Multiple ischemic strokes after transcatheter arterial chemoembolization for hepatocellular carcinoma with a radiographic and pathological correlate.

INTRODUCTION: Transcatheter arterial chemoembolization (TACE) is a widely used form of therapy in advanced hepatocellular carcinoma. We report the first pathological data from an autopsy case of multiple cerebral emboli occurring during TACE. METHODS: A Medline search for previous cases of cerebral embolism and TACE revealed 11 other cases. FINDINGS: Multiple microscopic subacute infarcts were found in the cerebrum, midbrain, and cerebellum of our patient on autopsy, but no embolic material was seen. Embolic material was noted in dilated vessels throughout the fibrotic right diaphragm and in the upper lobe of the right lung. Combining the literature search with our patient, the mortality of cerebral embolism after TACE is 25% (n = 12). Intracardiac shunts were seen in 20% of the cases (n = 10). Hyperdense lesions were seen on head CT in 80% of the patients evaluated (n = 10). Chest imaging revealed infiltrate or consolidation in 60% of the cases (n = 5). Pulmonary emboli were reported in 100% of the cases (n = 8). CONCLUSIONS: Cerebral embolism after TACE is devastating. Brain pathology supports embolization of ethiodized oil rather than DC beads as the mechanism of cerebral injury. Further pathological studies are needed to better understand the pathophysiology of this condition. Lung pathology confirmed the presence of embolic material in the distal lung, suggestive of a hepatopulmonary shunt undetectable by current modalities. Evaluation for such shunts with emerging modalities such as TCD with emboli detection may be an area of future research.

Fatal head injury in children younger than 2 years in New York City and an overview of the shaken baby syndrome.

CONTEXT: Shaken baby syndrome is a controversial topic in forensic pathology. Some forensic pathologists state that shaking alone is insufficient to explain death and that an impact must have occurred even if there is no impact site on the head. OBJECTIVE: To examine a large cohort of fatal, pediatric head injuries for patterns of specific autopsy findings and circumstances that would support or dispute pure shaking as the cause of death. DESIGN: We retrospectively reviewed 59 deaths due to head injuries in children younger than 2 years certified in our office during a 9 year period (1998-2006). The review included autopsy, toxicology, microscopy, neuropathology, and police and investigators' reports. RESULTS: There were 46 homicides, 8 accidents, and 1 undetermined death from blunt-impact injury of the head. In 10 (22%) of the homicides, there was no impact injury to the head, and the cause of death was certified as whiplash shaking. In 4 (40%) of these 10 deaths, there was a history of shaking. In 5 (83%) of the other 6, there was no history of any purported accidental or homicidal injury. All 8 accidental deaths had impact sites. Of the 59 deaths, 4 (6.7%) had only remote injuries (chronic subdural hematomas, remote long bone fractures) that were certified as undetermined cause and manner. These 4 deaths were excluded from the study. CONCLUSIONS: We describe a subset of fatal, nonaccidental head-injury deaths in infants without an impact to the head. The autopsy findings and circumstances are diagnostic of a nonimpact, shaking mechanism as the cause of death. Fatal, accidental head injuries in children younger than 2 years are rare.

Dexmedetomidine related cardiac arrest in a patient with permanent pacemaker; a cautionary tale.

Dexmedetomidine (Precedex), an alpha-2 adrenergic receptor agonist is frequently and safely used as sedative agent during surgical procedures. We report a case of a 76-year-old woman who developed cardiac arrest from the use of dexmedetomidine during pacemaker lead extraction procedure.

Use of "therapeutic complication" as a manner of death.

Analyses of deaths due to therapeutic complications (TCs) provide important quality of care information for medical providers. In New York City, 463 deaths were investigated by the Office of Chief Medical Examiner and certified with TC as the manner of death in 2003. The TC manner of death is used for fatalities due to predictable complications of appropriate medical therapy. All death certificates and select autopsy, hospital, and investigation reports were reviewed. Data concerning cause of death, contributing conditions, age, race, and sex were extracted. The types of complications and the causes of death were classified into various types of surgical and nonsurgical categories of complications. These included: postoperative infections, pulmonary emboli, and technical and medication complications. The use of TC as a manner of death has benefits and limitations. Without the TC option, one is forced to certify certain deaths (e.g., penicillin anaphylaxis) either as natural or accident. The TC option allows easy identification and tracking of medical complications for public health purposes and also allows more consistent reporting of natural and medical-accidental deaths. In general, complications that occur during emergency surgeries/procedures for natural disease, tend to be certified with a natural manner. The "but for" test may be used to distinguish natural from TC deaths. There are criteria for distinguishing TC from accidents and homicides. TCs that occur during treatment of a potentially life-threatening injury, are superseded by the manner dictated by the circumstances of the initiating injury. The certification of TC usually does not address errors of omission, clinical judgement/management, or missed diagnoses.

Fatal complications of bariatric surgery.

BACKGROUND: Bariatric surgery is an increasingly used method to treat morbid obesity. The mortality rate among patients undergoing bariatric operations is generally quoted as between 0.05-2.0%. Our focus was not on mortality rates but rather on the reasons patients die following the procedures. In New York City, deaths that are due to predictable complications of appropriate therapy are certified as therapeutic complications. METHODS: We retrospectively reviewed all deaths investigated by the Office of the Chief Medical Examiner in New York City between 1997 and 2005 in which bariatric surgery had been performed. We report the fatal complications, the interval between surgery and death, the type of procedure, and coexisting morbidities. RESULTS: Autopsies were performed on 95% of these fatalities. There were 97 deaths due to therapeutic complications of the operations. The interval between the initial surgery and death ranged from several hours to years. The most common complication was an anastomotic leak with subsequent infection. A high percentage of deaths occurred after discharge (40%) and/or >30 days after surgery (37%). There were 8 deaths from complications of bariatric surgery that occurred >1 year after surgery. CONCLUSIONS: Studies that report the mortality rate during hospitalization or within 30 days of surgery, underestimate the actual incidence. Bariatric surgery carries both short- and long-term risks.

The happy land homicides: 87 deaths due to smoke inhalation.

We reviewed all 87 deaths from the Happy Land Social Club fire. All deaths were due to smoke inhalation. The carboxyhemoglobin (COHb) concentrations ranged from 37 to 93% with a mean of 76.5%. The vast majority (97%) of the decedents had a COHb concentration over 50%. Cyanide blood concentrations ranged from 0 to 5.5 mg/L with a mean of 2.2 mg/L. Nine decedents had no cyanide detected, and seven had cyanide concentrations of less than 1 mg/L. Fewer than one third of the decedents had thermal injuries, and most were partial thickness burns involving less than 20% body surface area. Ethanol was detected in 72% of decedents with a range of 0.01 to 0.29 g% and a mean blood concentration of 0.11 g%. Cocaine or cannabinoid use was identified in 9% of the decedents. All decedents were visually identified, and all had soot in the airway extending to the major bronchi. Carboxyhemoglobin concentrations corresponded well with deaths from smoke inhalation. Cyanide concentrations did not correspond with the extent of smoke inhalation, and the role of cyanide in contributing to these deaths is doubtful. Hydrogen chloride inhalation, as evidenced by comparison of the pH of tracheal mucosa to controls, was not a factor.

Bodies found in the waterways of New York City.

We reviewed the case records for all decedents recovered from the waterways of New York City over a three year period (1997-2000). The epidemiological profile, circumstances, toxicology findings, putrefactive changes, date of recovery, length of immersion, and injuries were examined. There were 123 deaths: 52 suicides, 50 undetermined, 16 accidents, and five homicides. The causes of death included: 97 drownings, 13 undetermined, and 13 other. Of all the floating decedents, 27% were without putrefactive change. All found after two or more weeks of immersion were recovered from November to May. The detection of ethanol and illicit drugs was 53% in the accident, 41% in the suicide, and 33% in the undetermined groups. Detection of ethanol and/or drugs of abuse is not a reliable criterion to distinguish suicide from accident. The identification of the deceased is pivotal for determining the manner of these deaths. Therefore, a great reliance is placed upon the medical investigator and the police (including the missing persons bureau) to determine the circumstances and identification of the decedent.