Vivian S. Snyder

Utilitarian Aspects of Postmortem Computed Tomography

Computed tomography has been used in clinical medicine for decades, but only recently introduced into the forensic pathology setting. The reasons for the slow adoption of this technology into the autopsy suite are various, including concerns about funding, infrastructural maintenance, training, competency, and scope of utilization. Practical experience in a busy statewide medical examiner department confirmed the utility of this technology as a part of daily practice. The impact of postmortem computed tomography (PMCT) on casework can be stratified into three broad groups: where PMCT 1) supplants invasive autopsy, 2) supplements invasive autopsy, or 3) has limited or no potential for impact on practice. A detailed understanding of the practical uses of this science is important for the practicing forensic pathologist so as to guide decisions about the ways in which PMCT can be implemented within their own institutions and utilized on a daily basis. Dramatic changes in personal and institutional practice trends can be observed once forensic pathologists are comfortable with the evaluation, documentation, and interpretation of PMCT data. Examples of potential paradigm shifts include the performance of only external examination and PMCT instead of invasive autopsy in many cases of motor vehicle fatalities, suicide with violence, and broad categories of death due to natural disease. Over time, the authors believe that the PMCT will become one of the fundamental tools in the forensic pathologists toolkit.

Intraoperative Magnetic Resonance Imaging–Guided Biopsy in the Diagnosis of Suprasellar Langerhans Cell Histiocytosis

BACKGROUND Magnetic resonance imaging (MRI)-guided biopsy is an emerging diagnostic technique that holds great promise for otherwise difficult to access neuroanatomy. CASE DESCRIPTION Here we describe MRI-guided biopsy of a suprasellar lesion located posterior and superior to the pituitary stalk. The approach was implemented successfully in a 38-year-old woman who had developed progressive visual deterioration. CONCLUSION Intraoperative MRI revealed the need for trajectory adjustment due to an unintended, minor deviation in the burr hole entry point, demonstrating the benefit of an MRI-guided approach. Langerhans cell histiocytosis was diagnosed after biopsy, and the lesion regressed after cladribine treatment. Technical nuances of the case are reviewed in the context of the available literature.

Ruptured Dural Arteriovenous Fistula/Malformation

When “common things are common,” the discovery of a subdural hemorrhage in an adult is most likely to be due to trauma. When the subdural hemorrhage is associated with an intraparenchymal hematoma, statistically speaking, the subdural hemorrhage is likely the result of a hypertensive hemorrhage that has ruptured into the subdural space or trauma that resulted from a collapse to the ground following hypertensive intra-axial bleeding. However, “common things” do not always explain the source of a subdural hemorrhage or intraparenchymal hematoma. In this case, an adult woman presented to the hospital obtunded and was diagnosed with a subdural hemorrhage (with mass effect) and intraparenchymal hematoma as the result of a ruptured dural arteriovenous fistula/malformation. This case highlights an unusual source of intracranial bleeding that resulted in death.

Histologic Evidence for Arteriovenous Malformation-Like Vasculature Occurring within an Intracerebral Schwannoma: A Case Report and Review of the Literature

BACKGROUND The phenomenon of intracerebral schwannoma is exceedingly rare, and its etiology still a matter of debate. No documented cases of intracerebral schwannoma containing vascular elements consistent with those of an arteriovenous malformation (AVM) have been reported. We describe such a case here. CASE DESCRIPTION A left temporal intraparenchymal lesion was discovered incidentally in a 34-year-old man after he suffered a mild trauma. The lesion was resected and found on histologic examination to be an intracerebral schwannoma with AVM-like vasculature. The patient made a full recovery after resection. CONCLUSIONS To our knowledge, this is the first case of an intracerebral schwannoma with AVM-like characteristics to be reported in the literature. We hypothesize that the co-occurrence of this rare pathologic entity is caused by an interrelated etiologic process, with the tumor microenvironment of the schwannoma inciting the development of the vascular malformation.

Large benign de novo conjunctival hemangioma in an 11-year-old boy: case report and literature review

Benign hemangiomas are rare vascular tumors of the conjunctiva that typically present clinically in the first few weeks of life and resolve spontaneously. De novo presentation later in childhood has not been well documented. We present the unusual case of an 11-year-old boy with a rapidly growing benign de novo conjunctival hemangioma that was treated with surgical excision.

A Conceptual Overview of Axonopathy in Infants and Children with Allegedly Inflicted Head Trauma

Fatal, allegedly inflicted pediatric head trauma remains a controversial topic in forensic pathology. Recommendations for systematic neuropathologic evaluation of the brains of supposedly injured infants and children usually include the assessment of long white matter tracts in search of axonopathy — specifically, diffuse axonal injury. The ability to recognize, document, and interpret injuries to axons has significant academic and medicolegal implications. For example, more than two decades of inconsistent nosology have resulted in confusion about the definition of diffuse axonal injury between various medical disciplines including radiology, neurosurgery, pediatrics, neuropathology, and forensic pathology. Furthermore, in the pediatric setting, acceptance that “pure” shaking can cause axonal shearing in infants and young children is not widespread. Additionally, controversy abounds whether or not axonal trauma can be identified within regions of white matter ischemia — a debate with very significant implications. Immunohistochemistry is often used not only to document axonal injury, but also to estimate the time since injury. As a result, the estimated post-injury interval may then be used by law enforcement officers and prosecutors to narrow “exclusive opportunity” and thus, identify potential suspects. Fundamental to these highly complicated and controversial topics is a philosophical understanding of the diffuse axonal injury spectrum disorders.