The occurrence of acute subdural haematoma and diffuse axonal injury as two typical acceleration injuries.

Closed head injuries have already been classified into contact injuries and acceleration-deceleration injuries. Two typical acceleration-deceleration injuries and at the same time, the two worst head injuries are acute subdural haematoma (ASDH) and diffuse axonal injury (DAI), and that is where they got their medico-legal importance. Using experiments, it has been shown that acceleration with an impact time of more than 20-25 min (which occurs in traffic accidents in real life) causes DAI, whereas an impact time of 5-10 min is more likely to produce acute subdural haematoma. The aim of this research is to show that not all, but some types of traffic accidents are more typical for the occurrence of DAI, as well as that the ASDH is not a common feature for all types of fall. The analysis conveyed covered 80 cases of closed head injuries (traffic accidents, falls and assaults) where a complete forensic medical autopsy has been undertaken, followed by a complete forensic-neuropathological examination. For the purpose of diagnosing DAI, immunohistochemistry using antibody against ß-amyloid precursor protein has been involved. Results show that ASDH is more likely to occur in cases of simple fall, assaults and cyclists and DAI is more typical for vehicular traffic accidents and cases of falling from a considerable height. The paper also comprises discussion about some open questions regarding the diagnosis of DAI in the medico-legal practice.

Dilemmas concerning the diffuse axonal injury as a clinicopathological entity in forensic medical practice.

Dilemmas and discussions concerning the diffuse axonal injury (DAI) and still existing in forensic medical practice are as it follows: 1. Whether the occurrence of DAI can indicate the type of traumatic event that has caused the head trauma, 2. Whether the presence of axonal damage in cases of hypoxia, ischaemia and other pathological conditions casts a shadow on the post-mortem pathological diagnosis of DAI and totally negates it, or there are certain clues in the findings that can point to the aetiology of the axonal damage. This paper discusses our findings based on neuropathological examination of 60 forensic cases of closed head injury. The neuropathological examination included: a macroscopic examination of the coronal sections and a microscopic examination involving an immunohistochemical method with antibody against ß-amyloid precursor protein. Our findings indicate that DAI, as a clinicopathological entity, is undoubtedly an acceleration-deceleration injury, predominant in road traffic accidents as it is classically outlined, and cases of falling from a considerable height. Our findings point to a certain difference between the features of traumatic and ischaemic axonal damage. In this paper we also investigate the correlation between pathological grades of DAI and the impairment of the brain function before death.

The importance of the detail forensic-neuropathological examination in the determination of the diffuse brain injuries.

UNLABELLED: According to the contemporary classification, traumatic brain damage is divided on focal and diffuse brain injuries, and primary and secondary brain damage. The aim of this paper is to emphasize the necessity of the forensic-neuropathological examination in the determination of the diffuse brain injuries. In those injuries frequently neither the most sophisticated clinical-investigation techniques like CT and MRI, nor the routine post-mortem forensic pathological examination, give any results with discovering an intracranial mass lesion, despite the fact that patients had manifested a serious brain failure. In a series of 80 cases with closed head injuries where forensic-neuropathological examination has been undertaken (examination of a fixed brain tissue and immunohistochemistry using monoclonal antibodies against ß-amyloid precursor protein), the occurrence of the diffuse brain injuries in the absence of any other massive intracranial lesion has been established in 14 (17,7%) of the cases. Hence, forensic-neuropathological examination has been the only way to establish the diagnosis of the brain injury that caused a serious brain failure and in most of them occurred as a concrete cause of death. This method has already been affirmed in the forensic medicine science and has been implemented in a Recommendation No 99 of the Council of Europe where medico-legal autopsy rules are given, thus, establishing it as an unavoidable part of the daily forensic medicine practice. KEYWORDS: diffuse axonal injury - diffuse vascular injury - closed head injuries - traumatic brain damage - diffuse brain damage.