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Intracerebral hemorrhage as the cause of death in a severely burned body
Legal Medicine 5 (2003) 108–109 www.elsevier.com/locate/legalmed
Letter to the Editor Intracerebral hemorrhage as the cause of death in a severely burned body To the editor: In performing an autopsy on a severely burned body, it is sometimes difficult to judge the cause of death because of the severe damage to the body [1,2,3]. A sudden onset of intrinsic disease may be one of the important differential diagnoses. However, these kinds of reports are rare, and the incidence of such cases has not ever been published.
1. Case report One day in the late autumn, a 72-year-old woman, non-smoker, was found dead in the bedroom of her burned-down house. She had been suffering from left hemiplegia for about 20 years due to right intracerebral hemorrhage (ICH). As a result, she had to spend most of her daily life in bed. Officials from the fire department determined that the fire began in the lady’s bedroom. Since the postmortem examination by the police surgeon could not determine the cause and manner of her death, a medico – legal autopsy was performed. The deceased was 144 cm in length and weighed 34.2 kg. On external examination, the whole body except for the right gluteal to the posterior femoral region was severely carbonized and destroyed. Severe splits of skin appeared on the thorax and the abdomen with destructions of their walls caused by the severe burning. The scalp burned thoroughly, and the blackened skull was exposed revealing a partial breakdown of the left frontal part. A previous operative scar could still be observed in the right temporal part of the skull where was repaired with artificial bone and the dura mater was adhered to this artificial bone. A small amount of heat hematoma was observed in the epidural space of the left temporal
region. A careful investigation of the scorched body by gross appearances did not reveal any obvious injuries that may have occurred before the fire. On the macroscopical examination of the removed brain, the frontal lobe to the parietal lobe was entirely discolored, brownish, and partly carbonized. The other part of the brain was denatured fragilely, except for the cerebellum and the brainstem. From the coronal sections of the cerebrum, it was observed that hemorrhage from the left thalamus had penetrated into the lateral ventricle (Fig. 1A). A cystic lesion about 2 £ 3 cm in size, which was considered to be a healed lesion of a previous ICH, was observed in the right thalamus. A dark-reddish fresh hematoma was seen on the surface of the pons and the cerebellum, and a cross-section of a posterior part of the upper pons showed that the fourth ventricle was filled in with partial-coagulated hematoma (Fig. 1B). Herniations of the cerebrum and cerebellum were not evident. A careful examination of the tracheal and bronchial mucosa did not reveal soot deposits. However, only a little pink-colored froth appeared in the air-passages. The right lung weighed 410 g, was elastic, and showed mild congestion. On the other hand, the left lung shrunk and became hard because of carbonization. The blood in the heart was mostly a darkreddish fluid containing a small amount of coagulation. The surface of the heart exhibited dryness and the areas of both the pericardial fat and the myocardium were hardened. The right ventricle of the heart was mildly dilated; however, no other significant finding was observed in the heart. On the toxicological analysis, the concentration of CO-Hb in the blood of the heart was measured less than 15% by spectrophotometry. The hemorrhage of the cerebrum broke out in a common site of ICH, and ventricular hemorrhage was observed as its severe complication. Since the color of the hematoma that found in the brain was different
1344-6223/03/$ - see front matter q 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S1344-6223(03)00050-6
Letter to the Editor / Legal Medicine 5 (2003) 108–109
109
candles on a Buddhist altar. We believe that she did so when she experienced a sudden loss of consciousness due to ICH. This case suggests that cerebral apoplexy may be one of the important differential diagnoses of death by fire as determined by the autopsy, especially when the victim is elderly. However, the incidence of cerebral apoplexy and other disease in burned bodies has not been clarified yet. Only one case of acute cerebral infarction caused by prolonged burn shock has been reported [4]. Further investigation by examining the large number of cases may be needed for obtaining the cause of such incidences and rarely occurring homicidal cases in severe burned body [2,3]. Also, standardized skillful investigation during the autopsy, including gross appearances, microscopic findings, toxicological examination, other serological analysis, and the police investigation, may be important to analyze the true cause of death.
References
Fig. 1. (A) Coronal section of the cerebrum. Hematoma was found in the left thalamus (arrow), and the hemorrhage was also seen in the lateral ventricle (arrowhead). In addition, a cystic legion due to previous hemorrhage is evident in the right thalamus (open arrowhead). (B) Posterior aspect of the pons and anterior lobe of the cerebellum. Fresh hematoma due to rupture of fourth ventricle was clearly observed.
from that of the heat-hematoma and remained localized in the brain and did not come into contact with any point of the skull, we concluded that this hematoma did not result from the exposure to the heat. Therefore, we believe that the cause of death was ICH. According to the investigation by the police department, the victim evidently knocked over some
* Corresponding author. Tel.: þ81-18-834-8712; fax: þ 81-18836-2610.
[1] Mason JK. Forensic medicine. London: Chapman and Hall; 1993. p. 108– 21. [2] Leonard B. Homicide-associated burning in Cape Town, South Africa. Am J Forensic Med Pathol 1994;15(4):344 –7. [3] Karhunen PJ, Lukkari I, Vuori E. High cyanide level in a homicide victim burned after death: Evidence of post-mortem diffusion. Forensic Sci Int 1991;49(2):179 –83. [4] Nishida N, Ikeda N, Tsuji A, Esaki R. Acute cerebral infarction caused by congenital hypoplasty of cerebral artery in a severe burn case. Legal Med 2002;4(2):119–22.
Takashi Chiba*, Naoki Nishida, Kunio Gonmori, Naofumi Yoshioka Department of Forensic Medicine, Akita University School of Medicine, Hondo 1-1-1, Akita 010-8543, Japan E-mail address: [email protected] Received 16 December 2002 Received in revised form 3 March 2003 Accepted 31 March 2003
Letter to the Editor Intracerebral hemorrhage as the cause of death in a severely burned body To the editor: In performing an autopsy on a severely burned body, it is sometimes difficult to judge the cause of death because of the severe damage to the body [1,2,3]. A sudden onset of intrinsic disease may be one of the important differential diagnoses. However, these kinds of reports are rare, and the incidence of such cases has not ever been published.
1. Case report One day in the late autumn, a 72-year-old woman, non-smoker, was found dead in the bedroom of her burned-down house. She had been suffering from left hemiplegia for about 20 years due to right intracerebral hemorrhage (ICH). As a result, she had to spend most of her daily life in bed. Officials from the fire department determined that the fire began in the lady’s bedroom. Since the postmortem examination by the police surgeon could not determine the cause and manner of her death, a medico – legal autopsy was performed. The deceased was 144 cm in length and weighed 34.2 kg. On external examination, the whole body except for the right gluteal to the posterior femoral region was severely carbonized and destroyed. Severe splits of skin appeared on the thorax and the abdomen with destructions of their walls caused by the severe burning. The scalp burned thoroughly, and the blackened skull was exposed revealing a partial breakdown of the left frontal part. A previous operative scar could still be observed in the right temporal part of the skull where was repaired with artificial bone and the dura mater was adhered to this artificial bone. A small amount of heat hematoma was observed in the epidural space of the left temporal
region. A careful investigation of the scorched body by gross appearances did not reveal any obvious injuries that may have occurred before the fire. On the macroscopical examination of the removed brain, the frontal lobe to the parietal lobe was entirely discolored, brownish, and partly carbonized. The other part of the brain was denatured fragilely, except for the cerebellum and the brainstem. From the coronal sections of the cerebrum, it was observed that hemorrhage from the left thalamus had penetrated into the lateral ventricle (Fig. 1A). A cystic lesion about 2 £ 3 cm in size, which was considered to be a healed lesion of a previous ICH, was observed in the right thalamus. A dark-reddish fresh hematoma was seen on the surface of the pons and the cerebellum, and a cross-section of a posterior part of the upper pons showed that the fourth ventricle was filled in with partial-coagulated hematoma (Fig. 1B). Herniations of the cerebrum and cerebellum were not evident. A careful examination of the tracheal and bronchial mucosa did not reveal soot deposits. However, only a little pink-colored froth appeared in the air-passages. The right lung weighed 410 g, was elastic, and showed mild congestion. On the other hand, the left lung shrunk and became hard because of carbonization. The blood in the heart was mostly a darkreddish fluid containing a small amount of coagulation. The surface of the heart exhibited dryness and the areas of both the pericardial fat and the myocardium were hardened. The right ventricle of the heart was mildly dilated; however, no other significant finding was observed in the heart. On the toxicological analysis, the concentration of CO-Hb in the blood of the heart was measured less than 15% by spectrophotometry. The hemorrhage of the cerebrum broke out in a common site of ICH, and ventricular hemorrhage was observed as its severe complication. Since the color of the hematoma that found in the brain was different
1344-6223/03/$ - see front matter q 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S1344-6223(03)00050-6
Letter to the Editor / Legal Medicine 5 (2003) 108–109
109
candles on a Buddhist altar. We believe that she did so when she experienced a sudden loss of consciousness due to ICH. This case suggests that cerebral apoplexy may be one of the important differential diagnoses of death by fire as determined by the autopsy, especially when the victim is elderly. However, the incidence of cerebral apoplexy and other disease in burned bodies has not been clarified yet. Only one case of acute cerebral infarction caused by prolonged burn shock has been reported [4]. Further investigation by examining the large number of cases may be needed for obtaining the cause of such incidences and rarely occurring homicidal cases in severe burned body [2,3]. Also, standardized skillful investigation during the autopsy, including gross appearances, microscopic findings, toxicological examination, other serological analysis, and the police investigation, may be important to analyze the true cause of death.
References
Fig. 1. (A) Coronal section of the cerebrum. Hematoma was found in the left thalamus (arrow), and the hemorrhage was also seen in the lateral ventricle (arrowhead). In addition, a cystic legion due to previous hemorrhage is evident in the right thalamus (open arrowhead). (B) Posterior aspect of the pons and anterior lobe of the cerebellum. Fresh hematoma due to rupture of fourth ventricle was clearly observed.
from that of the heat-hematoma and remained localized in the brain and did not come into contact with any point of the skull, we concluded that this hematoma did not result from the exposure to the heat. Therefore, we believe that the cause of death was ICH. According to the investigation by the police department, the victim evidently knocked over some
* Corresponding author. Tel.: þ81-18-834-8712; fax: þ 81-18836-2610.
[1] Mason JK. Forensic medicine. London: Chapman and Hall; 1993. p. 108– 21. [2] Leonard B. Homicide-associated burning in Cape Town, South Africa. Am J Forensic Med Pathol 1994;15(4):344 –7. [3] Karhunen PJ, Lukkari I, Vuori E. High cyanide level in a homicide victim burned after death: Evidence of post-mortem diffusion. Forensic Sci Int 1991;49(2):179 –83. [4] Nishida N, Ikeda N, Tsuji A, Esaki R. Acute cerebral infarction caused by congenital hypoplasty of cerebral artery in a severe burn case. Legal Med 2002;4(2):119–22.
Takashi Chiba*, Naoki Nishida, Kunio Gonmori, Naofumi Yoshioka Department of Forensic Medicine, Akita University School of Medicine, Hondo 1-1-1, Akita 010-8543, Japan E-mail address: [email protected] Received 16 December 2002 Received in revised form 3 March 2003 Accepted 31 March 2003