Sudden death caused by ruptured brain arteriovenous malformation in an adolescent with autism spectrum disorder.

Brain arteriovenous malformations (bAVMs) are infrequent disorders in the pediatric population. The rupture of a bAVM is a clinical emergency often followed by death. Autism spectrum disorder shares a number of symptoms with AVM malformation; this may impede antemortem diagnosis. An 11-year-old boy with autism spectrum disorder (ASD) without other medical history died suddenly. Initially, choking on a peanut butter sandwich was suspected; autopsy did not demonstrate aspiration, but identified a ruptured right cerebellar AVM, with the characteristic tortuous vessels. The histology on the lesion confirmed the presence of arterialized veins and showed gliotic tissue and hemosiderin-laden macrophages, consistent with prior bleeding. BAVM pathogenesis is unknown; congenital disease may have several mechanisms including genetic predisposition and familial risk factors; development de novo may occur after hemorrhagic intracranial events such as surgical intervention and head trauma. ASD may present with overlapping symptoms of bAVM and may also interfere with expressing subtle neurologic symptoms to caretakers. ASD and AVM are rarely reported in association.

Suicide by Close-Range Gunshot Wound to the Bridge of the Nose.

Suicidal gunshot wounds to the nasal bridge are rare, particularly at close range (defined as muzzle of the weapon not touching the skin surface, but near enough to deposit soot and stippling). Previously reported suicidal gunshot wounds to the nose have been through the left nostril (Forensic Sci Int 1995;71(1):25-31; J Forensic Radiol Imag 2013;1(2):63-7). The death of a 26-year-old man with a close-range gunshot wound to the bridge of the nose was deemed suicide due to history, scene, and autopsy findings. These findings included previous suicidal ideation, texted and written notes, the decedent's cross-legged position seated on the floor, the trajectory of the bullet through his head and into the ceiling fan and roof above him, and acute alcohol intoxication. This decedent may have been intending a hard contact forehead location but inadvertently fired the gun into the bridge of his nose while bending forward, prior to contact.

Complex Congenital Heart Malformation Including Transposition of the Great Vessels, Presenting as Sudden Unexplained Infant Death.

Transposition of the great vessels (TGV) is a common congenital heart defect that is difficult to diagnose before birth. Antenatal diagnosis is associated with increased survival. Unusual features such as anomalous pulmonary artery origin may delay cyanosis, decreasing clinical suspicion. A three-week old female infant who had never been cyanotic presented for forensic autopsy due to onset of unresponsiveness at home. History included risk factors for TGV and signs of heart enlargement that were not recognized during life. Cardiac pathology consultation identified D-type TGV with additional rare anomalies. TGV may present as sudden unexplained infant death (SUID) for forensic autopsy if variant features prevent development of cyanosis. Cardiac pathology consultation is helpful in clarifying these features.

Fatal Chest Injury Caused by Windblown Beach Umbrella.

We present the case of a windblown beach umbrella inflicting fatal penetrating blunt force to the chest of a 55-year-old female beachgoer. A postmortem examination and detailed case history review were performed which revealed left ventricular trauma, determined to be the cause of death. Using recorded wind speeds from the date of the incident and the weight of the umbrella, we were able to calculate the pressure with which the umbrella struck the victim to be 16,000 PSI. Witness reports, medical records, scene details, and examination of a rental beach umbrella allowed the forensic pathologist to conclude that the object causing this woman's death was a windblown beach umbrella.

Improving Forensic Pathologic Investigation of Sudden Death in the Young: Tools, Guidance, and Methods of Cardiovascular Dissection from the Sudden Death in the Young Case Registry.

The Sudden Death in the Young (SDY) Case Registry, a prospective, population-based registry active in ten states, has developed tools to aid pathologists and death investigators in the evaluation and autopsy of unexplained, natural sudden deaths in the pediatric population. The tools were developed by a team of experts representing forensic pathology; pediatric-, cardiac-, and neuropathology; cardiology; neurology/epileptology; pediatrics; genetic counseling; and public health. These tools focus on collecting data relevant to determination of cause of death with a focus on dissection of the cardiovascular system. The tools provide an objective checklist format for ease of use and data extraction. By sharing the tools here and highlighting the examination of the cardiovascular system, the SDY Case Registry encourages a standardized approach to death investigation, autopsy, and data collection for sudden, unexpected deaths in the young towards a goal of informing prevention efforts. Acad Forensic Pathol. 2018 8(2): 347-391.

Saddle Pulmonary Embolism with Paradoxical Coronary Artery Embolism through a Patent Foramen Ovale.

A 35-year-old male patient was found in cardiac arrest in his vehicle, with no apparent injuries after a minor motor vehicle collision. The decedent was found to have a saddle pulmonary embolus with a thromboembolus impacted across a patent foramen ovale and a paradoxical embolism in the circumflex coronary artery, as well as significant clotting in the deep veins of both lower extremities. There were no risk factors in his history to explain the deep venous thrombosis; family history suggested the possibility of an unrecognized clotting disorder.

COX-1 and COX-2 contributions to basal and IL-1 beta-stimulated prostanoid synthesis in human neonatal cerebral microvascular endothelial cells.

Mechanisms of endothelium-dependent regulation of cerebral circulation in human neonates are poorly understood owing to the lack of experimental data. Prostanoids, the products of the cyclooxygenase (COX) pathway, appear to be important regulators of blood flow in neonates. COX activity in cultured endothelial cells from small (60-300 microm) and large (>300 microm) microvessels from the autopsy specimens of neonatal human cerebral cortex and cerebellum (22-26 wk gestational age) was detected as production of vasodilator prostanoids, prostacyclin [as 6-keto-prostaglandin (PG) F(1 alpha)] and PGE(2) from arachidonic acid. Treatment of neonatal human cerebral microvascular endothelial cells (hCMVEC) with IL-1 beta (50 ng/mL, 17 h) stimulated COX activity 5- to 20-fold. Basal and IL-1 beta-stimulated COX activities were inhibited by NS-398, indicating substantial COX-2 contribution to endothelial prostanoid synthesis in neonatal human brain cortex and cerebellum at rest and when mimicking the inflammatory conditions. Increased COX-2-linked activity in response to IL-1 beta was observed in hCMVEC from both cerebrum and cerebellum (5- to 20-fold), while under the same conditions elevated COX-1-linked activity was detected only in hCMVEC from cerebellum (5- to 10-fold). In IL-1 beta-treated hCMVEC, a shift toward PGE(2) as the major vasodilator product of the COX pathway was observed. Acute treatment with the protein tyrosine kinase inhibitor, tyrphostin 25, inhibited basal and IL-1 beta-induced COX activities, suggesting the importance of posttranslational modifications in endothelial COX-2 activation in human brain. Altogether, these data indicate that both COX-1 and COX-2 contribute to endothelial prostanoid synthesis in the neonatal human brain under basal conditions and in response to proinflammatory cytokine IL-1 beta.