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Med Sci Law OnlineFirst, published on June 16, 2014 as doi:10.1177/0025802414536722
Original article
Sudden neuropathological deaths: An autopsy study
Medicine, Science and the Law 0(0) 1–5 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802414536722 msl.sagepub.com
Basappa Subhas Hugar, Harish Shetty, YP Girishchandra and Jayanth S Hosahally
Abstract Background: Sudden or unexpected death can occur from unnatural causes, such as violence or poisoning, as well as from natural causes. Second to cardiac causes, neuropathology is one of the main causes of sudden natural death. In spite of the increasing incidence of neuropathological deaths, few studies have been conducted in Asia – hence the reason for the present study. Methods: A 10-year (January 2003 to December 2012) retrospective study was conducted at the MS medico-legal institute in a metropolitan city of southern India. All the cases of sudden natural death, where the cause of death was opined to be due to a neuropathology after meticulous medico-legal autopsy and chemical analysis, were included. Results and conclusions: A total of 7520 reported deaths were investigated. These included 291 sudden natural deaths, amongst which the death was attributed to neuropathology in 43 cases (14.7%). Of these 43 cases, 69.7% were male and 30.3% were female. The majority of cases (25.5%) were in those aged 560 years. Causes of neuropathology were due to subarachnoid haemorrhage in 48.8% of cases, stroke in 30.2%, meningitis in 14% and tumours in 7%. There was history of hypertension in 46.5% of cases, diabetes in 32.5% of cases and cardiac disease in 18.6% of cases. Keywords Forensic pathology, sudden natural death, neuropathology, stroke, subarachnoid haemorrhage, meningitis
Introduction
dangerous disease, injury or poisoning is found dead or dies within 24 hours after the onset of terminal illness (World Health Organization). Natural death means the death is caused entirely by the disease, and the trauma or poison did not play any role in bringing about the death. The practicing forensic pathologist is likely to encounter cases where either the cause of death or a major contribution to the cause of death is underlying damage to or disease of the central nervous system (CNS).2 Hence, one should be well versed with the routine neuropathological conditions encountered in day-to-day practice. Neuropathologies constitutes about 10–18% of sudden natural deaths. The neuropathological causes for sudden natural deaths include cerebral haemorrhage, cerebellar haemorrhage, pontine haemorrhage, cerebral thrombosis and embolism, brain tumour,
Autopsy practice varies from country to country. In India, all unnatural deaths (accidents/suicides/homicides) are investigated and a medico-legal autopsy is conducted. But very often, natural deaths form the basis of medico-legal investigations if they have occurred suddenly in an apparently healthy person under suspicious circumstances.1 In certain cases of sudden death where the treating physician is convinced that the death is natural, there is no suspicion of foul play and the cause of death is certain, the physician certifies the cause of death, and such deaths are not investigated. If there is suspicion of foul play, the case is registered as an unnatural death, and a medico-legal autopsy will be conducted. In certain deaths due to natural diseases where the treating physician is keen to know the extent of the suspected pathology, the consent of the next of kin is obtained, and an autopsy MS Ramaiah Medical College, Bangalore, India is conducted by pathologists. Such cases are not investigated by the police or magistrate. Hence, sudden natCorresponding author: ural deaths are underreported in India by forensic Basappa Subhas Hugar, Associate Professor, Forensic Medicine, MS medicine practitioners. Ramaiah Medical College, MSRIT POST, MSR NAGAR, Bangalore, Death is said to be sudden or unexpected when a 560054 India. person not known to have been Downloaded suffering from any Email: [email protected] from msl.sagepub.com at Freie Universitaet Berlin on May 8, 2015
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2 meningitis, carotid artery thrombosis, brain abscess, epilepsy, and so on.3 In such deaths, it is a difficult task for the forensic experts or medical officer to establish the cause of death. In every case, a thorough history of the illness, duration of emerging signs and symptoms, any reports from the treating hospital, in addition to a meticulous autopsy (including biochemical analysis, histopathological examination, microbiological examination and chemical analysis), play a vital role in solving the puzzle of sudden death. Despite the availability of potent antibiotics, the mortality rate due to acute bacterial meningitis remains significantly high in India and other developing countries.1 The spectrum of causes of death attributed to meningitis ranges from systemic (e.g. septic shock) to severe neurological complication (e.g. brain oedema, hydrocephalus, cerebrovascular involvement and intractable seizure).4 It has been estimated that as many as 15% of patients with spontaneous subarachnoid haemorrhage (SAH) die before reaching the nearest hospital. 5 SAH as a cause of death in autopsies where death occurred before reaching medical attention has not changed over the years.6 SAH can cause virtually instantaneous death, even though the mechanism is obscure. The majority of the natural causes of SAH are spontaneous in nature. SAH comprises 1–7% of all strokes; therefore, it is a significant cause of morbidity and mortality, especially in the elderly.7 Most large intracerebral haematomas occur in middle-aged men with hypertension or in the elderly.8 Tumours of the CNS are among the rare causes of sudden and unexpected deaths.9
Material and methods The Department of Forensic Medicine at the MS Ramaiah Medico-Legal Institute provides a postmortem examination service for northern Bangalore, a metropolitan city in southern India. A 10-year (January 2003 to December 2012) retrospective study was conducted in the department, where a total of 7520 medico-legal autopsy reports were reviewed. All the sudden natural deaths were included, in which, after meticulous medico-legal autopsy and chemical analysis, the cause of death was attributed to neuropathology. This resulted in 291 cases of sudden natural death, out of which 43 cases were due to neuropathology. Natural deaths amongst unknown cases were excluded, as there were no proper data available. Descriptive statistics for the qualitative type of data were summarized using frequency and percentage.
Results and discussion
Medicine, Science and the Law 0(0) for 291 cases (3.9% of total unnatural deaths). Of these, neuropathology constituted the cause of death in 43 cases (0.57% of total autopsies and 14.8% of total sudden natural deaths). Similar findings have been noted in various studies, where neuropathology constituted 10–18% of sudden natural deaths.3 This is in contrast to a study conducted in Jamaica, where sudden natural deaths constituted 51.3% of medicolegal autopsies.10 This is because not as many natural deaths are investigated in India compared to Jamaica. In Jamaica, there are both a non-coroner’s autopsy and a coroner’s autopsy, which are similar to the pathological autopsy and medico-legal autopsy in India. The cases were equally distributed over the entire study period from 2003 to 2012, except in 2008 and 2009 during when nine cases were observed each year. Of the 43 cases (Table 1), 69.7% were male and 30.3% were female, since most of the cases were caused by stroke and SAH, and men carry higher risk factors such as smoking, hypertension, diabetes and so on. Other reasons for the higher incidence in males were because they are generally working outdoor and are subjected to more strenuous work (physical exertion) and mental stress which could cause a sudden rise in blood pressure and hence rupture of pre-existing undiagnosed aneurysms and stroke. The role of physical or emotional stress – for example, minor assault or a verbal argument – when someone dies from a natural disease process shortly after the event is not an uncommon medico-legal problem. Such deaths most frequently result from SAH or intracerebral haemorrhage or cardiac disease, with death possibly occurring as a consequence of a rise in blood pressure as a result of the stress.8 In an autopsy study of SAH, it was observed that 55.3% were female and 44.7% were male.7 Most cases (25.5%) belonged to the 560 years age group, followed by the 50–59 years age group (23.4%), with eight cases (18.5%) belonging to 40–49 years age group. The number of cases increased with age. This could be attributed to the higher incidence of stroke and spontaneous SAH in the elderly.
Table 1. Distribution of cases based on age and sex. Sl No 1 2 3 4 5 6 7
Age group (years)
Total
0–9 10–19 20–29 30–39 40–49 50–59 560 Total
0 3 6 5 8 10 11 43
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0% 7.0% 14.0% 16.4% 18.5% 23.4% 25.5% 100%
Males
Females
0 2 4 3 6 7 8 30
0 1 2 2 2 3 3 13
0% 4.7% 9.3% 7.0% 13.8% 16.4% 18.5% 69.7%
0% 2.2% 4.7% 4.7% 4.7% 7.0% 7.0% 30.3%
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No cases were reported in the 0–9 years age group. Only three cases (7%) belonged to 10–19 years age group (two were due to meningitis, and other one was due to epilepsy). SAH was the most common type of sudden neuropathological death (21 cases), comprising half of all cases (Figures 1–3). This high number of SAH deaths encountered could be because all sudden unexplained death in epilepsy (SUDEP) and the majority of deaths due to stroke are certified by the treating physician, and thus are not routinely autopsied. The second most common type of death was stroke (excluding SAH; Figure 4) constituting 30.2% of the cases. It was observed that there was no sex differences in cases due to tumours and infection, since these cases were independent of the risk factors. The mechanism of death in cases of tumours was sudden haemorrhage into the midbrain and brainstem leading to sudden death because of the effect of pressure on the vital
centres located in that region. Out of 21 cases of SAH, 16 were males and 5 were females (4:1), and among 13 cases of stroke, only three were females (4:1). Hamman found that 8% of all patients who had died suddenly had some sort of cerebral hemorrhage.11 SAH and stroke were commonly seen in middleaged and elderly individuals, whereas meningitis and tumours were found in the 10–39 years age group. SAH constituted 7.2% and stroke about 4.5% of sudden natural deaths (Table 2). In most cases of SAH, the haemorrhage was diffuse and mainly in the basal region. In 14 cases, it was due to the rupture of a saccular aneurysm, in one case due to arteriovenous malformation and in six cases the exact site of the bleed could not be identified. Amongst the 14 cases of aneurismal rupture, it was observed that six were in the posterior circulation of the Circle of Willis and eight in the anterior circulation. In eight cases of
Figure 1. Diffuse Subarachnoid haemorrhage (spontaneous) predominantly over left cerebral hemisphere.
Figure 3. Diffuse Subarachnoid haemorrhage (spontaneous) present over base of the brain.
Figure 2. Ruptured berry aneurysm present at the junction of anterior cerebral and anterior communicating artery causing subarachnoid haemorrhage (spontaneous).
Figure 4. Deep seated non-traumatic intra cerebral haemorrhage present in the region of basal ganglia.
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Table 2. Distribution of cases based on the pattern. Sl no Pattern 1 2 3 4 5
Total no. Males Females cases Percentage
Stroke 10 Sub arachnoid 16 haemorrhage Infection 3 Tumours 1 Epilepsy 1 Total 31
3 5
13 21
30.2% 48.8%
3 1 0 12
6 2 1 43
14% 4.7% 2.3% 100%
Table 3. Distribution of cases based on history. Sl No
History
Cases
1 2 3
Diabetes mellitus Hypertension Previous heart disease
14 20 8
astrocytoma, which presented as a haemorrhage into the brainstem, leading to sudden death. Intracranial tumours are said to account for 8% of non-traumatic intracerebral haemorrhage, and in about half, it may be the first manifestation.21,22 It was observed that the incidence of tumours was between 0.17% and 0.54% in several series of forensic autopsy studies.23,24 Twenty individuals were on medication for hypertension and 14 were diabetic. The majority of cases who died due to stroke or SAH had either hypertension or diabetes or both. Eight individuals had a cardiac illness such as ischemic heart disease, valvular heart disease and so on in addition to hypertension (Table 3). In a similar study, cerebrovascular accidents were the most common cause of death, and hypertension was associated with majority of the cases (78.1%).10
SAH, the haemorrhage also extended into the ventricles. In one study, it was observed that in 27 of 33 cases, the ruptured aneurysms arose in the anterior circulation of the Circle of Willis, and in only six cases was a ruptured posterior circulation aneurysm responsible for death.8 Studies have shown that 8–10% of deaths from a ruptured intracranial saccular aneurysm occur suddenly, before reaching hospital.12–14 In discussion, particular emphasis was placed on the exceptionally high fatality rate in patients with ruptured saccular aneurysms arising from the posterior circulation of the Circle of Willis. A few hospitalConclusion based studies have also suggested a somewhat higher mortality after the rupture of posterior circulation Neuropathology is one of the major causes of sudden saccular aneurysms,15,16 whereas others have failed natural deaths. The forensic pathologist plays a crucial role in ascertaining the cause of death in such to detect any differences in the outcome.17–20 cases. In every case, a thorough history of the illness, Out of six cases, five were due to acute bacterial the duration of emerging signs and symptoms, any meningitis, and the remaining case was due to the reports from the treating hospital, in addition to a spontaneous rupture of a cerebral abscess. Four meticulous autopsy, play a vital role in solving the cases had longstanding suppurative ear discharge puzzle of sudden death. The results of our study can before succumbing to sudden death. In the remaining be summarized as follows: two cases, there were no significant symptoms, except fever and headache which were symptomatically trea. Neuropathological deaths constituted 0.57% of ted at the tertiary level health-care centre on an outtotal unnatural deaths and 14.8% of sudden natpatient basis. ural deaths. In India, the treating physician usually certifies the . Causes of the neuropathological deaths were due to death in cases of status epilepticus. Thus, an autopsy stroke in 30.2% of cases, SAH in 48.8% of cases, is not conducted routinely in such cases. In the single meningitis in 14% of cases and tumours in 7% case of status epilepticus where an autopsy was concases. SAH constituted 7.2% and stroke constiducted, the treating family physician was not on duty, tuted 4.5% of sudden natural deaths. and the deceased was brought to our hospital and . The majority of cases occurred in the 560 years registered as an unnatural death. He was a known age group in both sexes, constituting 25.5% of all epileptic on irregular medication, and he had had a cases. continuous seizure lasting for about 8–10 minutes. At . There was history of hypertension in 46.5% of autopsy, there were findings consistent with a seizure, cases, diabetes in 32.5% of cases and cardiac disthat is, bruising of the tongue, pulmonary oedema, ease in 18.6% of cases. petechial haemorrhages in the mucous membranes and so on. Thus, the death was ascribed to status epilepticus. Funding Tumours constituted 6.9% of sudden CNS deaths, This research received no specific grant from any funding accounting for 1% of total sudden natural deaths. agency in the public, commercial, or not-for-profit sectors. Both the cases of tumours were undiagnosed Downloaded from msl.sagepub.com at Freie Universitaet Berlin on May 8, 2015
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References 1. Prajapati P, Singhal M, Sheikh MI, et al. Forensic diagnosis of sudden death due to pyogenic meningitis. J Indian Acad Forensic Med 2010; 32: 243–247. 2. Stewart W, Black M, Kalimo H, et al. Non traumatic forensic neuropathology. Forensic Sci Int 2004; 146: 125–147. 3. Reddy KSN. The essentials of forensic medicine and toxicology, 30th ed. Hyderabad: Medical Book Company, 2011, p.136. 4. McMillian DA, Lin CY, Aronin SI, et al. Community acquired bacterial meningitis in adults: categorization of causes and timing of death. Clin Infect Dis 2001; 33: 969–975. 5. Locksley HB. Natural history of subarachnoid haemorrhage, intracranial aneurysms and arteriovenous malformation based on 6,368 cases in the cooperative study. Parts 1 and 2. In: Sahs AL, Perset GE, Locksley HB, et al. (eds) Intracranial aneurysms and subarachnoid haemorrhage. Philadelphia: JB Lippincott, 1969, pp.37–108. 6. Schievink WE, Wijdicks EP, Piepgras DG, et al. Sudden death from aneurysmal subarachnoid hemorrhage. Neurology 1995; 45: 871–874. 7. Edirisinghe PAS. Subarachnoid haemorrhage as a cause of death: a review of forensic autopsies conducted in Edinburgh. Sri Lanka J Forensic Med Sci Law 2010; 1: 14–19. 8. Black M and Graham DI. Sudden unexplained death in adults caused by intracranial pathology. J Clin Pathol 2002; 55: 44–50. 9. Yalcin B, Arzu TA, Gulay K, et al. Sudden unexpected death due to cerebellar astrocytoma (pilocytic astrocytoma): an autopsy case. Adli Tip Derg 2006; 20: 35–39. 10. Escoffery CT and Shirley SE. Causes of Sudden natural death in Jamaica: a medico legal (coroner’s) autopsy study from the University Hospital of the West Indies. Forensic Sci Int 2002; 129: 116–121. 11. Hamman L. Sudden death. Bull Johns Hopkins Hosp 1934; 55: 387–415. 12. Crawford MD and Sarner M. Ruptured intracranial aneurysms: community study. Lancet 1965; ii: 1254–1257. 13. Phillips LH, Whisnant JP, O’Fallon WM, et al. The unchanging pattern of subarachnoid haemorrhage in a community. Neurology 1980; 30: 1034–1040.
14. Schievink WI, Wijdicks EFM, Piepgras DG, et al. The poor prognosis of ruptured intracranial aneurysms of the posterior circulation. J Neurosurg 1995; 82: 791–795. 15. Kassell NF, Torner JC, Haley EC, et al. The international co-operative study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg 1990; 73: 18–36. 16. Rasmussen P, Bosch H, Haase J, et al. Intracranial saccular aneurysms: results of treatment in 851 patients. Acta Neurochir (Wien) 1980; 53: 1–17. 17. Nishioka H. Report on the co-operative study of intracranial aneurysms and subarachnoid haemorrhage. Section VII, Part 1: evaluation of the conservative management of ruptured intracranial aneurysms. J Neurosurg 1966; 25: 574–592. 18. Peerless SJ and Drake CC. Management of aneurysm of the posterior circulation. In: Youmans JR (ed.) Neurosurgical surgery: a comprehensive reference guide to the management of aneurysmal problems. vol. 3, 3rd ed. Philadelphia: WB Saunders, 1990, pp.1764–800. 19. Sundt TM, Kobayashi S, Fode NC, et al. Results and complications of surgical management of 809 intracranial aneurysms in 722 cases. J Neurosurg 1982; 56: 753–765. 20. Troupp H. The natural history of aneurysms of the basilar bifurcation. Acta Neurol Scand 1971; 47: 350–356. 21. Adams JH and Graham DI. The relationship between ventricular fluid pressure and the neuropathology of raised intracranial pressure. Neuropathol Appl Neurobiol 1976; 2: 323–332. 22. Graham DI, Lawrence AE, Adams JH, et al. Brain damage in non-missile head injury secondary to a high intracranial pressure. Neuropathol Appl Neurobiol 1987; 13: 209–217. 23. Havlik DM, Becher MW and Nolte KB. Sudden death due to primary diffuse leptomeninges gliomatosis. J Forensic Sci 2001; 46: 392–395. 24. Di Maio SM, Di Maio VJ and Kirkpatrick JB. Sudden unexpected deaths due to primary intracranial neoplasmas. Am J Forensic Med Pathol 1980; 1: 29–45.
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Med Sci Law OnlineFirst, published on June 16, 2014 as doi:10.1177/0025802414536722
Original article
Sudden neuropathological deaths: An autopsy study
Medicine, Science and the Law 0(0) 1–5 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802414536722 msl.sagepub.com
Basappa Subhas Hugar, Harish Shetty, YP Girishchandra and Jayanth S Hosahally
Abstract Background: Sudden or unexpected death can occur from unnatural causes, such as violence or poisoning, as well as from natural causes. Second to cardiac causes, neuropathology is one of the main causes of sudden natural death. In spite of the increasing incidence of neuropathological deaths, few studies have been conducted in Asia – hence the reason for the present study. Methods: A 10-year (January 2003 to December 2012) retrospective study was conducted at the MS medico-legal institute in a metropolitan city of southern India. All the cases of sudden natural death, where the cause of death was opined to be due to a neuropathology after meticulous medico-legal autopsy and chemical analysis, were included. Results and conclusions: A total of 7520 reported deaths were investigated. These included 291 sudden natural deaths, amongst which the death was attributed to neuropathology in 43 cases (14.7%). Of these 43 cases, 69.7% were male and 30.3% were female. The majority of cases (25.5%) were in those aged 560 years. Causes of neuropathology were due to subarachnoid haemorrhage in 48.8% of cases, stroke in 30.2%, meningitis in 14% and tumours in 7%. There was history of hypertension in 46.5% of cases, diabetes in 32.5% of cases and cardiac disease in 18.6% of cases. Keywords Forensic pathology, sudden natural death, neuropathology, stroke, subarachnoid haemorrhage, meningitis
Introduction
dangerous disease, injury or poisoning is found dead or dies within 24 hours after the onset of terminal illness (World Health Organization). Natural death means the death is caused entirely by the disease, and the trauma or poison did not play any role in bringing about the death. The practicing forensic pathologist is likely to encounter cases where either the cause of death or a major contribution to the cause of death is underlying damage to or disease of the central nervous system (CNS).2 Hence, one should be well versed with the routine neuropathological conditions encountered in day-to-day practice. Neuropathologies constitutes about 10–18% of sudden natural deaths. The neuropathological causes for sudden natural deaths include cerebral haemorrhage, cerebellar haemorrhage, pontine haemorrhage, cerebral thrombosis and embolism, brain tumour,
Autopsy practice varies from country to country. In India, all unnatural deaths (accidents/suicides/homicides) are investigated and a medico-legal autopsy is conducted. But very often, natural deaths form the basis of medico-legal investigations if they have occurred suddenly in an apparently healthy person under suspicious circumstances.1 In certain cases of sudden death where the treating physician is convinced that the death is natural, there is no suspicion of foul play and the cause of death is certain, the physician certifies the cause of death, and such deaths are not investigated. If there is suspicion of foul play, the case is registered as an unnatural death, and a medico-legal autopsy will be conducted. In certain deaths due to natural diseases where the treating physician is keen to know the extent of the suspected pathology, the consent of the next of kin is obtained, and an autopsy MS Ramaiah Medical College, Bangalore, India is conducted by pathologists. Such cases are not investigated by the police or magistrate. Hence, sudden natCorresponding author: ural deaths are underreported in India by forensic Basappa Subhas Hugar, Associate Professor, Forensic Medicine, MS medicine practitioners. Ramaiah Medical College, MSRIT POST, MSR NAGAR, Bangalore, Death is said to be sudden or unexpected when a 560054 India. person not known to have been Downloaded suffering from any Email: [email protected] from msl.sagepub.com at Freie Universitaet Berlin on May 8, 2015
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2 meningitis, carotid artery thrombosis, brain abscess, epilepsy, and so on.3 In such deaths, it is a difficult task for the forensic experts or medical officer to establish the cause of death. In every case, a thorough history of the illness, duration of emerging signs and symptoms, any reports from the treating hospital, in addition to a meticulous autopsy (including biochemical analysis, histopathological examination, microbiological examination and chemical analysis), play a vital role in solving the puzzle of sudden death. Despite the availability of potent antibiotics, the mortality rate due to acute bacterial meningitis remains significantly high in India and other developing countries.1 The spectrum of causes of death attributed to meningitis ranges from systemic (e.g. septic shock) to severe neurological complication (e.g. brain oedema, hydrocephalus, cerebrovascular involvement and intractable seizure).4 It has been estimated that as many as 15% of patients with spontaneous subarachnoid haemorrhage (SAH) die before reaching the nearest hospital. 5 SAH as a cause of death in autopsies where death occurred before reaching medical attention has not changed over the years.6 SAH can cause virtually instantaneous death, even though the mechanism is obscure. The majority of the natural causes of SAH are spontaneous in nature. SAH comprises 1–7% of all strokes; therefore, it is a significant cause of morbidity and mortality, especially in the elderly.7 Most large intracerebral haematomas occur in middle-aged men with hypertension or in the elderly.8 Tumours of the CNS are among the rare causes of sudden and unexpected deaths.9
Material and methods The Department of Forensic Medicine at the MS Ramaiah Medico-Legal Institute provides a postmortem examination service for northern Bangalore, a metropolitan city in southern India. A 10-year (January 2003 to December 2012) retrospective study was conducted in the department, where a total of 7520 medico-legal autopsy reports were reviewed. All the sudden natural deaths were included, in which, after meticulous medico-legal autopsy and chemical analysis, the cause of death was attributed to neuropathology. This resulted in 291 cases of sudden natural death, out of which 43 cases were due to neuropathology. Natural deaths amongst unknown cases were excluded, as there were no proper data available. Descriptive statistics for the qualitative type of data were summarized using frequency and percentage.
Results and discussion
Medicine, Science and the Law 0(0) for 291 cases (3.9% of total unnatural deaths). Of these, neuropathology constituted the cause of death in 43 cases (0.57% of total autopsies and 14.8% of total sudden natural deaths). Similar findings have been noted in various studies, where neuropathology constituted 10–18% of sudden natural deaths.3 This is in contrast to a study conducted in Jamaica, where sudden natural deaths constituted 51.3% of medicolegal autopsies.10 This is because not as many natural deaths are investigated in India compared to Jamaica. In Jamaica, there are both a non-coroner’s autopsy and a coroner’s autopsy, which are similar to the pathological autopsy and medico-legal autopsy in India. The cases were equally distributed over the entire study period from 2003 to 2012, except in 2008 and 2009 during when nine cases were observed each year. Of the 43 cases (Table 1), 69.7% were male and 30.3% were female, since most of the cases were caused by stroke and SAH, and men carry higher risk factors such as smoking, hypertension, diabetes and so on. Other reasons for the higher incidence in males were because they are generally working outdoor and are subjected to more strenuous work (physical exertion) and mental stress which could cause a sudden rise in blood pressure and hence rupture of pre-existing undiagnosed aneurysms and stroke. The role of physical or emotional stress – for example, minor assault or a verbal argument – when someone dies from a natural disease process shortly after the event is not an uncommon medico-legal problem. Such deaths most frequently result from SAH or intracerebral haemorrhage or cardiac disease, with death possibly occurring as a consequence of a rise in blood pressure as a result of the stress.8 In an autopsy study of SAH, it was observed that 55.3% were female and 44.7% were male.7 Most cases (25.5%) belonged to the 560 years age group, followed by the 50–59 years age group (23.4%), with eight cases (18.5%) belonging to 40–49 years age group. The number of cases increased with age. This could be attributed to the higher incidence of stroke and spontaneous SAH in the elderly.
Table 1. Distribution of cases based on age and sex. Sl No 1 2 3 4 5 6 7
Age group (years)
Total
0–9 10–19 20–29 30–39 40–49 50–59 560 Total
0 3 6 5 8 10 11 43
During the study period, from January 2003 to December 2012, 7520 medico-legal autopsies were conducted, of which sudden natural deaths accounted Downloaded from msl.sagepub.com at Freie Universitaet Berlin on May 8, 2015
0% 7.0% 14.0% 16.4% 18.5% 23.4% 25.5% 100%
Males
Females
0 2 4 3 6 7 8 30
0 1 2 2 2 3 3 13
0% 4.7% 9.3% 7.0% 13.8% 16.4% 18.5% 69.7%
0% 2.2% 4.7% 4.7% 4.7% 7.0% 7.0% 30.3%
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No cases were reported in the 0–9 years age group. Only three cases (7%) belonged to 10–19 years age group (two were due to meningitis, and other one was due to epilepsy). SAH was the most common type of sudden neuropathological death (21 cases), comprising half of all cases (Figures 1–3). This high number of SAH deaths encountered could be because all sudden unexplained death in epilepsy (SUDEP) and the majority of deaths due to stroke are certified by the treating physician, and thus are not routinely autopsied. The second most common type of death was stroke (excluding SAH; Figure 4) constituting 30.2% of the cases. It was observed that there was no sex differences in cases due to tumours and infection, since these cases were independent of the risk factors. The mechanism of death in cases of tumours was sudden haemorrhage into the midbrain and brainstem leading to sudden death because of the effect of pressure on the vital
centres located in that region. Out of 21 cases of SAH, 16 were males and 5 were females (4:1), and among 13 cases of stroke, only three were females (4:1). Hamman found that 8% of all patients who had died suddenly had some sort of cerebral hemorrhage.11 SAH and stroke were commonly seen in middleaged and elderly individuals, whereas meningitis and tumours were found in the 10–39 years age group. SAH constituted 7.2% and stroke about 4.5% of sudden natural deaths (Table 2). In most cases of SAH, the haemorrhage was diffuse and mainly in the basal region. In 14 cases, it was due to the rupture of a saccular aneurysm, in one case due to arteriovenous malformation and in six cases the exact site of the bleed could not be identified. Amongst the 14 cases of aneurismal rupture, it was observed that six were in the posterior circulation of the Circle of Willis and eight in the anterior circulation. In eight cases of
Figure 1. Diffuse Subarachnoid haemorrhage (spontaneous) predominantly over left cerebral hemisphere.
Figure 3. Diffuse Subarachnoid haemorrhage (spontaneous) present over base of the brain.
Figure 2. Ruptured berry aneurysm present at the junction of anterior cerebral and anterior communicating artery causing subarachnoid haemorrhage (spontaneous).
Figure 4. Deep seated non-traumatic intra cerebral haemorrhage present in the region of basal ganglia.
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Table 2. Distribution of cases based on the pattern. Sl no Pattern 1 2 3 4 5
Total no. Males Females cases Percentage
Stroke 10 Sub arachnoid 16 haemorrhage Infection 3 Tumours 1 Epilepsy 1 Total 31
3 5
13 21
30.2% 48.8%
3 1 0 12
6 2 1 43
14% 4.7% 2.3% 100%
Table 3. Distribution of cases based on history. Sl No
History
Cases
1 2 3
Diabetes mellitus Hypertension Previous heart disease
14 20 8
astrocytoma, which presented as a haemorrhage into the brainstem, leading to sudden death. Intracranial tumours are said to account for 8% of non-traumatic intracerebral haemorrhage, and in about half, it may be the first manifestation.21,22 It was observed that the incidence of tumours was between 0.17% and 0.54% in several series of forensic autopsy studies.23,24 Twenty individuals were on medication for hypertension and 14 were diabetic. The majority of cases who died due to stroke or SAH had either hypertension or diabetes or both. Eight individuals had a cardiac illness such as ischemic heart disease, valvular heart disease and so on in addition to hypertension (Table 3). In a similar study, cerebrovascular accidents were the most common cause of death, and hypertension was associated with majority of the cases (78.1%).10
SAH, the haemorrhage also extended into the ventricles. In one study, it was observed that in 27 of 33 cases, the ruptured aneurysms arose in the anterior circulation of the Circle of Willis, and in only six cases was a ruptured posterior circulation aneurysm responsible for death.8 Studies have shown that 8–10% of deaths from a ruptured intracranial saccular aneurysm occur suddenly, before reaching hospital.12–14 In discussion, particular emphasis was placed on the exceptionally high fatality rate in patients with ruptured saccular aneurysms arising from the posterior circulation of the Circle of Willis. A few hospitalConclusion based studies have also suggested a somewhat higher mortality after the rupture of posterior circulation Neuropathology is one of the major causes of sudden saccular aneurysms,15,16 whereas others have failed natural deaths. The forensic pathologist plays a crucial role in ascertaining the cause of death in such to detect any differences in the outcome.17–20 cases. In every case, a thorough history of the illness, Out of six cases, five were due to acute bacterial the duration of emerging signs and symptoms, any meningitis, and the remaining case was due to the reports from the treating hospital, in addition to a spontaneous rupture of a cerebral abscess. Four meticulous autopsy, play a vital role in solving the cases had longstanding suppurative ear discharge puzzle of sudden death. The results of our study can before succumbing to sudden death. In the remaining be summarized as follows: two cases, there were no significant symptoms, except fever and headache which were symptomatically trea. Neuropathological deaths constituted 0.57% of ted at the tertiary level health-care centre on an outtotal unnatural deaths and 14.8% of sudden natpatient basis. ural deaths. In India, the treating physician usually certifies the . Causes of the neuropathological deaths were due to death in cases of status epilepticus. Thus, an autopsy stroke in 30.2% of cases, SAH in 48.8% of cases, is not conducted routinely in such cases. In the single meningitis in 14% of cases and tumours in 7% case of status epilepticus where an autopsy was concases. SAH constituted 7.2% and stroke constiducted, the treating family physician was not on duty, tuted 4.5% of sudden natural deaths. and the deceased was brought to our hospital and . The majority of cases occurred in the 560 years registered as an unnatural death. He was a known age group in both sexes, constituting 25.5% of all epileptic on irregular medication, and he had had a cases. continuous seizure lasting for about 8–10 minutes. At . There was history of hypertension in 46.5% of autopsy, there were findings consistent with a seizure, cases, diabetes in 32.5% of cases and cardiac disthat is, bruising of the tongue, pulmonary oedema, ease in 18.6% of cases. petechial haemorrhages in the mucous membranes and so on. Thus, the death was ascribed to status epilepticus. Funding Tumours constituted 6.9% of sudden CNS deaths, This research received no specific grant from any funding accounting for 1% of total sudden natural deaths. agency in the public, commercial, or not-for-profit sectors. Both the cases of tumours were undiagnosed Downloaded from msl.sagepub.com at Freie Universitaet Berlin on May 8, 2015
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References 1. Prajapati P, Singhal M, Sheikh MI, et al. Forensic diagnosis of sudden death due to pyogenic meningitis. J Indian Acad Forensic Med 2010; 32: 243–247. 2. Stewart W, Black M, Kalimo H, et al. Non traumatic forensic neuropathology. Forensic Sci Int 2004; 146: 125–147. 3. Reddy KSN. The essentials of forensic medicine and toxicology, 30th ed. Hyderabad: Medical Book Company, 2011, p.136. 4. McMillian DA, Lin CY, Aronin SI, et al. Community acquired bacterial meningitis in adults: categorization of causes and timing of death. Clin Infect Dis 2001; 33: 969–975. 5. Locksley HB. Natural history of subarachnoid haemorrhage, intracranial aneurysms and arteriovenous malformation based on 6,368 cases in the cooperative study. Parts 1 and 2. In: Sahs AL, Perset GE, Locksley HB, et al. (eds) Intracranial aneurysms and subarachnoid haemorrhage. Philadelphia: JB Lippincott, 1969, pp.37–108. 6. Schievink WE, Wijdicks EP, Piepgras DG, et al. Sudden death from aneurysmal subarachnoid hemorrhage. Neurology 1995; 45: 871–874. 7. Edirisinghe PAS. Subarachnoid haemorrhage as a cause of death: a review of forensic autopsies conducted in Edinburgh. Sri Lanka J Forensic Med Sci Law 2010; 1: 14–19. 8. Black M and Graham DI. Sudden unexplained death in adults caused by intracranial pathology. J Clin Pathol 2002; 55: 44–50. 9. Yalcin B, Arzu TA, Gulay K, et al. Sudden unexpected death due to cerebellar astrocytoma (pilocytic astrocytoma): an autopsy case. Adli Tip Derg 2006; 20: 35–39. 10. Escoffery CT and Shirley SE. Causes of Sudden natural death in Jamaica: a medico legal (coroner’s) autopsy study from the University Hospital of the West Indies. Forensic Sci Int 2002; 129: 116–121. 11. Hamman L. Sudden death. Bull Johns Hopkins Hosp 1934; 55: 387–415. 12. Crawford MD and Sarner M. Ruptured intracranial aneurysms: community study. Lancet 1965; ii: 1254–1257. 13. Phillips LH, Whisnant JP, O’Fallon WM, et al. The unchanging pattern of subarachnoid haemorrhage in a community. Neurology 1980; 30: 1034–1040.
14. Schievink WI, Wijdicks EFM, Piepgras DG, et al. The poor prognosis of ruptured intracranial aneurysms of the posterior circulation. J Neurosurg 1995; 82: 791–795. 15. Kassell NF, Torner JC, Haley EC, et al. The international co-operative study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg 1990; 73: 18–36. 16. Rasmussen P, Bosch H, Haase J, et al. Intracranial saccular aneurysms: results of treatment in 851 patients. Acta Neurochir (Wien) 1980; 53: 1–17. 17. Nishioka H. Report on the co-operative study of intracranial aneurysms and subarachnoid haemorrhage. Section VII, Part 1: evaluation of the conservative management of ruptured intracranial aneurysms. J Neurosurg 1966; 25: 574–592. 18. Peerless SJ and Drake CC. Management of aneurysm of the posterior circulation. In: Youmans JR (ed.) Neurosurgical surgery: a comprehensive reference guide to the management of aneurysmal problems. vol. 3, 3rd ed. Philadelphia: WB Saunders, 1990, pp.1764–800. 19. Sundt TM, Kobayashi S, Fode NC, et al. Results and complications of surgical management of 809 intracranial aneurysms in 722 cases. J Neurosurg 1982; 56: 753–765. 20. Troupp H. The natural history of aneurysms of the basilar bifurcation. Acta Neurol Scand 1971; 47: 350–356. 21. Adams JH and Graham DI. The relationship between ventricular fluid pressure and the neuropathology of raised intracranial pressure. Neuropathol Appl Neurobiol 1976; 2: 323–332. 22. Graham DI, Lawrence AE, Adams JH, et al. Brain damage in non-missile head injury secondary to a high intracranial pressure. Neuropathol Appl Neurobiol 1987; 13: 209–217. 23. Havlik DM, Becher MW and Nolte KB. Sudden death due to primary diffuse leptomeninges gliomatosis. J Forensic Sci 2001; 46: 392–395. 24. Di Maio SM, Di Maio VJ and Kirkpatrick JB. Sudden unexpected deaths due to primary intracranial neoplasmas. Am J Forensic Med Pathol 1980; 1: 29–45.
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