The importance of optic nerve sheath hemorrhage as a postmortem finding in cases of fatal abusive head trauma: A 13-year study in a tertiary hospital.

Fatal abusive head trauma is a major cause of death in children and toddlers who suffer from cruel physical abuse. Postmortem differentiation of fatal abusive head trauma from accidental head trauma can be a complicated process. This consecutive case series study aimed to determine the role of subdural optic nerve sheath hemorrhage (ONSH) in 70 autopsy cases of children ≤3 years old in making this differentiation. The study took place over a 13 year period (between August 1st 2003 and July 31st 2016) at a tertiary hospital in Thailand. Eleven cases were diagnosed with fatal abusive head trauma and 10 were identified as being accidental closed head trauma cases. Bilateral retinal hemorrhage was noted in antemortem medical records in every hospitalized abusive head trauma case (n=10). Upon autopsy, ONSH was observed in all 11 fatal cases of abusive head trauma (bilateral=10 and unilateral=1) but not in any cases of accidental head trauma (0/5). Subdural hemorrhage was found in 10 out of 11 abusive head trauma victims but not in any of the 10 with accidental head trauma. Other postmortem findings in abusive head trauma included subarachnoid hemorrhage (5/11), marked brain swelling (3/11), skull fracture (4/11) and brain contusion (1/11). This study suggests that ONSH, together with subdural hemorrhage, plays an essential role in an accurate postmortem diagnosis of fatal abusive head trauma. Therefore, an ocular investigation should be performed in all autopsy cases where child abuse is suspected and where there is no reliable history/witnesses, confession or antemortem ophthalmologic examination.

An unusual case of sudden unexpected death due to massive hemopericardium from primary mediastinal seminoma.

It is well-known that cardiovascular disease is the most common cause of sudden unexpected death, especially in the young. However complete postmortem investigation performed by qualified forensic pathologists is crucial in establishing the exact cause and manner of death. Sudden death caused by a cardiac tamponade occurring secondarily to a primary mediastinal tumor is extremely unusual. An autopsy on a 25-year-old man who died unexpectedly discovered a massive hemopericardium in association with an anterosuperior mediastinal mass. The tumor had invaded the pericardium and an ulcerative surface with hemorrhagic necrosis on the cut surfaces of the intrapericardial tumor was revealed. All cardiac chambers and intrathoracic great vessels were intact and both testes were normal. Histologic examination confirmed the diagnosis of primary mediastinal pure cell seminoma. Diffuse pulmonary edema, as well as generalized congestion of internal organs, was observed as evidence of acute decompensated heart failure. To our knowledge, this is the first reported case of unexpected death due to massive hemopericardium as a result of primary mediastinal seminoma.

Death from undetected acute myocardial infarction secondary to coronary artery dissection after blunt thoracic trauma.

Blunt thoracic trauma is a common occurrence in automobile accidents. Acute myocardial infarction (AMI) caused by coronary dissection following blunt thoracic trauma is rare. We report a case of healthy 24-year-old man with a history of blunt thoracic injury with subsequent undetected AMI who died of acute decompensated heart failure 4 days after the insult. The autopsy findings showed a 90% luminal narrowing of the left anterior descending coronary artery by dissecting hematoma, 3 cm in length. The myocardium revealed transmural myocardial infarction affecting apex, most part of left ventricular free wall, and interventricular septum. Both lungs were heavy, wet, and noncrepitant. Histological findings of the infarcted myocardium were consistent with 3-5 days post-AMI. Sections from both lungs revealed massive pulmonary edema, reflecting acute decompensated heart failure following a large AMI secondary to coronary dissection. Blunt thoracic trauma may obscure typical chest pain associated with cardiac ischemia especially in cases with a high tolerance for pain.