Mary E. S. Case

Position Paper on Fatal Abusive Head Injuries in Infants and Young Children

This article represents the work of the National Association of Medical Examiners Ad Hoc Committee on shaken baby syndrome. Abusive head injuries include injuries caused by shaking as well as impact to the head, either by directly striking the head or by causing the head to strike another object or surface. Because of anatomic and developmental differences in the brain and skull of the young child, the mechanisms and types of injuries that affect the head differ from those that affect the older child or adult. The mechanism of injury produced by inflicted head injuries in these children is most often rotational movement of the brain within the cranial cavity. Rotational movement of the brain damages the nervous system by creating shearing forces, which cause diffuse axonal injury with disruption of axons and tearing of bridging veins, which causes subdural and subarachnoid hemorrhages, and is very commonly associated with retinal schisis and hemorrhages. Recognition of this mechanism of injury may be helpful in severe acute rotational brain injuries because it facilitates understanding of such clinical features as the decrease in the level of consciousness and respiratory distress seen in these injured children. The pathologic findings of subdural hemorrhage, subarachnoid hemorrhage, and retinal hemorrhages are offered as “markers” to assist in the recognition of the presence of shearing brain injury in young children.

Inflicted Traumatic Brain Injury in Infants and Young Children

This article will discuss the subject of inflicted or abusive head injury in infants and young children. Inflicted neurotrauma is a very common injury and a frequent problem in attempting to distinguish between inflicted and accidental injury. Inflicted head injury occurs usually in the home in the presence of the individual who has inflicted the injury outside the view of unbiased witnesses. Distinguishing between inflicted and accidental injury may be dependent upon the pathological findings and consideration of the circumstances surrounding the injury.

Accidental traumatic head injury in infants and young children

This article will discuss accidental head injuries in infants and young children. The first category of injury is the crushing head injury. Static forces applied slowly to the head result in multiple fractures of the skull and contusions and lacerations of the brain resulting from the bone fragments striking the brain.

Sacral agenesis: Neurologic and neuropathologic features

The neurologic deficits in sacral agenesis involve motor function much more than sensory function, in a lumbosacral distribution; autonomic involvement, with neurogenic bladder, is variable. Relative sensory sparing may be due to the derivation of sensory nerves from neural cret tissue, which is uninvolved. An occult sacral meningomyelocele with ectopic neural tissue was found at necropsy in one of our patients. Primary amyoplasia may account for small but histologically normal muscles derived from the same somites as the aplastic vertebrae.

Forensic Pathology of Child Brain Trauma

The forensic approach to the autopsy differs rather significantly from the approach of the hospital pathologist to the autopsy. Hospital autopsies are done to determine why the patient has died and to evaluate the effects of therapeutic modalities and the accuracy of diagnostic procedures. Forensic autopsies are carried out on particular individuals who fall into the jurisdiction of the medical examiner or coroner system where the individual died. In a very broad sense these are individuals dying of unexpected or, possibly, unnatural causes of death. Other individuals who die from natural causes but because of age or circumstances are also included within the group of decedents of interest to society. The authority to autopsy without family consent is given by state statute to the medical examiner or coroner to investigate these deaths.The medical examiner or coroner system functions to safe guard public health. Forensic examinations, aside from determining the cause of death, provide other functions, including: identification of the body; obtaining evidence and toxicological specimens from the body; documentation of disease states; documentation and evaluation of injury patterns, significance and mechanisms; protection of personal property; identification of unsafe practices, conditions and lifestyles; and provision of information regarding forensic issues such as time of death. The forensic autopsy is also performed to establish the manner of death that requires consideration of accessory information from death scene investigation, agency records and reports, and medical records. The manner of death describes how the cause of death came about and includes homicide, suicide, accident, natural or undetermined. Establishing the manner of death requires consideration of the circumstances surrounding the death. Of cases investigated by some type of examination of the body by the St. Louis County Medical Examiners Office in 2005, 26% were natural, 7% were homicide, 22% suicide, 39% accidents and 6% were undetermined (St. Louis County Health Department Annual Report; St. Louis, MO, 2005) In addition to those cases in which bodies were actually examined by a forensic pathologist, many other deaths were reviewed by inspection of medical records to establish the cause and manner of deaths for the purpose of death certification. Of these cases about 91% were natural deaths in the St. Louis County Medical Examiner’s Office. Forensic autopsies are directed toward the mission of the medical examiner or coroner system to provide the cause and manner of deaths as well as to carry out the related forensic functions noted earlier. The forensic pathologist may not be particularly interested in strictly medical issues of the deceased, and these medical issues may not be as fully investigated as would be done in a hospital autopsy. This is not to imply that the forensic pathologist does not appreciate the value of those medical issues, it is just that the law under which the forensic pathologist functions does not specify that purpose. Because the forensic autopsy is authorized by a legal statute for particular purposes, some other purposes may not be fully considered. There is no obligation for the forensic pathologist to investigate medical issues of interest to others or—in most states—to provide tissues or material for research purposes. It is not permissible in fact for autopsies authorized by medical examiner or coroner statues to provide research tissues, unless such permission is specifically granted by the next of kin. The forensic pathologist may utilize a number of consultants to assist his investigations including forensic anthropologists, entomologists, toxicologists, odontologists and a variety of medical specialties including neuropathologists, cardiac pathologists, radiologists, pediatricians and psychiatrists. Forensic examinations provide a wealth of cases that are not available to hospital-based practices. However, the legal requirements that apply to the medical examiner or coroner concerning how tissues and bodies may be used also apply to these consultants. For the consultant neuropathologist, the opportunity to examine a wide variety of forensic materials is truly an educational experience. The purpose of those examinations remains to determine the cause and manner of death, and does not extend to other uses unless so granted by next of kin. A number of lawsuits have recently been initiated over such practices, as sending brains to a University center for neuropathologic examination and not informing the family that the brain was not buried with the body. Currently, medical examiners are behaving with caution in trying to utilize the consultants they need for their cases without becoming involved in litigation by families. Brain Pathology ISSN 1015-6305

Laceration of the stomach by blunt trauma in a child: a case of child abuse.

A case of perforation of the stomach following blunt abdominal trauma is described in a two-year-old boy. The abdominal trauma was the result of a blow to the abdomen by the stepfather. The child had ingested a large meal in the hour preceding the injury. The child died from peritonitis and shock 12 h following the injury. The literature on gastric perforation by blunt trauma is reviewed. Injuries to the stomach from nonpenetrating trauma are quite rare and are most often related to vehicular accidents. Gastric injury in a child presenting with a history of a minor home or play injury should arouse suspicion of more significant and perhaps intentional trauma.

Type II Arnold-Chiari Malformation with Normal Spine in Trisomy 18

SummaryA variety of anomalies of the central nervous system are observed in trisomy 18. The present case describes an infant having a type II Arnold-Chiari malformation without spina bifida. One previous case of an Arnold-Chiari malformation was reported in trisomy 18 but that infant also had a lumbar meningomyelocoele. Abnormalities of cerebral gyration, hydrocephalus, and agenesis of the corpus callosum were also found in the present case.

Homicide by Intravenous Injection of Naphtha

A case of homicide by the intravenous injection of Energine, a petroleum distillate spot remover, is presented. This case is the only known homicide committed with naphtha. This elderly man had severe natural disease in addition to chest trauma sustained in the assault leading to death; however, the rapid injection of approximately 25 mL of Energine was the overwhelming cause of death.

Fatal intoxication due to tranylcypromine.

Tranylcypromine (trans-DL-2-phenylcyclopropylaminc) is a potent inhibitor of monoamine oxidase recommended for the treatment of severe reactive or endogenous depression in hospitalized or closely supervised patients. The drug is capable of producing numerous serious side effects, particularly hypertensive crises. Several fatalities have been reported due to the use of tranylcypromine, alone or in combination with other drugs (Babiak. 1961; Bacon, 1962; Bell and Scaff, 1963; MacCaig and Edmondson, 1969; Mawdsley, 1968). However, in only a few instances has post-mortem toxicological analysis been performed (Basalt et al., 1977; Cuthill et al., 1964; Griffiths, 1973). This communication concerns a fatal intoxication due to tranylcypromine. The results of toxicological analysis are presented and discussed in relation to previously reported tranylcypromine deaths.

Traumatic Aneurysm of Vertebral Artery: A Case Report and Review of the Literature

A 64-year-old woman with a long-stand ing deformity of the neck presented with a rapidly enlarging neck mass following sud den turning of the head. Cervical radio graphs demonstrated a large erosion of the posterior elements of the cervical vertebra at the site of the deformity, and angiography revealed an aneurysmal sac of the left verte bral artery. The differential diagnoses of en larging neck masses associated with these ra diographic findings are discussed.