, evaluaremos el caso de un empleado de crucero de 33 años, sin historial médico/farmacológico previo, el cual falleció súbitamente mientras reposaba en su camarote. Debido a las sospechas iniciales de una posible muerte causada por una sobredosis de cocaína, se le realizó un panel toxicológico abarcador el cual resultó negativo. Empero, una tomografía computarizada (TC) craneal sin contraste revirtió la hipótesis inicial y la autopsia neuropatológica -sorpresivamente- confirmó que la verdadera causa de muerte fue la ruptura de un aneurisma sacular desconocido en el polígono de Willis.

Sudden death occurs within 24 hours after the onset of symptoms and is characterized by being clinically inexplicable, sudden, and unexpected. Due to the nature of sudden death, it is not possible an accurate diagnosis without performing an autopsy. In this brief communication, we will evaluate the case of a 33-year-old cruise employee, with no prior medical/pharmacological history, who suddenly died while resting in his cabin. Due to initial suspicions of a possible cocaine overdose death, a comprehensive toxicology panel was performed, although yielding a negative result. A cranial computed tomography without contrast reversed the initial hypothesis and the neuropathological autopsy -surprisingly- confirmed that the true cause of death was the rupture of an unknown saccular aneurysm in the Circle of Willis.

Forensic Analysis of 9 Cases of Sudden Unexpected Death in Epilepsy / 法医学杂志

OBJECTIVES@#To analyze the case, scene and forensic pathological characteristics of sudden unexpected death in epilepsy (SUDEP), to provide a practical basis for forensic identification.@*METHODS@#A total of 9 autopsy cases of SUDEP were collected. The basic information of the cases, the scene characteristics, the forensic pathological changes, the common drugs and antiepileptic drug test results, and pericardial fluid biochemical test results were analyzed.@*RESULTS@#All of the 9 cases were male epilepsy patients died during sleep at night, the age of death was (37.1±8.6) years, and the course of epilepsy was (21.3±5.6) years. Six corpses were in prone position and three in left lateral position. The hemorrhage of the sternocleidomastoid muscle, sternal thyroid muscle and sternohyoid muscle were found with 8 cases, 5 cases and 4 cases, respectively, all of them were unilateral. Six cases had bilateral hemorrhage of pectoralis minor muscle. Brain edema, phagocytosis of frontotemporal neurons and gliosis, cardiac fibers bend in wavy patterns and eosinophilic staining enhancement, pulmonary edema, pulmonary congestion, alveolar hemorrhage, pulmonary small bronchiole wall shrinking, tubular proteinuria and pancreatic parenchymal hemorrhage were the common histopathological changes. The biochemical test results of pericardial fluid indicated that there were myocardial ischemic damage.@*CONCLUSIONS@#Young male, early onset, long course of disease, sleep in the prone position, poor drug compliance or combination, epileptic seizure may be the risk factors of SUDEP. Cardiac dysfunction and respiratory depression might be the main death mechanism of SUDEP.

Forensic Analysis of Sudden Death Associated with Sexual Activity / 法医学杂志

OBJECTIVES@#To analyze the characteristics of sudden death associated with sexual activity to provide recommendations for forensic identification.@*METHODS@#A retrospective analysis was conducted on autopsy cases accepted by Forensic Identification Center of Huazhong University of Science and Technology from 1998 to 2018, and a total of 15 cases of sudden death associated with sexual activity were screened out. The general information, case data and pathological changes of 15 cases were collected to find the relationship between sexual activity and sudden death.@*RESULTS@#The ratio of male to female was 1.5∶1. The average age of males was 50.1 years and that of females was 35.0 years. Coronary artery diseases and brain diseases accounted for most of the cases (12/15). Sexual partners were associated with locations of deaths and body dumping behaviors.@*CONCLUSIONS@#Sudden death associated with sexual activity, although rare, may occur in people over 30 years old with pre-existing heart or brain diseases, which should be paid attention to in forensic practice.

Forensic Pathology Analysis of 363 Sudden Death Cases in Yunnan Province / 法医学杂志

OBJECTIVES@#To study the epidemiological and pathological features of sudden death （SD） in Yunnan Province and to provide scientific evidence for prevention and forensic identification of sudden death.@*METHODS@#Totally 363 SD cases were collected from the autopsies between 2009 and 2017 in the Forensic Centre of Kunming Medical University. The related factors such as etiology, age, inducing factor, time interval between the onset of disease and death, morbidity season and pathological change were retrospectively analysed.@*RESULTS@#The incidence of SD in males was significantly higher than that of females. The peak age was ≥35-55 years. The mortality rate was relatively high within 6 h after the onset of disease. The season order with descending number of deaths was spring, summer, winter and autumn. The top ten causes of SD were coronary heart disease, sudden unexplained death （SUD）, cerebral hemorrhage, acute hemorrhagic necrotic pancreatitis, aortic dissection rupture, cardiomyopathy, pneumonia, pulmonary thromboembolism, amniotic fluid embolism and allergy. Exercise, infusion, surgery, medication and minor injury were the most common predisposing factors of sudden coronary death. Consciousness disorder or coma, chest pain or chest tightness, and abdominal pain were the most common premortem symptoms of sudden coronary death.@*CONCLUSIONS@#The SD is more common in middle-aged males, which is the key population for the prevention of SD. For the forensic identification and prevention of SD, the attention on SUD should be paid.

Muerte súbita por malformación arteriovenosa cerebral rota: a propósito de un caso / Sudden death due to a broken cerebral arteriovenous malformation: a case report

Resumen:Las malformaciones arteriovenosas (MAV) son comunicaciones anómalas entre arterias y venas sin un lecho capilar intermedio. El nido de la malformación contiene una masa enredada de vasos. Estas malformaciones pueden ser asintomáticas o manifestarse con hemorragias intracerebrales o crisis convulsivas. Las hemorragias suelen estar precedidas por un cefalea intensa de inicio súbito y pueden ser mortales. A continuación se presenta el caso de un masculino de 36 años, sin antecedentes personales patológicos conocidos, que expresó vía telefónica que tenía un "fuerte dolor de cabeza", posteriormente fue encontrado en su casa de habitación por su esposa y el personal de la Cruz Roja en paro cardiorrespiratorio, le realizaron un ciclo de reanimación cardiopulmonar (RCP),presentó ritmo sinusal y fue trasladado al Hospital San Francisco de Asis, donde ingresó sin signos vitales, le realizaron varios ciclos de RCP avanzado, no respondió y se declaró fallecido minutos después.

Abstract:Arteriovenous malformations (AVM) are abnormal communications between arteries and veins without an intervening capillary bed. Malformation nidus contains a tangled mass of vessels. These malformations can be asymptomatic or present with intracerebral hemorrhages or seizures. Bleeding usually preceded by a sudden onset of severe headache and can be fatal. Then the case of a male aged 36 presents with no known medical history, who said by telephone that he had a "headache", was later found in his house by his wife and staff Cruz Red in cardiac arrest, he held a series of cardiopulmonary resuscitation (CPR) presented sinus rhythm and was taken to San Francisco de Asis, where he entered without vital signs Hospital, he performed several cycles of advanced CPR, he did not respond and declared deceased minutes then.

Epidemiological characters of Yunnan sudden death syndrome and its research progress / 法医学杂志

Yunnan sudden death syndrome (YSDS) is an abruptly fatal disease of unknown etiology, found mostly in central or northwestern mountain area (with altitude between 1,815 and 2,225 meters) of Yunnan province from June to September every year. It occurs mostly in young female adults, with high incidences in Lisu, Yi and Miao ethnics and high familial aggregation. The clinical manifestation of YSDS is changeful and the pathological characteristic is lack of specificity. The pathogenesis may be attributed to several factors including poor hygiene and lower socioeconomic conditions, lack of Selenium or Chromium, infection of Coxsackie B virus, mushroom consumption and special geological conditions. This article reviews the epidemiologic features, clinical manifestations, pathological features, etiology and hypothesis in order to provide clues for the research of YSDS.

Application of MSCT's coronary artery calcification score in evaluation of sudden death caused by coronary artery disease / 法医学杂志

OBJECTIVE@#To access application value of multi-slice spiral computed tomography (MSCT) and coronary artery calcium scoring (CACS) in investigation the coronary artery disease (CAD), and to explore the effective way of virtual autopsy to evaluate the sudden death due to CAD.@*METHODS@#Nine cases of sudden cardiac death were collected to analyze MSCT before the autopsy. The quantitative analysis of the degree of coronary artery calcium was made by Agatston's method. The CACS of all the subjects were calculated based on the diagnostic criteria for CAD, in which calcium scoring was more than 400. The results of CACS were compared with that of the autopsy.@*RESULTS@#Only 2 cases got the high calcium scoring which were more than 400 in the 9 cases died of CAD confirmed by the autopsy. The prediction rate of CACS for CAD was only 22.2%. Pulmonary edema of different severity was found in both autopsy and MSCT. There was a higher morbidity rate in the left anterior descending of coronary artery than the other branches.@*CONCLUSION@#Obvious calcification of coronary artery can be detected by MSCT and calculating CACS. To detect subtle calcification needs other technologies such as postmortem angiography.

Sudden death caused by aortic dissection: 63 cases of forensic pathological analysis / 法医学杂志

OBJECTIVE@#To explore the cause of death, clinical manifestations and forensic pathological features of death cases caused by aortic dissection.@*METHODS@#Sixty-three cases of aortic dissection were selected from forensic medical center, Sun Yat-sen University from 2001 to 2011 and retrospectively analyzed.@*RESULTS@#The patients were mostly young and middle-aged male, aged from 30 to 49 years old. The DeBakey type II was the most common pathological type and the main cause of death was pericardial tamponade. The most common symptom was abdominal pain. However, the location of aorta dissection did not always correlate with the location of pain. Some cases showed no obvious clinical symptoms. The rupture was usually located in ascending aorta with atherosclerosis and pathological changes of hypertension.@*CONCLUSION@#It is significant for diagnosis and evaluation the cause of death of aortic dissection by knowing the clinical symptoms and forensic pathological features.

Abordaje de la muerte súbita en niños y jóvenes desde la patología forense en Bizkaia y Sevilla (España) / A forensic pathology approach to sudden death in children and young adults in Biscay and Seville (Spain)

La muerte súbita (MS) en niños y jóvenes constituye un complejo problema multifactorial con implicaciones médico-legales y socio-familiares. En su investigación, la patología forense tiene una función importante ya que al tratarse de muertes inesperadas es necesaria una autopsia médico-legal para determinar la causa y el mecanismo de la muerte. La mayor parte de estas muertes tienen un origen cardiovascular y muchas de ellas tienen un componente hereditario. La autopsia puede ser la única posibilidad de que se efectúe un diagnóstico correcto de la enfermedad y que la familia reciba una orientación médica adecuada que permita la identificación de familiares asintomáticos y la prevención de futuras muertes. Para realizar un abordaje adecuado se requiere la colaboración de las distintas especialidades médicas implicadas (médicos forenses, patólogos, pediatras, cardiólogos, microbiólogos, genetistas), quienes deben trabajar de forma coordinada de acuerdo a protocolos internacionales. En este artículo se revisan las características epidemiológicas y clínico-patológicas de las principales enfermedades que se pueden manifestar como MS en niños y jóvenes y se presenta la casuística de las provincias de Sevilla y Bizkaia en los últimos años. Finalmente, se destaca la trascendencia de la patología forense en el abordaje y prevención de estos fallecimientos.

Sudden death (SD) in children and young adults is a complex multifactorial problem that entails medical forensic and socio-familial implications. Forensic pathology plays an important role in these cases due to the fact that they tend to occur unexpectedly, and therefore a postmortem examination is needed to determine cause and mechanism of death. Most of these deaths are of cardiovascular origin and many of them have a hereditary component. The autopsy may be the only way to establish the correct diagnosis of the underlying condition enabling the family to receive proper medical counseling, to identify asymptomatic relatives at risk, and to prevent subsequent deaths. A proper approach requires the collaboration of various medical specialties (coroners, pathologists, pediatricians, cardiologists, microbiologists, geneticians), who must work in coordination in accordance to international protocols. In this article, the epidemiologic and clinical-pathological features of the main conditions that may lead to SD in children and young adults are reviewed and a case series from Seville and Biscay provinces is presented. Finally, the importance of forensic pathology in the management and prevention of these cases is underlined.

Características epidemiológica, clínica y patológica de la muerte súbita en el servicio de patología del instituto de medicina legal durante el periodo del 2007 -2009 / Features epidemiological, clinical and pathological sudden death in the service of pathology forensic institute during the period 2007 -2009

Estudio descriptivo, corte transversal. Se encontró que el riesgo de Muerte Súbita es significativamente superior en varones que en mujeres, la incidencia es más alta en mayores de 50 años que los adultos jóvenes. La enfermedad ateroesclerosis coronaria fue la principal patología de muerte súbita cardiaca la cual está en relación directa con la edad, y la hora de fallecimietno que fue en horas de la mañana. La hemorragia subaracnoidea fue la principal causa de muerte súbita extracardiaca. Se recomienda la importancia de la realización de una autopsia completa en todos los casos de muerte súbita para obtener datos fiables respecto a las causas reales de muerte. Elaborar un sistema de base computarizado que permita la introducción de los datos registrados en los protocolos de autopsia realizadas desde año 2000 y hasta las actuales. Al Ministerio de Salud que elabore campañas de sensibilización y educación sanitaria sobre medidas de resucitación cardiopulmonar, así como la necesidad de ambulancias móviles con personla calificado

Muerte súbita e inesperada en la epilepsia (SUDEP) / Sudden unexpected death in epilepsy (SUDEP)

El SUDEP se refiere a la muerte súbita e inesperada con o sin testigos, no traumática, y no por ahogamientos en un paciente epiléptico, con o sin evidencia de que haya sufrido una crisis epiléptica al morir, en el que se haya descartado un estado convulsivo como causa de muerte y en el que la autopsia no proporcione evidencia alguna de una causa anatómica o tóxica de la muerte. Aunque SUDEP ha sido reconocido desde el siglo XIX, solo en las últimas dos décadas se le ha dado la importancia que ésta requiere. La frecuencia de SUDEP depende de la severidad de la epilepsia pero en general el riesgo de muerte súbita es de 20 veces mayor que el de la población en general. El edema pulmonar neurógeno, la apnea central y la arritmia cardiaca, inducidos por una descarga a-adrenérgica de origen central, constituyen los tres mecanismos fisiopatogénicos más estrechamente relacionados con la SUDEP. Por lo anterior obliga al clínico a realizar una minuciosa autopsia la cual debería incluir un examen neuropatológico que documente los cambios cerebrales que subyacen a la epilepsia, toxicología y el examen del corazón, los pulmones y otros órganos...

Narrowed lumen of the right coronary artery in chronic chagasic patients is associated with ischemic lesions of segmental thinnings of ventricles / El lumen estrecho de la arteria coronaria derecha en pacientes chagásicos crónicos está asociado con lesiones de adelgazamientos segmentales de los ventrículos

Thinning of myocardial segments, mainly at the apex and basal posterior region of left ventricle, are frequent lesions in chronic chagasic cardiopathy (CCC), but still without a well determined etiology. Previously we found severe myocardial microvascular dilatation that could cause ischemia in watershed regions. In this study we analyzed whether narrowness in epicardial coronary arteries in CCC might explain these thinned ventricular lesions. Two groups of dilated hearts with similar weights were compared: eleven hearts from patients with CCC versus four hearts from patients with dilated cardiomyopathy (IDCM). As normal controls we studied three non dilated normal weight hearts. There were no atherosclerotic plaques in the main branches of epicardial coronary arteries and cross-sectional luminal areas of proximal and distal segments were histologically measured. It was found that CCC hearts presented a lower mean luminal area in the right coronary artery (RCA) branch than IDCM, in proximal (4.3 ± 1.4 vs 6.6 ± 2.0 mm2; p= 0.02) and in distal (1.6 ± 1.0 vs 3.4 ± 0.9 mm²; p= 0.01) segments, with no statistical differences with normal hearts (2.7 ± 1.3 and 1.5 ± 0.3 mm²) in proximal (p= 0.2) and distal (p=0.11) sections. In conclusion thinning of ventricular wall in CCC patients seems to be ischemic lesions in the peripheral territory irrigated by the right coronary artery, possibly due to a steal phenomenon by the left coronary, induced by micro vessels dilatation.

Adelgazamientos segmentares del miocardio son frecuentes lesiones en la cardiomiopatía crónica chagásica (CCC), principalmente en el ápice de la región posterior del ventrículo izquierdo, cuya etiopatogenia todavía no está bien conocida. En trabajos anteriores se observó intensa dilatación de la micro circulación que podría llevar a isquemia en regiones de irrigaciones limítrofes. Este estudio analizó si estrechez de las arterias epicárdicas in CCC podrían explicar las lesiones de adelgazamientos ventriculares. Se compararon 2 grupos de corazones con pesos semejantes: 11 corazones de pacientes con CCC versus 4 corazones de pacientes con cardiomiopatia dilatada idiopática (IDCM). Como controles normales fueran estudiados 3 corazones no dilatados y con pesos normales. No estuvieron presentes placas ateroscleróticas en los principales ramos de las arterias coronarias epicárdicas. Las áreas de lumen en cortes transversales de los segmentos proximales e distales arteriales fueran medidas por histología. Los corazones con CCC mostraron una media de lumen menor en el ramo de la coronaria derecha que en los con IDCM, tanto en los segmentos proximales (4,3 ± 1,4 vs 6,6 ± 2,0 mm2; p= 0,02) como en los distales (1, 6 ± 1, 0 vs 3,4 ± 0,9 mm²; p= 0,01) y ninguna diferencia estadística fue observada cuando se compararon con los corazones normales (2,7 ± 1,3 vs 1,5 ± 0,3 mm²) tanto proximal (p= 0,2) como distal (p=0,11). Adelgazamientos ventriculares en pacientes con CCC parecen ser lesiones isquémicas en territorios distales, irrigados por la arteria coronaria derecha, posiblemente por un fenómeno de sustracción por la coronaria izquierda, debido a vasodilatación de micro circulación.

Timpanismo espumoso em bovinos leiteiros em pastagens de Trifolium spp. (Leg.Caesalpinoideae) / Leguminous bloat in dairy cattle on Trifolium spp. pastures

O pastejo de plantas leguminosas que provocam fermentação excessiva pode causar surtos de timpanismo e mortes em ruminantes. Em uma propriedade no município de São Francisco de Paula, Rio Grande do Sul, oito bovinos de um total de 66 morreram subitamente, ao haverem sido transferidos de um potreiro de campo nativo, para outro cuja pastagem era composta por Trifolium repens e Trifolium pratense. Os animais foram encontrados mortos no amanhecer do dia seguinte à transferência, não foram observados sinais clínicos prévios. Os principais achados macroscópicos incluíram aumento de volume abdominal, protrusão de vagina e língua, distensão ruminal, fígado de coloração pálida e aumento do baço. Na histologia, havia congestão e edema pulmonares e hiperplasia linfóide difusa e acentuada no baço. A evidência de ingestão das leguminosas associada aos achados patológicos e à ausência de microrganismos no exame bacteriológico confirmaram o diagnóstico de timpanismo.

Leguminous bloat may occur in cattle which graze pastures consisting of lush forages. In a dairy farm located on the municipality of São Francisco de Paula, Rio Grande do Sul, eight out of 66 cows died suddenly after being transferred to a paddock whose pastures were composed of Trifolium repens and Trifolium pratense. Animals were found dead in the morning of the next day after being transferred; no clinical signs were noticed. Main gross findings included enhanced abdominal volume, protrusion and congestion of the tongue and vagina, ruminal distension, pale liver, and enhanced spleen. Histologically, there were lung congestion and edema, and splenic lymphoid hyperplasia. The evidence of leguminous forages consumption associated with the pathological findings and the absence of growth on bacteriology confirmed the diagnosis.

Origem anômala das artérias coronárias: [revisão] / Anomalous origin of coronary arteries: [review]

A origem anômala das artérias coronárias é uma doença potencialmente letal, sobretudo em lactentes e atletas jovens. O entendimento da fisiopatologia da doença permitiu a diferenciação entre as diferentes apresentações clínicas. Apesar de ser causa de isquemia miocárdica, os exames indutores de isquemia podem ser normais. A cineangiocoronariografia foi durante muito tempo considerada o exame ideal para o diagnóstico da doença, mas os exames de imagem cardiovascular não-invasivos têm mostrado uma melhor definição da origem e do trajeto das artérias coronararias. O tratamento cirúrgico deve ser indicado em pacientes sintomáticos, principalmente em crianças com origem anômala da artéria coronária esquerda da artéria pulmonar. O manejo ideal para os pacientes assintomáticos permanece indefinido.

The anomalous origin of the coronary arteries is a potentially lethal pathology, especially in neonates and young athletes. The understanding of the pathophysiological pattern of the disease has allowed the recognition of the different forms of clinical presentation. Despite being a cause of myocardial ischemia, functional tests can be normal. Coronary angiography used to be the gold standard for the diagnosis of this pathology, but non-invasive cardiovascular imaging tests have shown better definition of the origin and course of coronary arteries. Surgical treatment should be indicated for symptomatic patients, mainly in children with the anomalous origin of the left coronary artery from the pulmonary artery. The ideal management of asymptomatic patients remains undefined.

Síncope / Syncope

Síncope é definida como a perda da consciência e do tônus postural, que ocorre secundariamente à hipoperfusão cerebral global, seguida de recuperação espontânea. As causas mais freqüentes em geral não causam danos aos pacientes, mas seu diagnóstico diferencial é importante porque os episódios de síncope de origem cardíaca podem ser preditores de morte súbita. A intenção deste artigo é abordar este tema e chamar a atenção para os casos mais graves.

Causes of sudden death during the process of venous infusion: an analysis of 12 cases / 法医学杂志

Twelve cases died during the process of venous infusion were collected from 208 autopsy cases during the period of 2002-2004 in our center. The rate was 5.8% (12/208). In these 12 cases, 8 occurred in countryside clinic with poor medical condition. Negligence to take care of the indications and contraindications of venous infusion was the main cause of these accidents. Autopsy data showed that the cause of sudden death of 9 cases were related to the venous infusion directly or indirectly. The other 3 cases were died from original diseases of these patients and the time of these deaths was time of coincidence occasionally with the time of venous infusion.

Fibronectin immunohistochemical staining for diagnosing sudden death caused by viral myocarditis / 法医学杂志

OBJECTIVE@#To study the value of Fibronectin(Fn) immunohistochemical staining for diagnosing slight viral myocarditis.@*METHODS@#The heart samples of human with myocarditis were studied by using LSAB immunohistochemical staining with anti-fibronectin antibody.@*RESULTS@#Dense deposition was found in the myocardium of human with myocarditis. Some Fn-positive cardiomyocytes were observed.@*CONCLUSION@#Slight degeneration of cardiomyocytes could be identified by Fn-LSAB immunohistochemical staining and Fn-deposition is one of the reliable marks for inflammation in the myocardium.

Incidência e preditores de morte súbita na cardiopatia chagásica crônica com função sistólica preservada / Incidence predictors of sudden death in chronic chagas cardiopathy with preserved systolic function

Objetivos:Avaliar a incidência e os preditores de morte súbita em uma coorte de pacientes com cardiopatia chagásica crônica e função sistólica preservada (FE maior 45 por cento).Métodos: Estudo prospectivo, longitudinal de uma coorte de 1053 pacientes com doença de Chagas, recrutados no período de 03/1990 a 03/2002 e acompanhados até 03/2003.todos foram submetidos a exame clínico, ECG, RX tórax e ECO na admissão.Na análise da incidência, foram descritas a incidência cumulativa e a incidência dencidade.Foram utilizaod o teste qui-quadrado para a comparação de variáveis categóricas e o teste t de Student para a comparação de médias entre 2 grupos. Resultados:Não houve qualquer caso de morte súbita entre os pacientes com ECG inicial normal.Nos 539 pacientes com ECG alterado, 377 aparesentavam FE maior 45 por cento e constituem a coorte de interesse