Myocardial lesions induced after trauma and treatment

Forensic Science International,

Elsevier Scientific Publishers

MYOCARDIAL TREATMENT

54 (1992) 181 - 189

181

Ireland Ltd.

LESIONS

INDUCED

AFTER

TRAUMA AND

KEN-ICHI YOSHIDAa. YOSHIAKI OGLJRAb and CHOEI WAKASUGI” aDepartment of Legal Medicine, Yamaguchi University University Medical School, Osaka (Japan)

School of Medicine, Yamaguchi

and bOsaka

(Received March 3&t, 1992) (Accepted April 21st, 1992)

Summary In order to clarify the effect of trauma and treatment as stresses on myocardia, we examined histological changes of myocardia in victims who received various kinds of traumata and treatments. We also undertook a histochemical study for calmodulin, which we found useful in the diagnosis of early ischemia. Those who died shortly after stab wounds, traffic accident or head injuries, showed mild cardiac lesions such as contraction bands or fragmentation and mild diffusion of calmodulin, a marker for necrosis. A case with hemorrhagic shock after a traffic accident, involving intense resuscitation for 2 h, showed severe cardiac lesions such as contraction bands, hydropic change and subendocardial hemorrhage along with severe diffusion of calmoduhn. In most of the instant death cases after falls, severe contraction band necrosis and severe calmodulin diffusion were observed. Myocardia of victims, who died several days after head injuries or traffic accidents, generally demonstrated distinct diffusion of calmodulin as compared to the mild and nonspecific lesions detected by hematoxylin-eosin (H&E) staining. In cases of long-term survival in a state of brain death, calmodulin staining was very low, which was not always associated with the severity of the lesions on H&E staining. In cases with intensive or extended treatment, it appeared to be difficult to determine the cause-effect relationship between trauma and cardiac lesions or to distinguish the lesions due to extrinsic factors from those of disease. In some cases, calmodulin intensely stained the areas with hydropic appearance or hypereosinophilia, which may be related to calcium overload. Key words: Trauma;

Myocardial lesion; Contraction

band; Calmodulin; Calcium overload; Brain

death

Introduction Various stresses are known to induce cardiac lesions in animals [ 1 - 41 and there are some reports on myocardial histopathology in cases of homicide, [5] drowning [6] and brain injury [7,8]. The human cases were supposed to provide a model for the pathological study of human stress in myocardium. As medicolegal practitioners, we are sometimes required to determine whether cardiac lesions are due to intrinsic or extrinsic factors. The extrinsic factors may Correspondence to: Ken-ichi Yoshida, Department of Legal Medicine, Yamaguchi University School of Medicine, 1144 Kogushi, Nishi-ku, Ube-city, Yamaguchi 755, Japan. 0379-0738/92/$05.00

0 1992 Elsevier Scientific Publishers Printed and Published in Ireland

Ireland Ltd.

182

be accidents, violence, psychological stress or even treatment [9- 121, but not enough attention appears to have been paid to the effects of these factors on myocardial lesions. We sought to examine the myocardial histopathology of various trauma cases, some of which were subjected to resuscitation and intensive treatment. We also undertook a histochemical study for calmodulin, which we had found useful in the diagnosis of sudden cardiac death cases [13]. Materials and Methods Specimens (4 - 6) were obtained from transverse sections of about 1 cm thick at the middle portion of the hearts of autopsy cases aged 14 - 39 years old in the Department of Legal Medicine (Osaka University Medical School) within 24 h after death and fixed in formalin. The subjects were free from myocardial disease as determined by macroscopic examinations and history. The sampies were stained with hematoxylin-eosin (H&E). Localization of calmodulin was visualized by the immunoperoxidase technique using sheep anti-bovine testis calmodulin IgG (Transformation Res., Inc., Framingham, MA) and Vectastain ABC kit (avidin-conjugated peroxidase anti-bovine IgG from Vector Laboratories, Burlingham, CA) as described previously [13]. Results and Discussion Table 1 summarizes the profile and histological findings of various cases of trauma. Victims, who died shortly after stab wounds, showed only mild hypereosinophilia or fragmentation (dissociation of intercalated discs), if any and calmodulin diffused, at most, moderately, in localized areas (cases 1 - 5). Experimental hemorrhagic shock was reported to be associated with contraction bands or fragmentation 121. Myocardium of our cases showed these lesions but the severity was mild probably because the victims died so quickly after injury before the full development of hemorrhagic shock. In support of this idea, 2-h-survival in hemorrhagic shock induced clear contraction bands and severe calmodulin diminution (case 13). On the other hand, the victims who died quickly would have been burdened with a great fear, possibly for several seconds to minutes, before they died. But the short duration of the psychological stress appeared not to be enough time to induce clear lesions in myocardium. Extensive contraction band necrosis, associated with severe diffusion of calmodulin, was observed in most of the instant death cases of fall, many of whom had major injuries in the thoracic vicera (cases 6, 7, 9, 10) (Fig. 1). The contraction band might have been induced by severe concussion of the hearts although we examined parts of myocardia without apparent macroscopic injuries. Stab or gun shot wounds were reported to induce contraction bands at the sites of injury and their vicinity [14], but a fall has not been described as a cause of severe and extensive contraction band necrosis. The existence of severe necrosis without macroscopic damage of the hearts in cases of fall should be emphasized to emergency doctors and transplantation surgeons. Those who died shortly after traffic accidents, gun shot, or head injury showed

183 TABLE 1 MYOCARDIAL LESIONS IN VARIOUS TYPES OF TRAUMA CB, contraction bands; frag, fragmentation; eosin, eosinophilia; vat, vacuolation; lysis, myolysis; wav., waving; cell, cell infiltration; subarachnoid. hemorr., subarachnoidal hemorrhage; CaM, calmodulin; Severity of the lesions or the diffusion of calmodulin is mild, + ; moderate, + + ; or severe, + + + ; n.p., nothing particular. Indicates the extention of the lesion was localized; int., shows an intense staining for calmodulin. Case no.

Age (sex)

1

15 (m)

2 3 4

38 W 36 W 39 (m)

5

22 (m)

6

29 (m)

7 8

25 (0 29 On)

9 10 11

20 0

12

20 W

13

20 (m)

24 0-1 18 W

14

25 (m)

15

26 (m)

16

37 Cm)

17

40 (ml

18

37 Cm)

19

15 b-d

Cause of death

Cow-se

Histology

Hemorrhage, stab of atrium and aorta Hemorrhage, stab of lung Hemorrhage, stab of liver Hemorrhage, stab of pulmonary artery Hemorrhage, stab of atrium and aorta Fall, thoracic and abdominal injury Fall, atria1 contusion Fall, brain contusion

Short

eosin.+,

Short Short Short

frag + np. frag +

n.p. n.p. n.p.

Short

eosin +

n.p.

Short

CB +

++

Short Short

Fall, rupture of arota Fall, atria1 contusion Traffic accident, cervical dislocation Traffic accident, rupture of atrium and arota Traffic accident, rupture of subclavial vein & liver, cervical dislocation, resuscitated Traffic accident, brain contusion, hemorrhage of pons Gunshot, brain contusion Head bruise, subarachnoid. hemorr., Head bruise, subarwhnoid. hemorr., brain death Head bruise, brain contusion, brain death

Short Short Short

CB + frag + +, vat + f, lysis + + CB +++ CB +++,eosin+ eosin +, vat +, CB + frag +, eosin +

;i; int. ++t +tt (+ +)

Endocardial bleeding,

tt+ int.

Head bruise, subarachnoid brain death

hemorr.,

Short 2h

CaM

CB +

(+ +I

+

vat +++,

eosin +,

9 days

CB + CB +++,

vat ++

Short

CB +

(+l

Short

vat + f, eosin +

6 days

vat + + , eosin + + +

(+ +) int. +++

6 days

frag +

(+ +1 int.

7 days

frag +

t+

+++

184 TABLE 1 (continued) Case no.

Age

20

20 (m)

21

14 (f)

22

35 (m)

23

15 (m)

24

16 (m)

Cause of death

Course

Histology

CaM

Head bruise, brain hemorrhage, brain death Asphyxia (thoracic compression), brain death Tetrodotoxin poisoning, brain death

23 days

CB +, vat +, lysis +, swollen nuclei frag +, wav +

+++

+++

Bronchial asthma, resuscitated Myocardial infarct., single coronary artery, resuscitated

lh

lysis +++, CB +++, eosin +++, cell + + + , fibrosis + + + n.p.

(sex)

3 days

15 days

2h

eosin ++, CB +, fibrosis + +

+

not done (+ +)

Fig. 1. Severe contraction bands (A: H&E staining) and diffusion of calmodulin (B) are noted in case of fall as indicated by arrows (case 10).

a

185

mild lesions such as fragmentation, contraction bands, hypereosinophilia or vacuolation (cases 11, 12, 15, 16). Calmodulin diffused mildly or moderately (in localized areas). Intensive resuscitation for 2 h, including catecholamine administration and hemostatic operation in a traffic accident case (case 13) resulted in focal bleeding, contraction bands and hypereosinophilia, accompanied by an extensive calmodulin diffusion even where there was no remarkable change in H&E staining (Fig. 2). This agrees with the reports of Broda [lo] which showed that catecholamine aggravated cardiac lesions in experimental hemorrhagic shock. On the other hand, catecholamine infusion and defibrillation for the resuscitation in cases of sustained asphyxia (case 21), status asthmatics (case 23) and myocardial infarction (case 24) induced only a mild contraction band, fragmentation or eosinophilic change along with mild loss of calmodulin. Contraction bands and fragmentation, thought to indicate hypercontraction through increased circulation of catecholamine, have been reported in various types of trauma both in humans and in animals [l- 141. Catecholamine administration is shown to induce lesions in animals [16], however, a contraction band or fragmentation induced with exogenous catecholamine alone was, if any, not severe, as described above. Ischemia reperfusion has also been well defined

Fig. 2. Severe bleeding (high density) and moderate hydropic change (low density) are observed in subendocardial regions (A). Calmodulin diffuses widely (B) in contrast with non-specific change on H&E staining (A). An area with hydropic appearance in the left portion was associated with increased staining for calmodulin (B) as indicated by arrows. The victim was intensively resuscitated for 2 h in a state of hemorrhagic shock (Case 13).

186

as a cause of contraction bands or other types of cardiac lesions in experimental studies [17]. In human subjects, the ischemia-reperfusion has not attracted attention as a cause of contraction bands except for ‘stone heart’ after cardiac operation [ 181. Today, many subjects with trauma arrive at the hospital in a dead state and are resuscitated. Many of the hearts are in an ischemic state; some have stopped beating, while others are beating weakly, or are subjected to hypoxia due to respiratory failure. Extensive attempts of resuscitation are usually performed, which include artificial ventilation with high pressure oxygen, catecholamine administration and defibrillation. These situations lead to ischemia-reperfusion of myocardia, producing severe lesions synergistically with catecholamine. The lesions would be even more severe if the duration of ischemia and that of reperfusion were longer. Today, many victims of traffic accidents or head injury are resuscitated and treated extensively so as to prolong life. Most of the cases examined in this study eventually underwent brain death and died 6-23 days after the injuries (cases 17 - 20). We also examined non-traumatic brain death cases; sustained asphyxia and tetrodotoxin poisoning (cases 21, 22). We found contraction bands or fragmentation in most of these cases. In the cases of several days duration, the lesions were generally not severe on H&E staining, but calmodulin diffusion was often remarkable, supporting the usefulness of the method (Table 1). In one of

Fig. 3. H&E staining shows focal hypereosinophilia of myocardia (A) in association with focal diffusion of calmodulin (B) in a case of head injury after a traffic accident as shown by arrows. The victim underwent brain death and died 6 days after the accident (Case 17). Calmodulin intensely stains the endocardial region with a hydropic appearance at the lower left region.

187

these cases, there was exceptionably distinct focal hypereosinophila, which was associated with a loss of calmodulin (case 17) (Fig. 3). On the other hand, those after more extended treatment (15 and 23 days), showed fulminant diffusion of calmodulin (cases 20,22) (Figs. 4 and 5). The one case of head injury did not show severe lesions with H&E staining (case 20), while the case of tetrodotoxin poisoning exhibited severe necrosis (case 22) (Figs. 4 and 5). The severe lesion in the latter case might have been caused by the anoxia due to respiratory failure followed by artificial ventilation and other treatment. Thus, it appears even more difficult for pathologists to determine the cause-effect relationship between trauma and cardiac lesions or to distinguish the cardiac lesions due to extrinsic causes from those of the disease itself if the treatment is intensive and prolonged. Consistent with our observation, Rajs and Jakobsson reported cases where deaths were supposed to be due to cardiac lesion a long time after head injury [8]. Yamour et al. [15] reported a close correlation between brain lesion and electrocardiographic changes, which might lead to cardiac arrest. Animal experiments also supported the findings that head injury or brain death is associated with contraction bands or fragmentation through the increase of endogenous catecholamine release from sympathetic nerve endings or adrenal glands [11,12].

Fig. 4. H&E staining detects no remarkable change except atrophic appearance of muscle (A) but diffusion of calmodulin is severe and extensive (B) in a head injury case who underwent brain death and died 23 days later (Case 20). Fig. 5. H&E staining shows severe contraction bands (-) and hypereosinophilia (*), evolving into severe necrosis with lymphocyte infiltration (A), while calmodulin diffuses fulminantly (B) in a case who died 15 days after tetrodotoxin poisoning in the state of brain death.

Fig. 6. Intense staining for calmodulin case as indicated by arrows (case 8).

(B) is associated

with scattered

hypereosinophilia

(A) in a fall

In the pathogenesis of the ischemia-reperfusion or other types of myocardial injuries, calcium overload is shown to play an important role [l’i’]. We have previously observed that intense staining for calmodulin very often occurs in association with a contraction band or hydropic change in sudden cardiac death cases and in the dog ischemia model [13]. In this study, the intense staining was also found in regions of hypereosinophilia (case 8) (Fig. 6) in addition to areas with hydropic appearance (case 13, 17) (Figs. 2 and 3). The intense staining for calmodulin might be a result of translocation of this calcium-binding protein from soluble to membrane fractions in response to the increase of cytoplasmic calcium during the evolution of cardiac injury as we have previously proposed [13]. Acknowledgements Supported

in part by a Grant-in-aid

from the Japanese

Education

Ministry.

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3 4 5 6 7 8 9 10 11

12

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14 15 16

17 18

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