H. Maxeiner

Demonstration and Interpretation of Bridging Vein Ruptures in Cases of Infantile Subdural Bleedings

Report of two cases of lethal infantile subdural bleedings (SDB). Bridging vein (BV) ruptures were directly proven as the source of the (minimal) SDB by a postmortem X-ray. In the controversial discussion concerning the causes of infantile SDB, proof of the occurrence of several BV ruptures is seen as an important sign of a trauma of significant degree. Although infantile SDB undoubtedly can result from accidental as well as intentional injuries, and therefore, the SDB itself does not allow far-reaching conclusions as to the cause of injury, the presence of several BV ruptures combined with an SDB of insignificant volume, in an infant dead or in a deep coma on clinical presentation, is not compatible with the supposition of a minor fall as the cause. We have not observed such findings as the result of a minor accidental event for more than 15 years.

Pure subdural hematomas: a postmortem analysis of their form and bleeding points.

OBJECTIVE Although the literature concerning subdural hematomas (SDHs) is vast, few data are available as to the sources and related clinical differences of SDHs. Pure SDHs of arterial versus venous origin should be compared in terms of cause, size, space-occupying effect, and form. METHODS We analyzed data from 46 patients who died as a result of pure SDHs. Twenty-three SDHs resulted from bridging vein ruptures and 23 from torn cortical arteries. We performed a morphometric analysis of the intracranial situation on the horizontal plane at the level of the greatest fronto-occipital diameter. We included in our analysis the clinical one-dimensional parameters (e.g., hematoma thickness, midline shift); the areas of the hemispheres, the SDHs, and their displacement; and the hematoma volume. RESULTS Most of the investigated postmortem characteristics of both types of hematomas were similar, with the exception of the form and the midline shift. SDHs resulting from arterial ruptures (which are generally located in the temporoparietal region) differ in form from those caused by bridging vein ruptures (which typically rupture in the frontoparietal parasagittal region). CONCLUSION The form difference allows the probable rupture site to be estimated; this observation might prove useful for clinical purposes.

Homicidal and suicidal ligature strangulation—a comparison of the post-mortem findings

Suicides by ligature strangulation are rare events. In Berlin (3.5 million inhabitants; ca. 500 suicides per year) approximately one case per year occurs. Here, we present the main findings of 19 cases investigated between 1978 and 1998, compared to 47 cases of homicidal ligature strangulation. Two of the 19 suicidal victims had single fractures of the upper thyroid horns and one victim a fracture of a lower thyroid horn; other types of laryngohyoid injuries were not observed. In the homicidal series, the laryngohyoid structures were unaffected in 26 cases (12 of these victims were children or adolescents), single thyroid horn fractures were present in three cases and more significant injuries in 18 cases. Macroscopic bleedings of the laryngeal muscles were found in 12 victims of the homicidal group and in none of the suicidal. Bleedings in the neck muscles seldom occurred in suicides. According to these findings, the laryngohyoid injuries can be helpful in the differentiation of suicide from homicide, if more than a single thyroid horn fracture or a laryngeal soft tissue trauma is present.

Postmortem radiological investigation of bridging vein ruptures

In the usual method of brain removal in forensic autopsies, the upper bridging veins were invariably torn. There are several types of head injuries, in which ruptures of these vessels are the predominant intracranial injury. For the past 5 years we have investigated nearly all cases of lethal head injuries by a simple X-ray method (axial X-ray after instillation of contrast material into the superior sagittal sinus). The evaluation of the 350 X-rays which were available until today can be summarized by the following statements. (a) Anatomy of the parasagittal bridging veins: regarding the numbers and diameters of the veins, we can separate cases with many bridging veins of small diameter from a group with few veins of a large diameter. (b) Causes of injury and direction of impact: bridging vein ruptures resulted more often from frontal than from occipital, parietal and lateral impacts and occurred in traffic accidents in the majority of our cases.

Neck Injuries Caused by Being Run Over by a Motor Vehicle

We report a homicide involving the use of a motor vehicle and simulating a traffic accident. This observation was the reason for a retrospective analysis of neck injuries in victims of traffic accidents, in which a person has been run over (RO) by a motor vehicle. The autopsy material of two institutes from 1990-1996 was used. The following findings were obtained in 63 victims: laryngohyoid fractures (LH-fx): 10 cases (16%) with a clear difference between the institutes (22% versus 7%). This resulted from examination with special regard to such injuries in many cases at one of the institutes, whereas only autopsy reports were taken retrospectively from the other institute. Five of these cases had suffered only minor LH-fx (as seen frequently in strangulation), although extensive run over (RO) injuries of the other cervical tissues were present. All LH-fx were caused by direct compression of the neck; in eight of the cases they were combined with mandibular fractures. Petechial hemorrhages (petH) at the eye lids/conjunctivae were seen in 19 cases (30%); 16 of these were related to thorax RO injuries, three to abdominal RO only. Four cases involved LH-fx, petH as well as cervical skin lesions and additional cervical soft tissue hemorrhages. Interpretation can be extremely difficult with this combination of findings if the character of the event cannot be established as accidental beyond doubt on the basis of the circumstances.

Zur Bewertung von Subduralblutungen bei Säuglingen nach angeblichen Bagatelltraumen

ZusammenfassungFragestellung. Angesichts einer kontroversen Diskussion in der Literatur, ob lebensbedrohliche intrakranielle Verletzungen mit Subduralblutungen bei Säuglingen (im 1. Lebensjahr) durch sog. Bagatelltraumen möglich sind, sollte eine Übersicht über tödliche Fälle dieser Art gegeben werden. Inhalt der Untersuchung waren keine Fälle mit Schädelbruch und fokalen Hirnverletzungen, sondern isolierte Subduralblutungen. Methodik. Auswertung der amtlichen Todesursachenstatistik von Berlin (1978–1998) sowie des Obduktionsmaterial des Instituts für Rechtsmedizin der FU Berlin (1978–1999). Ergebnisse. In der amtlichen Todesursachenstatistik findet sich kein einziger Todesfall eines Säuglings, der als Folge eines unfallmäßigen Sturzes aus geringer Fallhöhe angesehen wurde. In unserem Institut wurden 21 tödliche Kopftraumen bearbeitet, von denen 10 den oben genannten Kriterien entsprachen; in keinem war nachvollziehbar von einem Bagatelltrauma auszugehen. Schlussfolgerungen. Die Kombination mehrere/multiple Brückenvenenrupturen, Ausbleiben einer raumfordernden Subduralblutung und Koma oder Todeseintritt ist mit der Annahme eines unfallmäßigen Bagatelltraumas nicht vereinbar.AbstractQuestioning. Recently the discussion concerning the causes of infantile subdural bleedings (SDB) has become quite controversial. The wide-spread interpretation that most of these cases are the result of abuse, especially by the shaken-baby-syndrome, was doubted, and the role of (even minor) accidental events was emphasized. Methods. This situation should be analyzed basing on the official statistics of the causes of death in the city of Berlin (1978–1998) and the autopsy material of our institute (1978–1999). Results. In this period, approximately 440.000 children lived their first year of life in our city. Only 80 violent deaths of infants (up to 1 year old) were recorded in the official statistics, including 27 deaths due to blunt forces, with 24 lethal head injuries as the main group. Only two cases were attributed to “falls under unclear conditions”; all other accidental cases were the results of traffic accidents or falls from a height. No death due to an undoubted minor fall was recorded, nor was any in our autopsy material.We investigated 10 cases of infantile SDB, all without skull fractures and gross brain injuries. Only 1 victim had a SDB of a significant volume; in all other cases only small amounts of blood were present in the subdural space. Bridging vein ruptures were directly demonstrated in 8 cases and were bilaterally in most instances; recently their detection has been simplified by postmortem x-ray using contrast material. All 10 cases were interpreted as typical acceleration-deceleration injuries (as in shaking), although only in 2 cases a confession of this procedure could be obtained. Conclusion. Comparing cases of accidental and non-accidental SDB in the literature, infantile SDB obviously cannot be looked at as a homogeneous entity: two quite different types should be kept separate: the patients suffering from an accidental SDB due to a minor fall mostly do not deteriorate immediately after the trauma, develop SDB of some volume, up to a space-occupying mass lesion, and have often a good prognosis. A lethal outcome is extremely uncommon; we have not observed a single case of an infantile lethal SDB resulting from such a minor injury for more than 20 years. The source of the SDB in those cases currently is unknown in most instances. The second group of infantile SDB includes the well-known group of shaken-baby-syndrome: no adequate history, infants dead or nearly dead on clinical presentation, often a poor outcome if the event is survived, typically no significant volume of SDB, and – according to our experiences – in all cases BV ruptures. This combination of several BV ruptures with no significant subdural bleeding is not compatible with a supposition of a minor fall causing this.

Über Brückenvenenverletzungen bei tödlich verunglückten Kraftfahrzeuginsassen

ZusammenfassungSubduralblutungen treten nach einem Teil der Literaturangaben bei Verkehrsunfallopfern seltener auf als bei anderen Ursachen von Kopftraumen. Die Schlußfolgerung, daß dies auch für Rupturen der parasagittalen Brückenvenen (als eine der häufigsten Ursache von Subduralblutungen) gilt, trifft nach eigener Erfahrung jedoch nicht zu. Dies liegt daran, daß es trotz solcher Gefäßverletzungen und einiger Überlebenszeit nicht zu einer Blutung kommen muß, so daß weder klinisch noch im Falle des Todes postmortal ein Hinweis auf solche – schwer zu diagnostizierende – Läsionen vorliegt. Im Rahmen einer systematischen postmortalen Untersuchung dieser Gefäßregion mittels Röntgenkontrastdarstellung wurden bei 5 von 6 fortlaufend untersuchten tödlich verletzten PKW-Insassen (Alter 4–31 Jahre) Brückenvenenrupturen nachgewiesen. In 3 dieser Fälle lag trotz einer Überlebenszeit zwischen 4 und 15 h weder eine thrombotische Abdichtung der Rupturstellen noch eine nennenswerte Subduralblutung vor. Als Erklärung wird ein Zusammenbruch der Hirndurchblutung sehr rasch nach dem Trauma infolge Hirnschwellung angenommen.AbstractExperimental data and clinical as well as postmortem experiences have indicated that subdural hematomas are less frequent in acceleration injuries in traffic accidents compared to falls or assaults. The present report demonstrates that this does not hold true in the same way for bridging vein ruptures (one of the predominant causes for subdural bleedings). Ruptures of these vessels without subdural bleeding (SDB) are only seldom mentioned in the literature. However, if no SDB is present, no one will look for these structures. In our institute a systematic analysis of the bridging veins in all cases of lethal blunt head injury is made: prior to the careful morphological preparation we investigate these vessels by radiographic imaging after filling with contrast medium. 6 car passengers (age between 4 and 31 years) which suffered a lethal head injury were examined in the last year. 2 victims had impressed fractures with cerebral compression injuries. In 1 case the base of the skull was broken and in 3 cases no skull fracture was present; no serious focal brain injury had occured in these 4 cases, but 3 victims had signs of diffuse brain injury. In 5 cases a direct impact of the head against the interior of the car was obvious. In 5 cases ruptures of serveral bridging veins could be demonstrated. In one case (survival for 3 days) a minor SDB (20 ml) was present and the ruptures had been closed by thrombosis; another victim died at the scene. The other 3 victims survived between 4 and 15 hours without developing SDB and without closing of the ruptures by thrombosis. This combination is surprising and shows that our knowledge concerning the relationship between bridging vein ruptures and SDB is restrictred. The frequency of bridging vein lesions in severe head injuries is likely underestimated in the clinical as well as in the postmortem literature. A rapid increase of intracranial pressure after the accident resulting in a collapse of the cerebral circulation is probably responsible for the absence of the SDB in the presented cases.

Death caused by a letter bomb.

Abstract A 48-year-old man was killed by the explosion of a letter bomb after receiving severe injuries to his face and left hand. The autopsy ascertained that the right eye and orbit had been completely destroyed by a large piece of metal from a tin can that had entered the cranial cavity through the right eye and caused fatal brain damage. The victim had also sustained a severe injury to his left hand. Reconstruction of the metal and plastic fragments showed that the victim had received a padded envelope with a video cassette in which a simple explosive device was hidden in a flat tin. The explosive charge consisted of a mixture (ca. 60 g) of sodium chlorate, sodium chloride and sucrose. The charge was detonated by a nylon cord attached to the inside of the envelope which was stretched when the video cassette was pulled out of the envelope. This removed a piece of plastic from between two contacts, and the explosion was set off immediately by a battery which activated two flash bulbs placed within the charge.

Kehlkopfpräparation bei der forensischen Obduktion

ZusammenfassungEs werden die Standardmethode der Kehlkopfpräparation bei der forensischen Obduktion sowie deren Unzulänglichkeiten bei geringfügigen morphologischen Veränderungen und Verletzungen beschrieben. Ein detailliertes Untersuchungsprotokoll für Routine- und forensisch relevante Fälle wird vorgestellt. Diese Sektionstechniken sollen sicherstellen, dass Verletzungen am Schildknorpel, am Ringknorpel und am Zungenbein entdeckt, dass Einblutungen der kleinen Kehlkopfmuskeln gefunden, und Kapsel- oder Gelenkblutungen der Kehlkopfgelenke nicht übersehen werden und dass artifizielle Verletzungen, die zu Missinterpretationen führen können, ausgeschlossen werden.SummaryThis article outlines the standard method of dissection of the larynx and points out the deficiencies when confronted with the sometimes subtle morphological alterations and injuries which can be encountered in forensic autopsies. A detailed dissection protocol to be used in such cases is given as well as recommendations for the demonstration of forensically relevant injuries and for the avoidance of artefacts and pitfalls which could lead to false interpretation of the findings.

Der Kurs Rechtsmedizin für Medizinstudenten an der Freien Universität Berlin

ZusammenfassungVor dem Hintergrund der aktuellen Diskussionen in unserer Fachgesellschaft über einen effektiven praktischen Studentenunterricht im Fach „Rechtsmedizin“ stellen wir den Ablauf unseres Kurses „Rechtsmedizin“ vor. Neben den Vorlesungen zur Rechtsmedizin und zur ärztlichen Rechts- und Berufskunde, die sich am Gegenstandskatalog orientieren, konzentriert sich unser Kurs auf die ärztliche Leichenschau sowie die forensische Verletzungskunde. Bei der Leichenschau lernen die Studierenden die korrekte Einordnung der Todesart sowie ihre ärztlichen Pflichten im Zusammenhang mit den Bestattungsgesetzen. Bei der Verletzungskunde werden sie über die richtige Befunderhebung und Dokumentation sowie Rekonstruktion von Verletzungsbefunden geschult. Jeder Studierende bekommt 28 Stunden im Kleingruppenunterricht, verteilt über 12 Wochen. Der Kurs beinhaltet 12 Stunden im Hörsaal, 7 Stunden praktischer Unterricht an der Leiche, 5 Stunden systematische Verletzungskunde im Seminarraum sowie ¶3 Stunden Prüfungen und 1 Stunde ein freier Test über Todesarten. Die Prüfungen in der 3., 9. und 12. Woche haben sich als Wissenskontrollen bewährt.AbstractThe complete restructuring of the course in forensic medicine in the medical curriculum at the Institute of Legal Medicine of the Freie Universität Berlin led to two main results. An improvement in the students perception and acceptance of our course as well as the efficiency of the transfer of knowledge to the medical students. The new structure of the course includes lectures, seminars and practical training in postmortem examination. The intensiveness of the practical and theoretical training in small groups, in conjunction with oral (3rd and 9th weeks) and written (12th week) examinations during the course form the basis for the resounding success of our restructured programme.