The role of post-mortem imaging in a case of sudden death due to ascending aorta aneurysm rupture

The role of post-mortem imaging in a case of sudden death due to ascending aorta aneurysm rupture

Forensic Science International 228 (2013) e76–e80 Contents lists available at SciVerse ScienceDirect Forensic Science International journal homepage...

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Forensic Science International 228 (2013) e76–e80

Contents lists available at SciVerse ScienceDirect

Forensic Science International journal homepage: www.elsevier.com/locate/forsciint

Case report

The role of post-mortem imaging in a case of sudden death due to ascending aorta aneurysm rupture Laura Filograna a,b,1,*, Gary Hatch c, Thomas Ruder d, Steffen G. Ross a, Stephan A. Bolliger a, Michael J. Thali d a

Institute of Forensic Medicine, Center of Forensic imaging and Virtopsy, University of Bern, Bu¨hlstrasse 20, 3012 Bern, Switzerland Institute of Forensic Medicine, Catholic University of Rome, Largo Francesco Vito 1, 00168 Rome, Italy Center for Forensic Imaging, University of New Mexico, Camino De Salud NE, 1101 Albuquerque, NM, USA d Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, 8057 Zurich, Switzerland b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 24 July 2011 Received in revised form 13 June 2012 Accepted 27 January 2013 Available online 26 February 2013

A 65-year-old man collapsed suddenly, while on an escalator. Despite intensive cardio-pulmonary resuscitation, the subject died 1 h later. Post-mortem magnetic resonance imaging and post-mortem computed tomography angiography demonstrated rupture of an ascending aortic aneurysm, with haemorrhage into the pericardial cavity and the uncommon associated finding of haemorrhage into the left hemi-thorax through a small left-sided pericardial defect. The cause of death was thus attributed to the rupture of thoracic aortic aneurysm, and traditional autopsy was not performed. The circumstances of the case will be discussed, followed by a discussion of the imaging findings, mechanism of death, and explanation of the findings in this case. Finally, on the basis of this case report, we suggest that in selected cases, post-mortem imaging can be used as a screening tool for conducting hypotheses on the cause and mechanism of death before autopsy. ß 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords: Virtual autopsy Sudden death Ascending aorta aneurysm rupture

1. Introduction Thoracic aortic aneurysms are unfortunately a well known and frequent leading cause of sudden death, when complicated by dissection and/or rupture. Since most patients are often asymptomatic or manifest symptoms diverse and non-specific late in the course of the disease, and serious complications occur rapidly, ante-mortem diagnosis has proven difficult [1–5]. Thus, in many cases, sudden death is the first manifestation of the aortic pathology. As a consequence, in these unexplained, sudden deaths, medico-legal investigation is often requested. The external examination in such cases of natural death is not able to provide useful information for definitive and confident conclusions as to the cause of death, and autopsy is usually performed. The most common cause of death in cases of thoracic aortic aneurysm rupture is heart tamponade, if the leak occurs in the

* Corresponding author at: Institute of Forensic Medicine, Center of Forensic imaging and Virtopsy, University of Bern, Bu¨hlstrasse 20, 3012 Bern, Switzerland. Tel.: +41 031 6313054/079 8626816; fax: +41 031 6315363. E-mail address: laura.fi[email protected] (L. Filograna). 1 Present address: Department of Radiological Sciences, Catholic University of Rome, Largo A. Gemelli 8, 00168 Rome, Italy. Tel.: +39 06 35507031; fax: +39 06 35507033. 0379-0738/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.forsciint.2013.01.039

aortic root or the ascending aorta, or haemorrhage, if the rupture is localized in the descending aorta [1–6]. In clinical practice, the most frequently employed crosssectional imaging modalities for the diagnosis of aortic pathologies in not critically ill patients are currently CT and MRI techniques with or without contrast enhancement, due to their high diagnostic accuracy [7–10]. These modalities allow for identification and accurate characterization of aortic aneurysm, of its sizes and its relationships to the aortic branches. To date, CTangiography is the most widely used technique, despite the radiation exposure and the need for contrast administration, that are its main disadvantages. Although MRI is an important alternative technology when CT-angiography is contraindicated, its use is limited by long procedure times, lack of true real-time monitoring, and stent artefacts. In the last decade, post-mortem imaging using computed tomography, post-mortem CT angiography (pm-CTA) and postmortem MRI (pm-MRI) have proven to be a useful and noninvasive method to demonstrate critical forensic findings not only in traumatic deaths, but also in natural unexpected deaths [11–16]. In this case report, we demonstrate how post-mortem imaging, particularly pm-CT angiography and pm-MRI, can be used to diagnose a ruptured aneurysm of the ascendant aorta with pericardial effusion and the uncommon associated finding of left

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haemothorax, as the cause of sudden death, without the need for traditional autopsy.

2. Case report A 65-year-old man with no significant past medical history, except for hypertension, experienced sudden syncope while on an escalator. Cardio-pulmonary resuscitation (CPR) manoeuvres were immediately performed and continued after intubation by the emergency physician during transport to the nearest hospital. Upon admission, the patient had Glasgow Coma Score (GCS) of 3 on neurological examination. Peripheral pulses were symmetrical and weak. Two performed eco-FAST documented a small pericardial collection and a following emergency transthoracic echocardiography demonstrated absent motion of the left ventricle, only few contractions of the right heart, and confirmed the small pericardial effusion. CPR was continued for 15 min, but the patient failed to respond. He was declared dead 1 h after the initial collapse. The body was delivered to the Institute of Forensic Medicine, University of Bern, to investigate the cause of this unexpected death. The external examination revealed a bruised and lacerated wound on the head. As is routine in the Virtopsy project, a department within the Institute of Forensic Medicine, after external examination, the deceased underwent pm-CT scanning on a Somatom Emotion 6 scanner (Siemens Medical Solutions, Forchheim, Germany) with 6  1.25 mm collimation. The reconstruction interval was 0.625 mm. The pm-CT scan was performed 18 h after death and was completed in 15 min. 2-dimensional reformations and 3dimensional reconstructions were performed using a Leonardo workstation (syngo CT software, Siemens Medical Solutions). A board certified radiologist, with specific training and experience in post-mortem imaging, interpreted the obtained images. He noted an aneurysm of the ascending aorta of 4.5 cm, a large pericardial effusion, and a left pleural effusions (Fig. 1). He described the pericardial effusion as composed by a relatively high-density ring (50–60 HU) suggestive of coagula, surrounding asymmetrically the epicardial surface, with a thicker part around the left chambers, and few fluid of lower density (40–50 HU) interpreted as fluid blood/serum, the most localized at the emergence of the great vessels [16]. Mediastinal hyperdensity, left pleural effusion (54 HU), and rightward shift of the mediastinum were also reported. The aorta and coronary vessels showed some notdislocated calcifications. Fractures or other significant imaging abnormalities were not observed. According to these findings, the presence of ascending aortic aneurysm rupture was suspected.

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Next, pm-MRI scanning was carried out using a 1.5 T scanner (Symphony, Siemens Medical Solutions, Erlangen, Germany). A number of sequences, as standard T1- and T2-weighted fast spin echo, whole body coronal T1-weighted and TIRM, and for the cardiac study, short-axis, 4 chamber and 2 chamber T2 turbo spin echo were acquired. The MRI examination was completed in 1.5 h. The pm-MR images confirmed a large aneurysm of the ascending aorta, ruptured in the pericardial space and mediastinum (Fig. 2). A mediastinal haematoma, large pericardial, and left pleural effusions were observed. A pericardial defect at the origin of the pulmonary trunk was also suspected. Following pm-MR, a pm-CT angiography was performed, according to the Virtopsy approach [17]. The angiographic procedure took approximately 2 h. Angiography confirmed the results of MRI imaging. The ruptured ascendant aorta aneurysm was diagnosed. The pericardial defect was clearly displayed (Fig. 3). Finally, the volume of blood in the pericardial and left pleural spaces was measured, using a segmentation programme (except ‘program’ in computers) (Amira 5.2.2, Visage Imaging). Calculated volumes of the pericardial and left pleural effusions were 400 ml and 1900 ml respectively. Based on the case circumstances, clinical data, external examination findings and the imaging evidence, the cause of death was attributed to a ruptured aneurysm of the ascending aorta, which gave rise to intrapericardial and intrapleural bleeding. When advised of these findings by the forensic examiner, the district attorney did not request an autopsy and closed the case. 3. Discussion In this case, we demonstrate that post-mortem imaging methods can thoroughly document the relevant pathology and establish the cause of death in an uncommon case of ruptured ascending aortic aneurysm, associated with haemorrhage not only into the pericardium, but also into the left pleural space. The traditional autopsy was thus not performed. In forensic medicine, prior research has verified that pm-CT angiography and pm-MRI are able to accurately assess the detailed anatomy of the great vessels and heart [11–19]. Nevertheless, to the best of our knowledge, this is the first case of fatal ruptured ascending aortic aneurysm haemorrhage into the pericardium and left haemothorax diagnosed and documented solely using pm-MRI and pm-CT angiography. Analysis of the CT images revealed an aneurysm of the ascending aorta, mediastinal hyperdensity, large hemopericardium with an appearance similar to pericardial bleeding described by Shiotani et al. [16], and left haemothorax (Fig. 1). Based on the

Fig. 1. Un-enhanced CT image of the thorax in the axial plane: The images (a) and (b) demonstrate ascending aorta aneurysm, pericardial and left pleural bloody effusions (according to the calculated HU density). Note in (b) the high-density ring (50–60 HU) constituted by coagula, surrounding asymmetrically the epicardial surface, with a thicker part around the left chambers, and few fluid of lower density (40–50 HU) interpreted as fluid blood/serum, localized anteriorly to the right ventricle.

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Fig. 2. Un-enhanced T1 and T2-weighted MRI images of the thorax in the coronal plane: The T2 weighted (a) better than the T1-weighted (b) MRI image presents: ruptured aneurysm of the ascending aorta at the level of the aortic root extended to the origin of brachiocephalic artery; mediastinal haematoma, pericardial effusion with a large clot; left pleural effusion. In both images, (a) and (b), a subtle area with hypointense signal is visible on the origin of the pulmonary trunk (arrows). It is better recognizable in the image (b), where the hyperintense signal of the pericardial fat is interrupted at this level.

presence of the ascending aortic aneurysm and the large haemorrhagic pericardial effusion, a rupture of ascending aorta was considered to be highly probable. However, the presence of the large haemorrhagic left pleural effusion, in absence of thoracic trauma, could not be completely explained by un-enhanced pm-CT images. Haemorrhagic left pleural effusion is, in fact, an unusual finding in cases of ruptured aneurysm of the ascending aorta, occurring more frequently in distal ruptures/dissections [7]. MRI detected the aneurysm of the ascending aorta, with rupture into the pericardial space and mediastinum (Fig. 2). The presence of a pericardial defect located in the proximity of the pulmonary trunk was highly suspected (Fig. 2). pm-CTA was then performed and redemonstrated results of MRI (Fig. 3) and clearly visualized the pericardial defect (Fig. 3). Considering the imaging results in sum, it is conceivable that the left haemothorax originated from bleeding through the pericardial defect, as well as extension from the mediastinal collection and resulting leak into the adjacent left pleural space. Although pm-CTA provided better visualization of the pericardial defect when compared to pm-MR, the latter technique was equal in describing the extent of aortic aneurysm, and demonstrating the site of rupture. In clinical practice, the diagnosis of pericardial defect can be very difficult, especially in emergent, life threatening episodes such as those associated with acute aortic rupture. As a consequence, the diagnosis is frequently reached intra-operatively or during post-mortem examination [20–26]. However, noninvasive, ante-mortem diagnosis of pericardial defects has been previously described using CT and MRI [20,27,28].

Fig. 3. Enhanced CT image of the thorax in the coronal plane: The image shows: ruptured aneurysm of the ascending aorta at the level of the aortic root extended to the origin of brachiocephalic artery; mediastinal haematoma, pericardial effusion with a large clot localized around the epicardium of the left ventricle; left pleural effusion; small-sized pericardial defect on the origin of the pulmonary trunk (arrow).

Regarding on the nature of the pericardial defect, we could not distinguish between traumatic and congenital origin, based solely on post-mortem imaging. Nevertheless, a congenital origin was suspected, due to the absence of thoracic traumatic injuries and the left-sided location of the pericardial defect, a common location for congenital pericardial defects [29]. Iatrogenic rupture of the pericardium, during the intensive CPR was considered unlikely, as rib fractures were not detected [30]. Undoubtedly, a traditional autopsy examination could have clarified the exact nature of the pericardial defect. Few published studies describe the association of large left haemothorax with ruptured aorta [22–24,31]. These works report clinical and not fatal cases. In the cases examined, a pericardial effusion was not found or it was minimal. In the majority of these studies, these evidences were explained by the presence of a congenital partial [22,23] or complete pericardial defect [24], that acted as a draining window, and prevented cardiac tamponade but lead to the development of the left haemothorax. This draining mechanism, provided a window of time in which surgical intervention could be performed. In this case, a large pericardial haematic effusion (400 ml) with coagula and a large haemothorax (1.900 ml) was observed on postmortal imaging. In contrast, the emergency trans-thoracic echocardiogram performed a few minutes before death demonstrated only a small pericardial effusion. As in the clinical cases mentioned above [22–24], the pericardial defect prevented, at least initially, a fast development of a large pericardial effusion and cardiac tamponade. The man in fact died already 1 h after the acute presentation of the symptoms. In our opinion, the most likely final cause of death in this case was left ventricle insufficiency due to internal haemorrhage, eventually combined finally with a mechanic obstacle caused by more dense, coagulated blood or a final blood accumulation probably due to the occlusion by coagula of the pericardial defect [6,32]. The appearance of the hemopericardium on unenhanced pm-CT imaging in the present case (Fig. 1b) is very similar to that described by Shiotani et al. as ‘‘hyperdense armoured heart’’ in their pm-CT study of fatal aortic dissection. According to Shiotani et al. [16] we attribute the presence of a high-density inner ring to cardiac motion, which selectively induced coagulation on the epicardial surface; in accordance with our reconstruction, this means that the heart continued beating for a certain time after acute intrapericardial bleeding. Finally, some considerations about the cause of the aortic aneurysm rupture are needed. Although the external examination did not show any macroscopic sign of thoracic trauma, it is a common knowledge that in some cases of traumatic rupture of aorta this evidence can be absent (e.g. due to thick garment). Nevertheless, in this case the analysis of case circumstances permitted to hypothesize a non-traumatic aortic rupture with

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sufficient confidence. Moreover, it has to be considered that although pm-CTA and pm-MRI could be able to detect intra/ subcutaneous haematoma, it has not yet been demonstrated that these techniques can be capable to show also subtle belt-like subcutaneous haematoma, as those found for example in cases of aortic rupture due to car crashes.

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of Rome, Italy), Renata Greco (Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield Teaching Hospital) for the useful discussion, and Lars Christian Ebert (Institute of Forensic Medicine, University of Zurich) for the experienced support during data analysis. References

4. Conclusion In this case report, we demonstrated that pm-MRI and pm-CTA, integrated with the analysis of case circumstances, clinical data, and external examination findings, allow to conduct diagnosis of cause and manner of death in a complex case of thoracic aorta aneurysm rupture. Death was attributed to non-traumatic ruptured aortic aneurysm at the level of the ascending aorta. Moreover, cross-sectional imaging was able to clarify the pathophysiological mechanism of death. Furthermore, it has to be noted that, after the first suspicion of aortic pathology suggested by un-enhanced CT images, all of the imaging evidence needed to make the final forensic conclusions in this case was demonstrated by the pm-MRI. The pm-CTA did not add significant additional value, with the exception of a better definition of the pericardial defect. In hindsight, the pm-CTA could have been avoided. pm-CTA is an invasive technique, in contrast to the non-invasive technique of pm-MRI, and the presence of vascular calcifications or advanced states of decomposition may make performance of a pm-CTA impossible in certain cases. Our findings suggest that in cases of suspected sudden death due to aortic pathology, pm-CT imaging may be performed as a screening method, followed by pm-MRI and/or pm-CTA as confirmatory studies, for conducting non-invasively effective hypotheses on the cause and mechanism of death. We are conscious of the possible danger of misinterpretation of post-mortem imaging, particularly if traditional autopsy, the actual gold standard, is not performed. It is undisputed that traditional autopsy could have driven faster and easier to more confident and certain diagnostic conclusions about the cause of aortic aneurysm rupture, the nature of the pericardial defect and the cause and mechanism of death in this and in similar cases. Although recently some limitations of minimal invasive techniques have been overcome by the introduction of percutaneous needle biopsy in post-mortem setting [33,34], some drawbacks actually prevent in many cases considering minimally invasive autopsy as a substitutive tool to autopsy. Post-mortem imaging techniques are, in fact, time consuming procedures and they provide in most cases inferior accuracy with respect to autopsy, mainly due to the lack of visual, tactile and even olfactory information. Additional prospective studies with autopsy correlation are necessary to confirm the accuracy of these cross-sectional imaging methods in the post-mortem setting. However, based on our experience in this case and the high accuracy noted in ante-mortem cases, we suggest that these imaging techniques can be considered useful documentation and diagnostic tools, at least complementary to autopsy, in natural deaths related to aortic pathology. Conflict of interest None. Acknowledgements The authors would like to thank Daniela Marchetti (Department of Legal Medicine, Institute of Forensic Medicine, ‘‘Catholic’’ University of Rome, Italy), Riccardo Marano (Department of Radiological Sciences, Institute of Radiology, ‘‘Catholic’’ University

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