Benjamin Ondruschka

S100B and NSE as useful postmortem biochemical markers of traumatic brain injury in autopsy cases.

Postmortem analysis of relevant biomarkers might aid in characterizing causes of death and survival times in legal medicine. However, there are still no sufficiently established results of practical postmortem biochemical investigations in cases of traumatic brain injury (TBI). The two biomarkers--S100 protein subunit B (S100B) and neuronal specific enolase (NSE)--could be of special interest. Therefore, the aim of the present study was to investigate changes in their postmortem levels for further determination of brain damage in TBI. In 17 cases of TBI (average age, 58 years) and in 23 controls with different causes of death (average age, 59 years), serum and cerebrospinal fluid (CSF) samples were analyzed with a chemiluminescence immunoassay for marker expression. An increase in serum S100B, as well as a subsequent decrease after survival times>4 days, were detected in TBI cases (p<0.01). CSF NSE values >6,000 ng/mL and CSF S100B levels >10,000 ng/mL seem to indicate a TBI survival time of at least 15 min (p<0.01). It is of particular interest that CSF S100B levels (p<0.01) and serum S100B levels (p<0.05) as well as CSF NSE values (p<0.01) were significantly higher in TBI cases in comparison to the controls, especially when compared with fatal non-head injuries. In conclusion, the present findings emphasize that S100B and NSE are useful markers in postmortem biochemistry in cases of suspected TBI. Further, S100B may be helpful to estimate the survival time of fatal injuries in legal medicine.

Cerebellar Gene Expression following Human Traumatic Brain Injury

Gene expression of specific brain biomarkers offers the possibility of shedding light on the difficult molecular pathways of traumatic brain injury (TBI) and may be useful to estimate the age of trauma. Gene expression rates of cerebellar injuries are not yet sufficiently established. In 12 cases (mean age 42 years) of TBI including a pathological change in cerebellum (with known survival times ranging from immediate death to 96 h), brain tissue samples from different brain regions were analyzed with real-time polymerase chain reaction (PCR) for expression of caspase-3, tyrosine kinase receptor B (TrkB), S100B, and glial fibrillary acidic protein (GFAP) mRNA. The pH was measured to gain information about a possible correlation to RNA degradation. For comparison, corresponding brain regions were arranged from control samples of subjects that died from sudden death. We found a correlation between pH and the degradation of RNA in samples from the contralateral site, where the samples with degraded RNA have a lower pH (p<0.05). For short survival times, the expression changes of caspase-3 (p<0.05) and the expression changes of TrkB (p<0.1) in the cerebellum show a significant increase compared to the controls. The cerebellar gene expression changes seem to occur much faster and stronger compared to the other investigated regions, in particular the cerebral trauma site. These findings could make the cerebellum an important target area to study the expression changes after TBI.

Post-mortem biochemistry of NSE and S100B: A supplemental tool for detecting a lethal traumatic brain injury?

PURPOSE Traumatic brain injury (TBI) is a very common entity that leads to numerous fatalities all over the world. Therefore, forensic pathologists are in desperate need of supplemental methodological tools for the diagnosis of TBI in everyday practice besides the standard autopsy. The present study determined post-mortem neuron specific enolase (NSE) and S100 calcium-binding protein B (S100B) levels as biological markers of an underlying TBI in autopsy cases. METHODS Paired serum and CSF samples of 92 fatalities were collected throughout routine autopsies. Afterwards, the marker levels were assessed using commercially available immunoassays (ECLIA, Roche Diagnostics). For statistical analysis, we compared the TBI cases to three control groups (sudden natural death by acute myocardial infarction, traumatic death without impact on the head, cerebral hypoxia). Moreover, the TBI cases were subdivided according to their survival time of the trauma. Brain specimens have been collected and stained immunohistochemically against the aforementioned proteins to illustrate their typical cellular staining patterns with an underlying TBI compared to non-TBI fatalities. PRINCIPAL RESULTS CSF NSE and S100B levels were elevated after TBI compared to all control groups (p < 0.001). Although this finding can already be investigated among the TBI cases dying immediately subsequent to the trauma, the marker levels in CSF increase with longer survival times until a peak level within the first three days after trauma. There is a strong correlation between both marker levels in CSF (r = 0.67). The presence or absence of cerebral tissue contusion following the initial trauma does not seem to affect the CSF levels of both proteins (p > 0.05). Post-mortem serum levels of both proteins were not elevated in TBI cases compared to controls (p > 0.05). Former elaborated cut-off values in CSF were confirmed and were only exceeded when a TBI survival time of at least 30 min was reached. MAJOR CONCLUSIONS The present results report that post-mortem NSE and S100B CSF levels are significantly elevated subsequent to a fatal TBI.

Rare cause of natural death in forensic setting: hemophagocytic syndrome

We report about the case of a sudden unexpected death of a 25-year-old male suffering from infectious disease. An autopsy was ordered with no final premortem diagnosis. Microscopic and microbiological examination revealed a pneumococcal bronchopneumonia and hemophagocytic lesions in the bone marrow. After integrating clinical and autopsy reports as well as additional postmortem investigations, the cause of death was found to be infectious-triggered hemophagocytic syndrome (HPS) with a final cytokine storm. This seems to be the first reported fatal case of a reactive form of HPS associated to Streptococcus pneumoniae to the best of our knowledge. HPS is a dangerous hyperinflammation with highly characteristic, but nonspecific, laboratory findings and symptoms. Autopsies in such cases must be carefully performed and include systematic tissue sampling done by an experienced pathologist.

Traffic accident or dumping? – Striking results of a traffic accident reconstruction

An atypical traffic accident scenario should be investigated directly at the crash site from all concerned professions, especially police men, forensic pathologists and technical experts, to get a personal overview and impression of the situation and the opportunity for interdisciplinary discussion. We present the rare case of a fatal traffic accident on a German motorway which was initially thought to be an accidental discovery of dumping a corpse. Based on autopsy findings, the technical investigation and the accident reconstruction, this case was solved as a spectacular form of a collision between a pedestrian and a bonnet-front car, which was not described elsewhere in scientific literature to the best of our knowledge. The pedestrian was hit in an upright body position, was lifted up by the car, smashed the windscreen and flew over the car with several body rotations. His flight curve ends directly at the roof of the car during brake processing, where the body touched the roof, smashed the rear-window and landed in the trunk. Based on the technical investigation, the driver of the car was not able to hide the accident. However, the pedestrian could have avoided the collision if he did not cross the motorway on foot.

Nodular pulmonary amyloidosis with spontaneous fatal blood aspiration.

Amyloidosis is a multisystem disease, which is characterized by the extracellular deposition of insoluble abnormal fibrils. Histological and subsequent immunohistochemical examinations are necessary for the determination of the diagnosis and the classification of the amyloid type. The most common systemic variant is immunoglobulin-derived light chain (AL) amyloidosis. However, local or organ-limited AL amyloidosis can occur. Isolated pulmonary amyloidosis is a rare condition and frequently an incidental finding at chest scans or during autopsy. Generally, it is associated with a benign prognosis. Here, we present two fatal cases, in which the cause of death was asphyxiation due to severe blood aspiration. During autopsy, several nodules were found in the lungs. Based on histological and immunohistochemical analysis, the diagnosis of an isolated nodular pulmonary AL amyloidosis lambda light chain was made. Amyloid was also present in pulmonary blood vessels, which lead to fragility and finally fatal hemorrhage.

Decellularized Iliotibial Band Recolonized with Allogenic Homotopic Fibroblasts or Bone Marrow-Derived Mesenchymal Stromal Cells

Decellularized scaffolds present promising biomimetic approaches in various fields of tissue engineering. Different tissues have been selected for decellularization, among them extracellular matrix (ECM)-rich tissues such as tendons, ligaments and cartilage. The dense ECM of ligaments is particularly challenging to achieve a completely non-immunogenic ECM void of any cells. Here, the methods for decellularization adapted to ligamentous tissue of the iliotibial band (ITB) are presented along with cell isolation and several recolonization techniques using allogenic ITB-derived fibroblasts or mesenchymal stromal cells (MSCs).

Suicide by the intraoral blast of firecrackers — experimental simulation using a skull simulant model

Suicides committed by intraorally placed firecrackers are rare events. Given to the use of more powerful components such as flash powder recently, some firecrackers may cause massive life-threatening injuries in case of such misuse. Innocuous black powder firecrackers are subject to national explosives legislation and only have the potential to cause harmless injuries restricted to the soft tissue. We here report two cases of suicide committed by an intraoral placement of firecrackers, resulting in similar patterns of skull injury. As it was first unknown whether black powder firecrackers can potentially cause serious skull injury, we compared the potential of destruction using black powder and flash powder firecrackers in a standardized skull simulant model (Synbone, Malans, Switzerland). This was the first experiment to date simulating the impacts resulting from an intraoral burst in a skull simulant model. The intraoral burst of a “D-Böller” (an example of one of the most powerful black powder firecrackers in Germany) did not lead to any injuries of the osseous skull. In contrast, the “La Bomba” (an example of the weakest known flash powder firecrackers) caused complex fractures of both the viscero- and neurocranium. The results obtained from this experimental study indicate that black powder firecrackers are less likely to cause severe injuries as a consequence of intraoral explosions, whereas flash powder-based crackers may lead to massive life-threatening craniofacial destructions and potentially death.

Pulmonary artery perforation and coronary air embolism-two fatal outcomes in percutaneous left atrial appendage occlusion.

Percutaneous left atrial appendage (LAA) closure is a routinely performed method to reduce the risk of stroke in patients suffering from atrial fibrillation, when an oral anticoagulation is no longer indicated due to relevant bleeding complications. Currently, the Amplatzer Amulet and the Watchman system are two equally used systems. While there is an acute success rate of more than 95 per cent for this intervention, several minor and major complications such as pericardial effusions, air embolism, vascular lesions in proximity to the heart or even death can occur. Here, we report two cases of very rare fatal outcomes in percutaneous LAA occlusion. Eight hours after deployment of an Amplatzer Amulet a patient died, after the pulmonary trunk was perforated by a hook of the occluder device causing pericardial tamponade. In the second case during final radiological position control of the deployed Watchman occluder air was injected accidentally. The patient immediately died due to coronary air embolism. Forensic autopsies are necessary to solve the cause and manner of death, to evaluate and develop medical devices and to rule out medical malpractice. Thus, a close collaboration of legal medicine and the various cardiologic departments is proposed.

Cervical vagus nerve morphometry and vascularity in the context of nerve stimulation - A cadaveric study

Vagus nerve stimulation (VNS) has become a well-established therapy for epilepsy and depression, and is emerging to treat inflammatory disease, with the cervical vagus nerve (CVN) as major stimulation site. CVN morphometries are missing for VNS, considering its variability. Morphometric data were obtained from CVNs in 27 cadavers, including branching patterns and histology. Cross-sectional area, greater and lesser diameters averaged 7.2 ± 3.1 mm2, 5.1 ± 1.5 and 4.1 ± 1.3 mm, and were ≤11.0 mm2, ≤7.0 and ≤5.8 mm in 90% of the specimens, respectively. Midline distance (position lateral to the laryngeal eminence) and skin distance (anterior-posterior from skin) averaged 34.5 ± 6.2 and 36.2 ± 9.4 mm, ≤49.0 and ≤41.0 mm in 90%, respectively. Nerve dimensions and surface topography correlated closely, but without gender-, side- or branching-dependent differences. The nerve fascicle number averaged 5.2 ± 3.5. Vagal arteries were observed in 49% of the cases. Negative correlations were found for age and cross-sectional area, as well as subperineural vessel count. Detailed anatomical data on the CVN and its vascularity are given, forming the morphometric basis for VNS refinement, filling an evident gap in light of the CVN being a structure with variable positions and branching. A 35 × 35-mm rule may apply for the CVN position, irrespective of branching or positional variation.