Danica Cvetković

Hyperostosis frontalis interna as an age-related phenomenon – Differences between males and females and possible use in identification

Hyperostosis frontalis interna (HFI) is a condition manifested by thickening of the inner surface of the frontal bone and it could be useful when dealing with the identification of human remains in various anthropological and forensic investigations. We compared the macroscopic appearance and morphologic (metric) features of the skulls in cases with and without HFI, in both sexes, and wanted to establish whether age determined occurrence of HFI. To achieve this aim, we performed prospective autopsy study, covering ten-year period (2007-2016). Study group consisted of southeast Europe Caucasian subjects, with determined age and sex. The severity of HFI was classified by two forensic pathologists independently, according to the four types (A-D) proposed by Hershkovitz et al. Thicknesses of the frontal and temporal bones, as well as the longitudinal and frontal diameters of the skulls were measured. The sample consisted of 35 males and 112 females with HFI, and 55 males and 202 females without HFI (404 individuals in total). Type B was the most common type of HFI among males (45%) and type C among females (41%). HFI type D was almost four times more common in females than in males (OR = 3.73). Frontal and temporal bones were thicker in all subjects who have HFI. Thickness of the skull was not age-dependent, in the entire sample, or in subjects with HFI, or in the control group (in all the cases Spearmans Rho was <0.3). Age seemed to be a predicting factor for HFI occurrence only in females. Females younger than 55 years have similar risk for HFI occurrence as males. An unidentified skull with the general markers of old age and severe form HFI is most probably from a female decedent.

Commentary on: Prahlow SP, Prahlow JA. Homicide in a horse barn? J Forensic Sci https://doi.org/10.1111/1556-4029.13774. Epub 2018 Mar 8

Sir, We read with interest article by Prahlow S and Prahlow J. entitled “Homicide in a Horse Barn?” which describes a case of elderly female found partially nude, with injuries, on the floor of her horse barn (1). The autopsy shown that some of the injuries were determined to be postmortem, caused by horses. Gastric Wischnewsky spots were also present as a sign of hypothermia, as an immediate cause of death. Finally, an acute hip fracture was identified, which explained why she was incapable of moving from the potentially dangerous environment. We agree, in the most, with the conclusion of the authors regarding the cause of death and reconstruction of the event. However, we have some addition to their work. First, the authors found left hip fracture in the victim. According to authors, internal soft tissue hemorrhage around the site of the hip fracture indicated that the fracture was likely antemortem. This is probably right. However, soft tissue hemorrhage is a relative and not an absolute vital reaction; that is, it might occur even postmortem to some extent. To confirm the vitality of the injury, the pathologist should have searched for the histological signs of pulmonary fat embolism (either with H/E stain or even better with some of the specials stains for fat). The finding of fat emboli in lung vessels would be an absolute vital reaction and an indubitable proof of vitality of hip fracture. The histological finding of fat emboli using some of special stains (Sudan, Oil Red O, etc.) in the lungs is possible even in cases of advanced putrefaction (2). Second, in their case report, the authors describe rare scalp contusions (without more precise localization) and left-sided periorbital ecchymosis. The authors say that “while it could not be determined with one hundred percent certainty that the periorbital ecchymosis was postmortem, the absence of associated intracranial trauma suggested that it likely was postmortem, as postmortem periorbital ecchymosis is known to occur.” Although this conclusion is also fair, there is an additional possibility for the periorbital bruising to occur. Falling on her left side (when she also got her hip fractured), the woman might have hit the occipital region of her head causing motion of the eye bulbs and traction by the optical nerve. Such motions may cause conjunctival hemorrhage, periorbital hematoma, discoloration of orbital roof, or even orbital roof fractures, and they do not have to be associated with either brain injury or (direct) skull fractures (3), as in the presented case. Therefore, regardless of the fact that no skull fracture, intracranial bleeding or brain injury was present, left periorbital hematoma might have been antemortem due to fall on the occipital part of the head. Finally, based on finding of the gastric Wischnewsky spots, as well as the fact that the woman was lying down for some time on the wet floor of the barn, and the possibility of paradoxical undressing, the authors concluded that the main cause of death was hypothermia, despite the relatively warm weather. We agree with this conclusion, adding another sign which supports this conclusion. As shown in Fig. 6, there is a red-bluish discoloration on the right knee. Although there is a possibility that this was a bruise (we cannot tell that from the photograph), there is even greater possibility that this was actually a frost erythema, with a typical localization, on the opposite side of the fall. The diagnosis of hypothermia might have also been strengthened with a possible finding of so-called inner knee sign—hemorrhages of the synovial membrane and bloody discoloration of synovial fluid (4). With the complete reconstruction of the event, we can agree that the manner was accidental and that the horses were innocent!

Commentary on: Langlois NEI, Byard RW. Arterial perfusion—a useful technique for evaluating incised wounds. J Forensic Sci https://doi.org/10.1111/1556-4029.13682. Epub 2017 Oct 30.

Sir, We have recently read the article “Arterial Perfusion—A Useful Technique for Evaluating Incised Wounds” by Langlois and Byard (1). The authors described a case of suicidal death due to incised wounds of the wrist and neck with blood loss and air embolism. During autopsy, perfusion of the thoracic ascending aorta produced leakage of water emanating from an incised wound of the right ulnar artery, as well as from the facial artery branch of the right external carotid artery. Described arterial perfusion method has additional application in cases of ruptured cerebral berry aneurysms. Usually, the diagnosis of subarachnoid hemorrhage at autopsy is self-evident. The usual point of bleeding is in the circle of Willis, with the most dense hemorrhage over the base of the brain (2). However, postmortem identification of the exact spot of bleeding may be very difficult with either naked eye or magnifying glass, as the rupture length may be minimal, and the aneurysm may be very small and may collapse after the rupture. Most of the textbooks advise the search for the rupture spot, while the brain is fresh, that is, prior to fixation in formalin, as formalin fixation hardens the blood clot so much, that it cannot be removed without the danger of tearing the underlying vessels and any aneurism (2,3). After careful removal of the brain from the skull, the blood should be carefully washed away in a continuous stream of water. The procedure, which is routinely carried out in our institution, and also suggested by Saukko and Knight (2), includes injecting water into one of the cut ends of a vertebral artery, after carefully tying or clamping the other vessels and the two cut terminations of carotid arteries, to see where the water leaks from. Additionally, a couple of drops of ink into the injecting syringe may improve contrast and make a rupture spot more obvious. However, the removal of the brain from the skull must be carried out very carefully, as forceful (or better said less careful) removal may produce damage on the smaller vessels, resulting in multiple artefactual tearing. Perfusion method of arteries of the circle of Willis is simple, cheap, and easily carried out, especially compared to other auxiliary methods such as postmortem angiography of vertebral arteries or en bloc dissections of the lower brainstem, cervical spine cord, brain base, and cervical vertebrae followed by decalcification and other various examination procedures (4). The described method also facilitates microscopic analysis by lowering the number of samples. Langlois and Byard (1) concluded in their paper that perfusion testing can be used as a screening test prior to formal dissection and also to identify small vessels that may not be obvious on standard examination of an exsanguinated field. We can absolutely agree with this conclusion, and the paper reminded us of the additional application of perfusion method in everyday forensic work.

Regarding “Fatal air embolism in hospital confirmed by autopsy and postmortem computed tomography”

We read with interest the article by Edler et al. entitled “Fatal air embolism in hospital confirmed by autopsy and postmortem computed tomography” [1], which describes a case of unusual fatal air embolism in an 83-year-old woman. The authors mentioned several autopsy findings indicating air embolism, one of them being air locks in cerebral vessels. In this paper Fig. 7 shows small bubbles of air, clearly visible in the cerebral vessels [1]. However, air locks in these – pial vessels, cannot be taken as an indubitable sign of an air embolism. This sign was described as a common artifact in (at least) three major textbooks. In “Knight’s Forensic Pathology” it is stated that in cases of suspected air embolism, the head should be dissected first, “not to detect air bubbles in the cortical veins, as almost every textbook erroneously states, but to look for air in the cerebral arteries”. It is also stated, in a critical manner, that “descriptions and photographs of air segments in the cerebral veins are part of the mythology of forensic pathology, handed on uncritically from one book and one author to another” and concluded that the bubbles in pial vessels are artifacts that can be seen in many routine autopsies where there is no suggestion of an air embolism being present [2]. In “Forensic Pathology” by DiMaio and DiMaio, it is explained that the process of removing the skull cap, cutting through the dura, and putting traction on the brain to see the cerebral circulation might introduce air bubbles into the circulation, and therefore, the presence of a few air bubbles in the cerebral circulation does not necessarily indicate an embolus [3]. Finally, Spitz and Fisher’s “Medicolegal Investigation of Death” states that “an interrupted blood column, i.e. fragmentation of the blood line in... the arteries of the meninges or elsewhere in the body, is often artifactual and must not be regarded as evidence of air embolism” [4]. In the case presented by Edler et al. air embolism is undoubtedly confirmed by postmortem computed tomography, a positive test for cardiac air embolism at autopsy, and by microscopic examination – intravasal air locks were observed in the lungs. However, air locks in cerebral – pial vessels seen at the autopsy were also unadvisedly presented as a sign of air embolism, which might mislead some less experienced forensic pathologists, especially if it were presented as a sole “proof” of an air embolism. This is an artifact, described in major textbooks, and should be regarded in this way.

Regarding ligature induced blister formation in hanging – the “pinch” effect

We have recently read the article “Ligature induced blister formation in hanging – the “pinch” effect” by Spinelli et al. [1], where the authors described three cases of hanging, with a rare finding – the blistering of the skin trapped between the ligatures. In two cases, the ligature was doubled and looped around the neck, and blisters were encountered between the ligature marks. In the third case, a thick metal chain was used as a noose, and patchy blistering with crusted exudates arose between the chain links. Histological examination showed “blistering with separation along the dermoepidermal junction and no apparent exudate or cellular infiltrate in the space”. The authors concluded that “blisters are thought to arise when compression of the neck at two levels increases the pressure on trapped fluid-rich soft tissues, producing a “pinching” effect”. We encountered a case of a 39-year-old man who was found hanging from the branch of a tree, in the kneeling position (Fig. 1a), during summer. He used the shoulder strap of his laptop case as a noose, having crossed and attached it to the branch without making a knot (Fig. 1b). During scene investigation, a hanging mark with almost parallel stripes of desiccations and hematomas in the most superficial layers of the skin were observed, in concordance with the texture of the shoulder strap (Fig. 2). Additionally, just below the hanging mark, the photographs from the scene revealed several blisters filled with clear fluid (Fig. 2). Autopsy was performed about 28 h after the body had been found. At the time of the autopsy, the hanging mark on the neck had a significantly different gross appearance compared to the mark observed and photographed at the scene. Besides that, during autopsy, the blisters were no longer visible (Fig. 3b). At the autopsy, the hanging mark was more clearly visible, and it was more pronounced than during the investigation at the scene of death; it was brown and dried, but also with less clearly visible transverse stripes from the imprint of the inner side of the shoulder strap, inside the hanging mark, and without blisters. Above all, this case demonstrates that blisters do not necessarily arise only as a result of the “pinch” effect, when the skin of the neck is compressed between two levels of loop. The mechanism of this phenomenon could also include the edge of the noose pressing on the skin, expelling fluid, which can apparently move either above [2] or below the ligature mark, making blisters a postmortem phenomenon [3]. Since this was a case of an incomplete hanging without a knot and with a wide noose made of relatively soft material, we can assume that this pressure does not even have to be very firm. Secondly, this case indicates that we do not always take into consideration the very rapid and dramatic change in the appearance of the hanging mark that can * Slobodan Nikolić bobanvladislav@yahoo.com; slobodan.nikolic@mfub.bg.ac.rs

Copper-beaten skull appearance in the setting of Marfan syndrome

We have recently read the article by Ginelliová et al. regarding sudden deaths associated with syndromic craniosynostosis [1]. In patients with Crouzon syndrome, severe premature fusion of the cranial bone sutures and reduced cranial growth may result in raised intracranial pressure. This then causes the growing brain to exert pressure on the cranium, producing gyral patterns on the inner table of the skull and resulting in the appearance known as a copper-beaten skull. Therefore, a diffuse and severe beaten-copper pattern is an indicator of chronic elevated intracranial pressure [2]. Recently, we had a case of sudden death of a 24-year-old man due to thoracic aortic dissection that caused cardiac tamponade (Fig. 1a). According to the revised “Ghent” criteria, the man had the following features of Marfan syndrome [3]: arachnodactyly; a high arched palate, teeth and mid-face anomalies; an anomalous fourth toe of the left foot, which was inserted about 1 cm more proximally compared to the other toes; ectasia of the aortic and the pulmonary artery root, with diameters of 82 mm and 84 mm, respectively; bivelar aorta with anomalous aortic origin of coronary arteries (both arteries originated from the same aortic sinus) (Fig. 1a); and elongated chordae of papillary muscles, with the possibility of a prolapsed mitral valve (Fig. 1b). Microscopic examination showed the presence of longitudinal splitting of the wall and advancing dissecting hematoma in the outer layers, and cystic degeneration changes and medial necrosis, without inflammation in the middle and inner layers of aortic media (Fig. 1c). Examination of the skull revealed dolichocephaly (the diameters were 172 mm and 124 mm, and the mean cephalic index was 72.1). Additional findings were present in the cranial cavity with prominent gyral impressions on the inner table of the skull, most notably in the frontal region (Fig. 2). Diffuse copper-beaten skull

Suicidal head impalement with a hydraulic press machine – occupation-related suicide in a psychiatric patient

A 63-year-old mechanic, diagnosed with schizophrenia, was found next to a hydraulic press used for removing car wheel bearings. He was in a sitting position, bent towards the machine, with his head placed between the piston and the pressing plate. His flexed left arm was resting on the lever beneath the machine pedestal, and on the right side there was a power switch that was still in the “on” position. His right arm was beside his body, but away from the machine. On the pressing plate, beneath the decedents head, was a piece of bloody cloth. Blood spatters were present on the left hand and left trouser leg. At autopsy there was a gaping laceration in the right temporal area extending to the right ear lobe, where a piece of helix was missing. This missing tissue was found on the inner surface of the left temporal bone. The temporal lobes and brain-stem were destroyed along the wound trajectory but there were no brain contusions present. There was blood aspiration in both lungs, but all other findings were unremarkable. Death was attributed to the fatal head injury that resulted from the low-velocity penetration of the hydraulic press piston. While the cause of death was self-evident and undoubted, the manner of death required medico-legal investigation. The protective cloth that had been placed on the pressing plate, a medical history of schizophrenia, and the absence of any defensive injuries, all led to the conclusion that this was a case of a rather unusual suicide, which could be regarded as related to the decedents occupation.

Unnatural and Violent Death in Cases with High Blood Alcohol Concentration— Autopsy Study

The use of alcohol increases the risk of dying from unnatural or violent causes. The presented study explored the distribution of age, gender, cause, and circumstances of death in persons who died in an unnatural and violent manner, with a blood alcohol concentration (BAC) higher than 0.3 g/dL, and where the cause of death was not alcohol intoxication. We defined the control (0 < BAC < 0.3 g/dL) and study (BAC ≥ 0.3 g/dL) groups, as in subjects with these concentrations, there is a significant risk of gross intoxication, stupor, and death. The subjects from the study group were older, with no difference in gender distribution. Traffic accidents were the most common fatal event in both groups, followed by suicides. Other accidents (choking on food and exposure to fire) were more frequent in the study group. Compared to the control group, subjects from the study group were older persons whose deaths were mainly accidental.

Double suicidal gunshot wounds to the heart

A case of double gunshot wounds to the heart is reported, where police investigations determined the manner of death to be suicide. In addition, the autopsy findings supported this conclusion. The localization, appearance, and mutual relations of the inflicted wounds, as well as the direction of the bullet trajectories, helped to determine the most probable sequence of events. The victim had been able to act after the first shot and inflict the second shot as the conduction system of the heart was at least partially preserved. Even when the circumstances indicate the most probable manner of death, multiple gunshot wounds represent a challenge for forensic pathologists; a victim’s ability to act after the first shot must be determined with respect to the degree of initial incapacitation.

Unusual appearance of facial petechiae and conjunctival hemorrhages: the trout phenomenon in a case of fatal subarachnoid hemorrhage due to ruptured berry aneurysm

A 66-year-old man was found unconscious in his home. He was transported to hospital, where he died about 2 h after being found. Cardiopulmonary resuscitation, including defibrillation, was applied for approximately 45 min. The man had been treated for hypertension for 10 years and had been diagnosed with coronary artery disease. During the police investigation of the death scene no suicide notes or blood traces were found. An autopsy was performed the following day. The deceased was 168 cm tall and weighed 100 kg. Postmortem hypostasis was well established, and moderate head cyanosis was noticed. Petechiae were present on the upper eyelids and on the skin between the eyebrows (Fig. 1a). Conjunctival hemorrhages were noticed bilaterally; in the inner corners of the eyes they were confluent, in the form of ecchymoses (Fig. 1b, c). Internal examination revealed a massive subarachnoid hemorrhage, up to 5 mm in thickness, especially around the brain-stem and the inferior aspect of the brain (Fig. 2a). A saccular berryaneurysm of the anterior communicating artery was found after removal of blood clots (Fig. 2b). The ruptured aneurysm was approximately 5 mm in diameter. The arteries of the Circle of Willis had moderate to severe atherosclerosis. Other major autopsy findings were: congestion of all internal organs, cerebral and pulmonary edema, concentric left ventricle hypertrophy consistent with hypertensive heart disease, moderate to severe atherosclerosis of coronary arteries, fatty liver, and benign nephrosclerosis. The autopsy excluded any external or internal injury, especially neck injuries (all the soft and solid neck structures were examined by layer dissection). There was no alcohol in the blood sample taken from the femoral vein. The cause of death was subarachnoid hemorrhage due to a ruptured saccular berry-aneurysm.