Technical note: Excel spreadsheet calculation of the Henssge equation as an aid to estimating postmortem interval

In forensic cases for which the time of death is unknown, several methods are used to estimate the postmortem interval. The quotient (Q) defined as the difference between the rectal and ambient temperature (Tr - Ta) divided by the initial difference (T0 - Ta) represents the progress of postmortem cooling: Q = (Tr - Ta)/(T0 - Ta), (1 ≥ Q ≥ 0). Henssge was able to show that with the body weight and its empirical corrective factor, Q can be reasonably predicted as a double exponential decay function of time (Qp(t)). On the other hand, actual Q is determined as Qd by measuring Tr and Ta under an assumption of T0 = 37.2 °C. Then, the t value at which Qp(t) is equal to Qd (Qd=Qp(t)) would be a good estimate of the postmortem interval (the Henssge equation). Since the equation cannot be solved analytically, it has been solved using a pair of nomograms devised by Henssge. With greater access to computers and spreadsheet software, computational methods based on the input of actual parameters of the case can be more easily utilized. In this technical note, we describe two types of Excel spreadsheets to solve the equation numerically. In one type, a fairly accurate solution was obtained by iteration using an add-in program Solver. In the other type (forward calculation), a series of Qp(t) was generated at a time interval of 0.05 h and the t value at which Qp(t) was nearest to Qd was selected as an approximate solution using a built-in function, XLOOKUP. Alternatively, a series of absolute values of the difference between Qd and Qp(t) (|Dq(t)| = |Qd - Qp(t)|) was generated with time interval 0.1 h and the t value that produces the minimum |Dq(t)| was selected. These Excel spreadsheets are available as Supplementary Files.

Esophageal cooling during ablation of persistent atrial fibrillation is associated with improved freedom from arrhythmia at one-year follow up

Background

Various factors influence successful freedom from atrial arrhythmia after pulmonary vein isolation (PVI) with radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF). Lesion transmurality and continuity (as measured by the Continuity Index) are two important factors, and these can be worsened by pauses in RF energy application due to esophageal overheating. Proactive esophageal cooling precludes the need for premature cessation of power, avoiding partially-formed lesions and the need to “hop-scotch” in the left atrium. The resulting improvement in lesion continuity may improve long-term freedom from atrial arrhythmia after PVI, particularly in patients with persistent AF, where more posterior wall ablation is often necessary.

Purpose

Determine differences in freedom from arrhythmia at one year between patients receiving LET monitoring and those receiving esophageal cooling during PVI for persistent AF.

Methods

We reviewed data from two healthcare systems for patient rhythm status at one-year follow up after PVI for the treatment of persistent or long-standing persistent AF. We then determined Kaplan-Meier estimates of freedom from arrhythmia (AF, atrial flutter, and atrial tachycardia), and compared these between patients receiving esophageal cooling and those treated with traditional LET monitoring.

Results

A total of 252 patients received PVI for persistent or long-standing persistent AF and had data available for review. Of these, 148 received LET monitoring (with either a single or multi-sensor temperature probe), and 104 received active cooling with a dedicated esophageal cooling device. Mean age and gender for each group was similar (67.2, range 21 to 88 years, 36% female for LET monitoring, and 67.8, range 32 to 89 years, 30% female for esophageal cooling). KM estimates for freedom from AF at the one-year follow-up were 44.2% for LET monitored patients and 79.3% for actively cooled patients (P=0.01).

Conclusions

Freedom from atrial arrhythmia at one-year after PVI for persistent AF is associated with significant improvement when using active esophageal cooling rather than LET monitoring.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Attune Medical

Autopsy findings of post-COVID-19 vaccination deaths in Tokyo Metropolis, Japan, 2021

BACKGROUND

COVID-19 vaccines have been used across Japan since 17 February 2021, and as of 17 April 2022, 1690 deaths potentially caused by vaccine-related adverse effects have been reported to the Ministry of Health, Labour and Welfare. However, the causal relationship between vaccination and death could not be fully evaluated because of a lack of sufficient information.

METHODS

Autopsy cases in which deaths occurred within seven days after COVID-19 vaccination in Tokyo Metropolis and were handled by medical examiners were selected (n = 54). Age, sex, vaccine-related information, cause of death, and possible causal relationship between vaccination and death were examined.

RESULTS

The mean age of the deceased individuals was 68.1 years, and the study sample consisted of 34 males (63.9%) and 20 females (37.0%). Thirty-seven and six individuals received Comirnaty and Spikevax, respectively (68.5% and 11.1% respectively). The manner of death included natural (n = 43), non-natural (n = 8), and undetermined (n = 3). The most frequent cause of death was ischemic heart disease (n = 16). Regarding causal relationships, 46 cases (85.2%) did not show a causal relationship to vaccination, except for myocarditis (n = 3), thrombosis-related death (n = 4), and others (n = 1).

CONCLUSION

Although many cases of deaths after COVID-19 vaccination in this study showed no definite causal relationship between the vaccination and deaths, some cases showed possible adverse events such as myocarditis. Autopsies are essential for detecting vaccine-related deaths, and the Japanese death investigation system needs to be reinforced from this viewpoint.

Arrhythmia recurrence reduction with an active esophageal cooling device during radiofrequency ablation

Funding Acknowledgements

Type of funding sources: None.

Background

As the burden of atrial fibrillation continues to rise with an aging population, there have been contrasting positions on the efficacy of left atrial ablation. While ablation techniques have continued to improve over the past decades, arrhythmia recurrence rates must be further reduced given the burden of ablation on patients. Since continuity of lesion sets has been associated with greater lesion durability, it has been theorized that the use of active esophageal cooling may facilitate greater freedom from arrhythmia.

Purpose

In order to investigate the association between use of active esophageal cooling and arrhythmia recurrence, we performed a multicenter retrospective study of arrhythmia recurrence rates in patients that received active cooling and compared them to those that received luminal esophageal temperature (LET) monitoring.

Methods

In this study, follow up data were collected from patients that underwent pulmonary vein isolation (PVI) at three separate large medical centers. Data were contained in a prospective hospital registry, a prospective physician registry, or the electronic health record, depending on the center. For each patient included, we recorded whether their ablation utilized LET monitoring or active esophageal cooling, along with their rhythm status at 1-year follow up. Rhythm status at follow-up was determined by either electrocardiogram, Holter monitor, or wearable heart rate monitor. Kaplan-Meier (KM) curves were created for freedom-from-arrhythmia at one year comparing those in the LET monitoring group to those in the active cooling group.

Results

Follow up data were collected from 1035 patients. There were 560 patients that received LET monitoring during their original ablation, and 475 patients that underwent active esophageal cooling. KM estimates for freedom-from-arrhythmia at one year were 42% in the LET monitored group and 65% in the actively cooled group (P<.001).

Conclusion

In this large multicenter study, there is a significant increase in freedom-from-arrhythmia at one year follow-up among patients that received active esophageal cooling as compared to those that underwent LET monitoring.

Effect of a proactive esophageal cooling device on procedure length - a multicenter comparison of persistent and paroxysmal atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

During left atrial ablation for the treatment of atrial fibrillation (AF), effective esophageal protection is essential for reducing or preventing thermal injury. Traditional methods include luminal esophageal temperature (LET) monitoring that lead to frequent pauses in the procedure when temperature alarms alert operators to dangerous temperature levels. While there have been recent studies that demonstrate an association between active esophageal cooling and a reduction in procedure duration regardless of AF type, these retrospective studies have been conducted at single or joint centers which may lead to confounding from other time-saving variables that have changed over time.

Purpose

Consequently, we sought to perform a large-scale multicenter comparison to better elucidate the association between procedure length and the use of active cooling in patients with persistent and paroxysmal atrial fibrillation.

Methods

In this study, we collected data from three large hospital centers, one hospital-maintained registry, one physician-maintained registry, and one through EHR data review and aggregated in groups separated by AF type as well as whether the patients received active cooling or LET monitoring. We then compared median procedure durations in each group.

Results

There were a total of 753 patients included in this study. Of the 360 patients with paroxysmal AF, 179 received active esophageal cooling while 181 underwent LET monitoring. In the persistent AF group with 393 patients, 157 received active esophageal cooling and 236 underwent LET monitoring. Among patients with paroxysmal AF, the median mean procedure duration was 137 minutes in the LET monitored group, and 90 minutes in the actively cooled group with an overall reduction of 47 minutes (P<.001). In patients with persistent AF, the median procedure duration was 148 minutes in the LET monitored group and 94 minutes in the actively cooled group with an overall reduction of 54 minutes (P<.001). The relative reduction as a percent of total procedure time was 34%, and 36%, for paroxysmal and persistent AF cases, respectively.

Conclusion

In this large multicenter review, there is a significant reduction in procedure length when using active esophageal cooling, regardless of AF type.

Interactions of human organic anion transporters 1-4 and human organic cation transporters 1-3 with the stimulant drug methamphetamine and amphetamine

Drug membrane transport system proteins, namely, drug transporters, are expressed in the kidney and liver and play a crucial role in the excretion process. This study aimed to elucidate the interactions of the drug transporters human organic anion transporters 1, 2, 3, 4 (hOAT1, 2, 3, 4) and human organic cation transporters 1, 2, 3 (hOCT1, 2, 3), which are expressed primarily in human kidney, liver, and brain, with the stimulants methamphetamine (METH) and amphetamine (AMP). The results of an inhibition study using representative substrates of hOATs and hOCTs showed that METH and AMP significantly inhibited (by >50%) uptake of the hOCT1 and hOCT3 representative substrate 1-methy1-4-phenylpyridinium ion (MPP+) and hOCT2 representative substrate tetraethyl ammonium (TEA). However, METH and AMP did not inhibit uptake of the representative substrates of hOAT1, hOAT2, hOAT3, and hOAT4, (i.e., p-aminohippuric (PAH) acid, prostaglandin F2α (PGF2α), estron sulfate (ES), and ES respectively). Kinetic analyses revealed that METH competitively inhibited hOCT1-mediated MPP+ and hOCT2-mediated TEA uptake (Ki, 16.9 and 78.6 µM, respectively). Similarly, AMP exhibited competitive inhibition, with Ki values of 78.6 and 42.8 µM, respectively. In contrast, hOCT3 exhibited mixed inhibition of representative substrate uptake; hence, calculating Ki values was not possible. Herein, we reveal that hOCTs mediate the inhibition of METH and AMP. The results of this uptake study suggest that METH and AMP bind specifically to hOCT1 and hOCT2 without passing through the cell membrane, with subsequent passage of METH and AMP via hOCT3.

An autopsy case of pulmonary artery intimal sarcoma: detailed observation of tumor and its related lesions in pulmonary arteries

We report an autopsy-proven case of a 33-year-old man who died of intimal sarcoma of the pulmonary artery. A large mass (5×4 cm) occluded the main and bilateral pulmonary arteries. Tumor cell morphology was consistent with that of undifferentiated pleomorphic sarcoma. Comprehensive histological observation of 18 pulmonary arteries from proximal to distal revealed continuous extension of the tumor from the main to the subsegmental arteries along the intima, forming an arteriosclerosis-like intimal thickening. Distal small arteries were also affected by eccentric intimal thickening or recanalization. Lung parenchyma was not involved, although there were two wedge-shaped small pulmonary infarctions caused by tumorous obstruction of the associated arteries. Histological results indicated that the intimal sarcoma in the pulmonary artery, which appeared occlusive with growth limited to the proximal artery, had in fact already spread more peripherally than expected. Both the proximal lesions and the distal small arteries were affected by peripheral tumor emboli or by pulmonary hypertension induced by the proximal tumor. However, as seen in this case, most of the occlusive tumor was located locally and intraluminally, in the proximal artery, and removing the proximal tumor by pulmonary endarterectomy was considered effective for symptomatic improvement.

Abdominal Stab Wounds with Tension Pneumopericardium Confirmed by Autopsy and Postmortem Computed Tomography

We present the first report of pneumopericardium observed by autopsy and on postmortem computed tomography (PMCT) images. The subject was a woman who died of self-inflicted stab wounds to the abdomen. The PMCT scan revealed air in the pericardial sac, a "flattened heart" sign, and retroperitoneal hemorrhage. Medicolegal autopsy revealed two abdominal stab wounds near the xiphoid process that had cut the apical pericardium and adjacent diaphragm and liver. Examination of the open thorax confirmed that the pericardial sac was distended with air. The wound extended to the abdominal aorta, causing retroperitoneal hemorrhage. PMCT images showed that the pneumopericardial volume was 133 mL. We believe that cardiac tamponade occurred resulting from the tension pneumopericardium; however, the effects were mitigated by hypovolemia secondary to the retroperitoneal hemorrhage as well as obstructive shock. Therefore, the cause of death appears to have been low-pressure cardiac tamponade.

Abstract P3-13-12: The margin of breast-conserving surgery when ductal carcinoma in situ is present within invasive ductal carcinoma

Objective: The presence of ductal carcinoma in situ (DCIS) in invasive ductal carcinoma (IDC) may increase the rates of positive margins and re-excision. Literature addressing this association is limited. This study aimed to explore the factors that are associated with positive margins and re-excision, as well as to evaluate the influence of positive margins on the survival of patients with breast cancer containing both invasive and in situ ductal carcinoma.

Methods: A retrospective medical chart review of patients diagnosed with DCIS within IDC who underwent BCS at the Revlon/UCLA Breast Center between January 2003 and December 2008 was performed.

Results: Of the 488 eligible patients, 267 patients (53.9%) underwent re-excision. The presence of residual disease upon re-excision was the highest in patients who initially had positive margins involved by both DCIS and IDC. In multivariate analysis, calcifications, tumor size, positive lymph nodes, and the presence of extensive intraductal component (EIC) were significantly associated with initial positive margins, with the latter having the highest hazard ratio (HR, 5.5–5.7, P = 0.000). Tumor size, molecular subtype, and final margin status were associated with disease-free survival. The final margin and regional lymph node status are significant prognosticators for breast cancer-specific survival.

Conclusions: In patients with ductal carcinoma of the breast containing both invasive and in situ components, the rate of initial positive margin after BCS was high and was significantly associated with calcifications, tumor size, regional lymph node status, and the presence of EIC.

Citation Format: Chen J, Ro A, Tan Q-W, Wang Z, Chang HR. The margin of breast-conserving surgery when ductal carcinoma in situ is present within invasive ductal carcinoma [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-12.

Pathophysiology of Venous Thromboembolism with Respect to the Anatomical Features of the Deep Veins of Lower Limbs: A Review

Here the pathophysiology of venous thromboembolism is reviewed with respect to the anatomical features of the deep veins of lower limbs. A thrombus is less likely to form in the thigh veins compared with that in the calf veins; however, clinical symptoms are more likely to appear in the thigh veins owing to vascular occlusion. When a patient is bedridden, thrombosis is more likely to occur in the intramuscular vein, which mainly depends on muscular pumping and the venous valve, rather than in the three crural branches, which mainly depends on the pulsation of the accompanying artery. Thrombi are prone to be generated in the soleal vein compared with those in the gastrocnemius vein because of the vein and muscle structures. A soleal vein thrombosis grows toward the proximal veins along the drainage veins. To prevent a sudden pulmonary thromboembolism-related death in bedridden patients, preventing soleal vein thrombus formation and observing the thrombus proximal propagation via the drainage veins are clinically important. When deep vein thrombosis occurs, avoiding embolization and sequela caused by the thrombus organization is necessary.

Fatal overdose from synthetic cannabinoids and cathinones in Japan: demographics and autopsy findings

BACKGROUND

Sixty-one autopsy cases involving cathinones and/or cannabinoids (synthetic cathinones/cannabinoids) use have been reported. However, little is known about the demographics and autopsy findings in fatal synthetic cathinones/cannabinoids users.

OBJECTIVES

To elucidate demographic and autopsy findings (i.e. major organ pathology and causes of death) in synthetic cathinones/cannabinoids cases.

METHODS

We reviewed forensic autopsy reports in Department of Legal Medicine of Tokyo Women's Medical University (Tokyo, Japan) between 2011 and 2015 (a total of 359). We compared demographic and autopsy findings between synthetic cathinones/cannabinoids and methamphetamine cases (as control subjects).

RESULTS

There were 12 synthetic cathinones/cannabinoids cases and 10 methamphetamine cases. Synthetic cathinones/cannabinoids users were significantly younger than methamphetamine users (p < 0.01), and there were no cases that used both synthetic cathinones/cannabinoids and methamphetamine. Acute intoxication and cardiac ischemia were the two most prominent causes of death in both synthetic cathinones/cannabinoids users and methamphetamine users. Excited delirium syndrome and pulmonary aspiration were found only in synthetic cathinones/cannabinoids cases.

CONCLUSIONS

The populations of synthetic cathinones/cannabinoids and methamphetamine users who died of an overdose are different in Japan. Acute intoxication, cardiac ischemia, excited delirium syndrome, pulmonary aspiration, and drowning are the major autopsy findings in synthetic cathinones/cannabinoids-related death. Clinicians shuld be aware of these potentially fatal complications in the medical management of synthetic cathinones/cannabinoids users.

Clinical Significance of the Soleal Vein and Related Drainage Veins, in Calf Vein Thrombosis in Autopsy Cases with Massive Pulmonary Thromboembolism

OBJECTIVE

To clarify the histopathological characteristics of deep vein thrombosis (DVT) resulting in lethal pulmonary thromboembolism (PE).

SUBJECTS AND METHODS

We investigated 100 autopsy cases of PE from limb DVT. The distribution and chronology of DVT in each deep venous segment were examined. Venous segments were classified into three groups: iliofemoral vein, popliteal vein and calf vein (CV). The CV was subdivided into two subgroups, drainage veins of the soleal vein (SV) and non drainage veins of SV.

RESULTS

Eighty-nine patients had bilateral limb DVTs. CV was involved in all limbs with DVT with isolated calf DVTs were seen in 47% of patients. Fresh and organized thrombi were detected in 84% of patients. SV showed the highest incidence of DVTs in eight venous segments. The incidence of DVT gradually decreased according to the drainage route of the central SV. Proximal tips of fresh thrombi were mainly located in the popliteal vein and tibioperoneal trunk, occurring in these locations in 63% of limbs.

CONCLUSIONS

SV is considered to be the primary site of DVT; the DVT then propagated to proximal veins through the drainage veins. Lethal thromboemboli would occur at proximal veins as a result of proximal propagation from calf DVTs.

Evaluation of the morphological changes of gastric mucosa induced by a low concentration of acetic acid using a rat model

Oral ingestion of concentrated acetic acid causes corrosive injury of the gastrointestinal tract. To assess the effects of a low concentration of acetic acid on gastric mucosa, we examined the gastric mucosal changes in rats at 1 and 3 days after the injection of 5% or 25% acetic acid into the gastric lumen. The area of the gastric ulcerative lesions in the 25% acetic acid group was significantly larger than that in the 5% acetic acid group. The lesion area was reduced significantly at 3 days after injection in the 5% acetic acid group, whereas no significant difference in lesion area was observed at 1 and 3 days in the 25% acetic acid group. Histologically, corrosive necrosis was limited to the mucosal layer in the 5% acetic acid group, whereas necrosis extended throughout the gastric wall in the 25% acetic acid group. At 3 days post-injection, the 25% acetic acid group showed widespread persistent inflammation, whereas the 5% acetic acid group showed widespread appearance of fibroblasts indicative of a healing process. These results indicate that a low concentration of acetic acid damages the gastric mucosa and that the degree of mucosal damage depends on the concentration of acetic acid.

Pathomorphometry of ruptured intracranial vertebral arterial dissection: adventitial rupture, dilated lesion, intimal tear, and medial defect

OBJECT

Subarachnoid hemorrhage (SAH) due to ruptured intracranial vertebral artery (VA) dissection is a life-threatening disease. Angiographic and symptomatic prognostic factors for rupture and rerupture have been investigated, but the pathological characteristics have not been fully investigated. The authors aimed to investigate these features by performing a pathomorphometic study of ruptured intracranial VA dissections.

METHODS

This study included 50 administrative autopsy cases of fatal SAH due to ruptured intracranial VA dissection among 517 fatal nontraumatic cases of SAH occurring between March 2003 and May 2011. Pathomorphometry was performed using serial 5-μm histological cross-sections with elastica van Gieson staining from each 0.2-mm segment around the ruptured intracranial VA. The longitudinal lengths of 4 types of vascular lesions-adventitial ruptures, dilated lesions where the internal elastic lamina (IEL) was ruptured with adventitial extension, intimal tears where the IEL was ruptured, and medial defects-were calculated based on the numbers of the slides in which these lesions were continuously detected (minimum 2 adjoining slides). The distance from the vertebrobasilar junction to the center of adventitial rupture was also calculated in 37 cases.

RESULTS

All cases showed one adventitial rupture with a mean length of about 1.9±1.1 mm. The center of the adventitial rupture was located 5.0-26.8 mm (mean 14.6±5.5 mm) from the intracranial VA bifurcation. Adventitial ruptures existed in the centers of dilated lesions, where the adventitia was highly extended. Other vascular lesions were serially observed surrounding the adventitial rupture. The mean lengths of dilated lesions, intimal tears, and medial defects were 9.4±4.8 mm, 13.2±6.3 mm, and 15.6±7.2 mm, respectively. The lengths between proximal lesions and distal lesions from the center of the adventitial rupture for both medial defects and intimal tears were significantly longer at proximal lesions than at distal ones (chi-square test, p<0.01).

CONCLUSIONS

Every ruptured intracranial VA dissection has a single point of adventitial rupture where the adventitia was maximally extended, so dilation appears to be a valuable predictive factor for hemorrhagic intracranial VA dissections. The adventitial ruptures were as small as 2 mm in length, and clinically detectable dilated lesions were about 9 mm in length. However, vascular vulnerability caused by IEL ruptures and medial defects existed more widely across a length of VA of 1.3-1.5 cm. Comparatively broader protection of the intracranial VA than the clinically detected area of dissection might be desirable to prevent rebleeding. Broader protection of proximal lesions than distal lesions might be effective from the viewpoint of site distribution of vascular lesions and blood flow alteration to the pseudolumen caused by the dissecting hematoma. Medial defects are the most widely seen lesions among the 4 types of vascular lesions studied. Medial degenerative disease, known as segmental arterial mediolysis, is suspected in the pathogenesis of intracranial VA dissections.

Autopsy-proven untreated previous pulmonary thromboembolism: frequency and distribution in the pulmonary artery and correlation with patients' clinical characteristics

BACKGROUND

This study aimed to evaluate untreated, previous pulmonary thromboembolism (PE) in patients with acute fatal PE.

PATIENTS AND METHODS

We studied 64 patients diagnosed as having died from acute PE by medico-legal autopsy. Previous PE was histologically confirmed on the basis of organized thrombi (OT). The distributions of OT were analyzed in five different sizes of pulmonary artery branches in each of 18 pulmonary segmental arteries (90 in total). The frequency of OT in each patient was evaluated by determining the percentage of examined sections containing OT.

RESULTS

OT were confirmed in 59 of 64 (92%) patients. The mean frequency of OT per patient was 27% of the 90 branches. Among the segmental arteries, the right posterior basal lobe showed the highest frequency of OT; among the five artery branches examined, the subsegmental branch showed the highest frequency of OT. OT were not detected in arterioles. Patients with recent trauma or surgery and inpatients showed significantly lower frequencies of OT than those without these risk factors. The 26 patients with prolonged pre-existing symptoms lasting more than a day showed a higher frequency of OT than the 12 patients who suffered for less than a day and the 26 without pre-existing symptoms.

CONCLUSIONS

Most patients with acute fatal PE have a subclinical history of recurrent PE. The frequency of their untreated PE is suspected to correlate with specific risk factors for venous thromboembolism and their clinical course.

Intracranial vertebral artery dissection resulting in fatal subarachnoid hemorrhage: clinical and histopathological investigations from a medicolegal perspective

Object

Subarachnoid hemorrhage (SAH) due to a ruptured intracranial vertebral artery (VA) dissection sometimes results in a sudden fatal outcome. The authors analyzed the relationship between clinical features and histopathological characteristics among fatal cases to establish valuable information for clinical diagnostics and prophylaxis.

Methods

This study included 58 medicolegal autopsy cases of ruptured intracranial VA dissection among 553 fatal nontraumatic cases of SAH that occurred between January 2000 and December 2007. Their clinical features were obtained from autopsy records. Histopathological investigations were performed on cross-sections obtained from all 4-mm segments of whole bilateral intracranial VAs and prepared with H & E and elastica van Gieson staining.

Results

The autopsy cases included 47 males and 11 females, showing a marked predilection for males. The mean age was 46.8 ± 7.7 years, with 78% of the patients in their 40s or 50s. Hypertension was the most frequently encountered history; it was found in 36% of cases from clinical history and in 55% of cases based on autopsy findings. Prodromal symptoms related to intracranial VA dissections were detected in 43% of patients. Headache or neck pain lasting hours to weeks was a frequent complaint. Of patients with prodromal symptoms, 44% had consulted doctors; however, in none of these was SAH or intracranial VA dissection diagnosed at a preventable stage.

Autopsy revealed fusiform aneurysms with medial dissecting hematomas. Apart from ruptured intracranial VA dissection, previous intracranial VA dissection was detected in 25 cases (43%); among them, 10 showed previous dissection of the bilateral intracranial VAs. The incidence of prodromal symptoms (60%) among the patients with previous intracranial VA dissection was significantly higher than that (30%) among cases without previous dissection (chi-square test; p = 0.023). Most previous intracranial VA dissections formed a single lumen resembling nonspecific atherosclerotic lesions, with the exception of 3 cases (12%) with a double lumen.

Conclusions

Intracranial VA dissection resulting in fatal SAH frequently affects middle-aged men with untreated hypertension. Related to the high frequency of prodromal symptoms, latent previous intracranial VA dissection was histopathologically detected. Furthermore, intracranial VA dissection tends to induce multiple lesions affecting both intracranial VAs recurrently. This suggests the importance of an awareness of sustained whole intracranial VA vulnerability for the prevention of recurrence. The incidence of prodromal symptoms was significantly higher among patients with previous intracranial VA dissections. Thus, earlier diagnosis of intracranial VA dissections at the unruptured stage is desirable for prophylaxis against fatal SAH.

Fatal vascular injury as a result of operations: experience of two surgery-related autopsies

We experienced two autopsy cases of unexpected death during surgical operation. Case 1 was a 60-year-old male. Salvage esophagectomy was performed from the right side of the thrax. After dissection of the lymph node, blood pressure decreased suddenly. Emergency thoracotomy was done for diffuse hemothorax in the left thoracic cavity. The patient died despite aggressive hemostasis. Autopsy findings revealed that the operator dissected the left subclavian artery instead of the lymph nodes. Case 2 was a 60-year-old male with advanced thyroid cancer with pelvic metastasis. Surgical removal of the sacrum was attempted for pain relief. The operation was interrupted because of massive hemorrhage from the iliac veins. After the operation, the patient's left leg quickly became necrotic. Despite the bypass grafting from the right to the left femoral artery, the patient died of reperfusion injury. Autopsy revealed ligation of the left common iliac artery along with the accompanying vein. The leg necrosis was thought to have resulted from the vascular ligation. In these two cases, the demonstration and elucidation of the causes of deaths were required with medicolegal autopsies. However, it proved difficult to visualize the operated vessels in detail. In autopsy investigations related to surgical operations, detailed information of the clinical course is valuable and should be provided by the operators themselves, as well as being obtained from clinical charts.

Visualization of azygos arch valves using computed tomography: comparison of scanning delay times

OBJECTIVE

To evaluate the frequency and appearance of azygos arch valves after short and long scanning delays and high injection rates of contrast material (CM) using a 64-slice multi-detector-row computed tomography (MDCT).

METHODS

We retrospectively reviewed the findings from 264 contrast-enhanced MDCT chest examinations. The rate of injection for 300 mg I/ml CM was 3.0 ml/sec; the short and long scanning delays were 20 and 180 sec, respectively. The presence of residual CM in the azygos arch valves and reflux of CM into the azygos arch were recorded. A chi-square test was used to compare the frequency of residual CM in azygos arch valves and reflux of CM into the azygos arch in both groups.

RESULTS

Of the 132 examinations with short scanning delays, 91 (68.9%) demonstrated residual CM in azygos arch valves and 103 (78.0%) demonstrated reflux of CM into the azygos arch. A significantly higher frequency of reflux of CM into the azygos arch and residual CM in azygos arch valves was seen with short scanning delays than with long scanning delays (P<0.05). However, no reflux of CM into azygos arch was seen with long scanning delays.

CONCLUSIONS

Both reflux of CM into azygos arch valve and residual CM in the azygos arch were frequently seen using short scanning delays.

Visualization of the azygos arch valves on multidetector-row computed tomography

To evaluate the frequency and appearance of the azygos arch valves on chest examinations using multidetector-row computed tomography (MDCT), we retrospectively reviewed findings from 194 contrast-enhanced MDCT examinations of the chest. Rate of injection of 300 mgI/ml contrast materials was low (2.0 ml/s) and high (3.0 ml/s). Scanning delay was 80 s on examination on low-rate injection of contrast material and 20 s on high-rate injection of contrast material. The presence of residual contrast material in the azygos arch valves and reflux of contrast material into the azygos arch were recorded. The Cochran-Armitage trend test was used to compare the frequency of residual contrast material in the azygos arch valves and reflux of contrast material into the azygos arch in both groups. Of 92 examinations of high-rate injection of contrast material, 63 (68.5%) demonstrated residual contrast material in the azygos arch valves and 71 (77.2%) demonstrated reflux of contrast material into the azygos arch. A significantly higher frequency of reflux of contrast material into the azygos arch and residual contrast material in the azygos arch valves was seen in the high-rate injection group than in the low-rate injection group (P < 0.05). Residual contrast material in the azygos arch valves was demonstrated more frequently when contrast material was administered in the right side of the arm than in the left side of the arm (P < 0.05). Reflux of contrast material into the azygos arch was common in the high-injection-rate group and residual contrast material in the azygos arch valves was far more frequently seen in the high-injection-rate group than in the low-injection-rate group on MDCT.

Significance of the soleal vein and its drainage veins in cases of massive pulmonary thromboembolism

In this report, we review the anatomical features of the crural veins and the importance of the soleal vein and its drainage veins for thrombi formation and propagation. The result of our investigation of 120 legs of 60 autopsy cases with fatal pulmonary thromboembolism showed that the soleal vein was the most frequent site of deep vein thrombosis, both for fresh and for organized thrombi. Furthermore, the detection rate of thrombi, both fresh and organized, showed that the most common site was in the soleal vein and then decreased progressively according to the drainage route of the soleal vein. Anatomical characteristics and physiological mechanisms play a major role in the occurrence and propagation of venous thrombi. Thus, an understanding of these features is essential for effective prophylaxis of venous thromboembolism.

[Significance of the soleal vein for the pathogenesis of deep vein thrombosis leading to acute massive pulmonary thromboembolism]

Prophylaxis of deep vein thrombosis (DVT) is a serious matter as the source of pulmonary thromboembolism (PTE) in hospitalized patients. Leg DVT is classified into three groups: iliac, femoral and calf types. Among them, calf type DVT is closely connected with PTE. Especially, soleal vein is the most frequent site of thrombi formation occurring with venous stagnation. Although most cases of soleal vein thrombosis are resolved soon without specific treatments: in around 20% of cases the thrombosis propagates to the proximal drainage vein as float thrombi e.g. from peroneal vein and posterior tibial vein to popliteal vein. Thereafter, the organization of thrombi leads to venous valve insufficiency, so-called postthrombotic syndrome. As a result, it worsens blood stagnation and induces recurrent thrombi formation. The broad prophylaxis of DVT in the soleal veins for inpatients is the most important point in the initial stage of hospitalization.

Severe brainstem compression by an unruptured giant vertebral aneurysm--an autopsy case

We describe an autopsy case of sudden unexpected death due to severe brainstem compression by an unruptured giant vertebral aneurysm. A 71-year-old male was found dead in his bedroom. The forensic autopsy revealed no severe trauma leading to his death. On internal examination, a giant intracranial aneurysm (3.4 x 2.6 x 2.7 cm) was observed on the trunk of the right vertebral artery. The aneurysm compressed the right side of the lower one-third of the pons and adjacent medulla oblongata. On sectioning, almost all of the aneurysm lumen was filled with a firm, clearly laminated organized thrombus. There was no evidence of subarachnoid hemorrhage. Histopathological analyses revealed congestion and hypoxic tissue changes in all organs examined. In microscopic sections of the giant vertebral aneurysm, thick fibrotic walls, intimal hyperplasia and organized thrombi in the lumen were found. Lots of intrathrombotic clefts with fresh erythrocytes were also observed. Moreover, Elastica van Gieson staining revealed fragmentation and disruption of the intimal elastic lamina in the aneurysmal wall. Collectively, we considered that some triggers in his daily life, including head rotation, might have caused the rapid onset of respiratory disturbance due to severe brainstem compression by a giant vertebral aneurysm.

Histopathological study of pulmonary arteries in 14 autopsy cases with massive pulmonary thromboembolism

As the pathological features of acute massive pulmonary thromboembolism (PTE) remain unclear, early diagnosis is difficult. We examined 14 autopsy cases of sudden death by massive PTE. Eight cases were male and six female, with a mean age of 57+/-18 years. While none of the cases were diagnosed with PTE during their lifetime, 12 cases had predicting factors for thrombosis. Deep vein thrombosis was found at autopsy in 11 cases. Cross sections of each segmental pulmonary artery were dissected for histological examination. The distribution of fresh thrombi and organized thrombi in the pulmonary arteries was investigated. Results revealed that 13 cases contained both fresh and organized thrombi. More detailed examination indicated that as the organized thrombi were spread in all lobes, the distribution of thrombi extended from the proximal to peripheral arteries. Our findings indicated that most cases of fatal PTE had a subclinical recurrent history. Thus, proper diagnosis and treatment of prior emboli may be vital for the prophylaxis of sudden death by PTE.

Acute coronary syndrome as a cause of sudden death in patients with old myocardial infarction: a pathological analysis

Old myocardial infarction (OMI) is one of the most important pathological manifestations in sudden cardiac death. Fatal arrhythmia arising from a fibrotic scar has been determined as the cause of death in most cases with old myocardial infarction. However, the significance of acute plaque disruption/thrombosis of the coronary arteries in those patients has not been investigated. We examined a series of 33 hearts from individuals with OMI who died suddenly during the period from 1998 to 2001. Detailed coronary pathological findings on these hearts indicated fresh or recent rupture of the coronary plaque with thrombosis in 18 cases (55%). As a result of comprehensive analysis, the sudden deaths were explained by acute coronary syndrome in 18 cases (55%), fatal arrhythmia in eight (24%), cardiac pump failure in five (14%), and other causes in two (6%) cases. Our findings revealed that a new coronary plaque rupture independent of the old infarct was a major cause of sudden cardiac death with OMI.

Sudden death due to cardiovascular disorders: a review of the studies on the medico-legal cases in Tokyo

The Tokyo Metropolitan Government has a medical examiner system, in which all cadavers classified as "unusual death" in the city of Tokyo should be examined, and if necessary, autopsied to determine the cause of death. Of about 10,000 unusual deaths examined per year, two thirds are usually determined to have died of natural causes. The most common cause of sudden natural death is ischemic heart disease, especially acute myocardial infarction. Pathological examination, however, proves acute myocardial ischemia in only one third of autopsies. Subarachnoid hemorrhage and intracerebral hemorrhage, acute myocarditis and cardiomyopathies and aortic dissection/aneurysm as well as pulmonary thromboembolism are frequent causes of death in medical examiner cases. Both pathological and socio-medical problems associated with these diseases are discussed.

Association between LDLR polymorphism and diseases in the Japanese population: aging and distribution of the polymorphism

A number of DNA polymorphisms have been found to be associated with the pathophysiology of some common disease. If the LDLR polymorphism is directly or indirectly related to some fatal disease, the distribution of the polymorphism may vary with age. We therefore investigated the aging-associated distribution of the LDLR polymorphism. Blood samples were collected from Japanese cadavers (aged 0-91) at autopsy. The LDLR polymorphism was detected using a AmpliType PM PCR Typing kit. When the LDLR genotype was examined in cadavers divided according to age into 0-29 year group, 30-59 year group, and 60-91 year group, there were significant differences in genotype among the three age groups and between the 0-29 year group and 60-91 year group. The LDLR-A genotype tended to be lower in the older cadavers. The present study revealed that there were aging-dependent differences in the distribution of the LDLR polymorphism in autopsy samples, suggesting that a common mutation involved in the occurrence of fatal diseases may be present near the LDLR-A polymorphism locus.

Papillary fibroelastoma of the aortic valve: a sudden death case of coronary embolism with myocardial infarction

Papillary fibroelastoma is a rare benign tumor, occasionally causing angina or sudden death. We report an autopsy case of an aortic valve papillary fibroelastoma with coronary artery embolism. The patient was a 68-year-old Japanese man who had collapsed suddenly in his house. He was a heavy drinker and had a history of liver disease but no notable cardiac event. The autopsy revealed extensive transmural infarction of the inferior wall of the left and right cardiac ventricles. The distal portion of the right coronary artery (segment 4, NYHA) was completely occluded by tumor emboli of the fibroelastoma. At the site of closure of the aortic non-coronary cusp, there was a typical papillary fibroelastoma, which was considered to have originated the coronary embolization.

Rotation of Listing's plane during vergence

When visually fixating targets on an isovergence surface, the position of each eye was constrained to a plane. Thus, Listing's law holds during vergence. The planes were, however, rotated temporally with respect to those when viewing distant targets. The effect of this rotation was to produce a torsion which depended on eye elevation; extorsion of the two eyes for downward gaze and intorsion for upward gaze. The saccadic velocity command was relatively unaffected during vergence. Computer simulations suggest that the saccadic tonic command and the vergence command interact multiplicatively in three dimensions.

Auditory function in Duane's retraction syndrome

We obtained audiograms and auditory brainstem responses from 44 patients with Duane's retraction syndrome to assess the incidence and nature of hearing deficit. Of 44 patients, seven (15.9%) had evidence of hearing impairment. Three (6.8%) subjects had a temporary conductive hearing loss because of middle ear fluid, and another patient had hearing loss from Crouzon's disease. The remaining three (6.8%) patients demonstrated sensorineural hearing deficit. This hearing impairment was attributed to a cochlear lesion and not to a pontine lesion. We believe that the frequency of sensorineural hearing loss in these patients warrants hearing screening programs similar to those used for infants in neonatal intensive care units.

Vertical congenital ocular motor apraxia

The authors describe a case of vertical congenital ocular motor apraxia (COMA). The pathways of vertical saccades and pursuits are briefly outlined, and a possible cause of vertical COMA is suggested. A neuropathological correlate is needed to confirm the cause of both vertical and horizontal ocular motor apraxia.

Duane's retraction syndrome: southwestern Ontario experience

We describe the clinical ocular and medical manifestations in 71 patients with Duane's retraction syndrome. We compare our results to those of recent studies, with special focus on the prevalence of anisometropia and amblyopia, found in 14% and 17% respectively.

Depressor area within caudal ventrolateral medulla of the rat does not correspond to the A1 catecholamine cell group

In an attempt to confirm reports of a depressor area corresponding to the location of the A1 noradrenaline cell group within the caudal ventrolateral medulla, cardiovascular responses associated with focal electrical stimulation of that region of the brainstem were measured. Depressor responses were reliably elicited by stimulation of an area immediately dorsomedial to the rostral third of the A1 cell group, but not by stimulation of the A1 group itself.