Tödliche stumpfe Schädel-Hirn-Traumen

The results of forensic neuropathologic (macroscopic) examinations of formalin-fixed brains in 676 cases of fatal blunt head injuries concerning involvement of the centro-axial/periventricular internal structures were analyzed. The causes of injuries were predominantly falls at ground level (n=195), traffic accidents (n=86), falling down stairs (n=61) and from a height (n=47), complex traffic accidents (n=65) and passengers (59). The most frequent main intracranial injuries were contrecoup lesions without (n=157) and with significant subdural hemorrhaging (n=122), followed by pure subdural hematomas (n=91) and diffuse injuries (n=66). Lesions characterized as inner cerebral trauma were present in 91 victims (13.5%), seldom in ground level falls (<10%) and frequent (23–30%) in traffic accidents. In frontal/frontolateral impacts the rate (20.4%) was twice as high as in occipital trauma. Massive ventricular bleeding was related to such injuries in only 5 cases in which other life-threatening intracranial injuries were also present. Summarizing the experiences, inner cerebral trauma was relatively frequent as a component of fatal head injuries, not as the decisive lesion but as a secondary finding. Only 3 cases of pure inner cerebral trauma (2 by bodily harm and 1 traffic accident) were observed in which a difficult differentiation from a spontaneous event was necessary.     

Medicolegal evaluation of vascular injuries of limbs in Turkey

This study evaluated 372 cases of post-traumatic extremity vessel lesions, for which the Forensic Medicine Council, Istanbul, Turkey prepared medicolegal evaluation reports between 1998 and 2000. The study group (n = 372) comprised of 346 men (93.0%) and 26 women (6.9%), and their ages ranged between 6 and 73 years (30.18 +/- 6.13). There were 378 artery (74.5%), and 131 vein injuries (25.5%) out of a total of 509 limb vascular injuries. The most frequently injured arteries and veins were the femoral artery (n = 73), and the deep femoral vein (n = 41), respectively. The causes of injuries were as follows: cutting and stabbing complements, in 160 cases (43.0%); gunshots in 136 cases (36.6%); traffic accidents in 52 cases (14%); work accidents in 23 cases (6.2%); and blunt trauma in one case (0.3%). These injuries were accompanied by local nerve lesions (27.1%), local bone lesions (37.1%), and injuries to other organs (11.0%). The medicolegal assessments by the Forensic Medicine Council showed that there were risk of death in 371 cases. Additionally, there was 'organ dysfunction' in 37 (9.9%) and 'organ loss' in 53 (14.2%) cases. The results of this study suggested that the main causes of severe vascular injuries (i.e. those accompanied by bone and nerve lesions) had serious consequences such as amputation, permanent disorders or loss of function and were caused by gunshot and traffic accidents.     

Postmortem computed tomography findings as evidence of traffic accident-related fatal injury

PURPOSE: Most traumatic deaths in Japan are due to nonpenetrating injuries, especially those that result from traffic accidents; however, the autopsy rate of traffic accident-related deaths is only about 5%. We investigated the diagnostic ability of postmortem computed tomography (PMCT) in cases of fatal trauma after traffic accidents. MATERIALS AND METHODS: Our subjects were 78 subjects (59 males, 19 females; mean age 50 years, range 15-87 years) who were brought to our institution in cardiopulmonary arrest on arrival after traffic accidents and died despite resuscitation attempts. PMCT findings of damage to the head, neck, thorax, abdomen, and pelvis were classified into three grades according to the Abbreviated Injury Scale (AIS) severity: A: 1 (minor), 2 (moderate); B: 3 (serious), 4 (severe), 5 (critical); C: 6 (maximum). RESULTS: The percentage ratio of A/B/C in 78 head injuries was 32/60/8, in 41 neck injuries 83/5/12, in 76 thorax injuries 5/38/57, in 76 abdominal injuries 70/24/7, and in 76 pelvic injuries 79/21/0, respectively. CONCLUSION: PMCT can detect or presume fatal trauma when diagnosing the cause of death after traffic accidents.     

Frequency,types and causes of intraventricular haemorrhage in lethal blunt head injuries

Autopsy findings and neuropathological examination of formalin-fixed brains in 676 deaths due to blunt head injury, here with special attention to injuries of the inner (periventricular) cerebral structures and haemorrhages into the ventricles.Intraventricular haemorrhage of any degree was present in 17.6%, considering only distinct and massive haemorrhage in 10% of all cases. Considering the types of trauma, the frequency was lowest in ground level falls and highest in traffic accidents (pedestrians with head contact to the car) – indicating a relation between the severity of impacts and the likelihood of ventricular haemorrhage. They predominantly resulted from periventricular injuries (27%) or retrograde expansions of infratentorial lesion with subarachnoid bleeding (19%), from massive contrecoup lesions (14%) or deep intracerebral ruptures (13%). In cases with predominant lesions of the cerebral surface the rate was lower than in those with more diffuse or internal damages.Injuries of the internal cerebral regions (away from cortex and subcortical white matter) were classified into those directly affecting the periventricular structures (9.1–13.5%; half of them affecting corpus callosum and/or fornix) and lesions of deep white matter or basal ganglia not adjoining the ventricular walls (4.0–5.9%). Intraventricular haemorrhage as well as injuries of the inner cerebral structures mostly are one element of a complex and severe blunt head injury. Solitary lesions – without other intracranial findings clearly indicating a trauma and therefore cases producing difficulties in forensic classification (spontaneous? traumatic?) – are rarities according to literature as well as our experiences.     

Traumatic axonal injury revealed by postmortem magnetic resonance imaging: A case report

In forensic investigations, it is important to detect traumatic axonal injuries (TAIs) to reveal head trauma that might otherwise remain occult. These lesions are subtle and frequently ambiguous on macroscopic evaluations. We present a case of TAI revealed by pre-autopsy postmortem magnetic resonance imaging (PMMR).A man in his sixties was rendered unconscious in a motor vehicle accident. CT scans revealed traumatic mild subarachnoid hemorrhage. Two weeks after the accident he regained consciousness, but displayed an altered mental state. Seven weeks after the accident, he suddenly died in hospital. Postmortem computed tomography (PMCT) and PMMR were followed by a forensic autopsy.PMMR showed low-intensity lesions in parasagittal white matter, deep white matter, and corpus callosum on three-dimensional gradient-echo T1-weighted imaging (3D-GRE T1WI). In some of these lesions, T21-weighted imaging also showed low-intensity foci suggesting hemorrhagic axonal injury. The lesions were difficult to find on PMCT and macroscopic evaluation, but were visible on antemortem MRI and confirmed as TAIs on histopathology.From this case, it can be said that PMMR can detect subtle TAIs missed by PMCT and macroscopic evaluation. Hence, pre-autopsy PMMR scanning could be useful for identifying TAIs during forensic investigations.     

爆胎与高速公路交通事故的相关性分析

目的探讨爆胎与高速公路交通事故的相关性。方法对1998—2000年3年间广州-深圳高速公路(以下简称广深高速公路)爆胎交通事故进行回顾性分析。结果1998—2000年3年间广深高速公路共发生交通事故2484起，其中848起交通事故出现爆胎，发生率为34．14％(848／2484)。时间因素以10：00～16：00为高发段，占55．54％(471／848)，其中14：00最高，占9．67％(82／848)；每年4～9月份为高发期，占56．84％(482／848)。爆胎部位以单个右后胎高发，共398起，占46．93％(398／848)；左后胎次之，共295起，占34．79％(295／848)。848起爆胎事故中，死亡12例，受伤200例，占同期2484起事故总伤亡人数的22．55％(212／940)。其中颅脑损伤58例，胸部损伤32例，腹部损伤7例，脊柱损伤25例，骨盆损伤4例，四肢损伤52例，全身软组织挫伤127例；多发伤106例。结论爆胎是南方高速公路交通事故的重要因素，防止超速驾驶、加强轮胎质检和规范化管理是减少高速公路交通事故的有效措施。     

Cardiac injuries in aircraft occupants resulting from aircraft accidents.

The author reports that relatively frequent injuries to the thorax and to the heart are established in autopsies of aircraft fatalities. A review of 128 autopsy protocols of aircraft accident fatalities revealed 111 cases of severe contact injuries to the thorax and 98 cases of traumatic injuries to the pericardium and the heart. Accepting the fact that persons injured if traffic accidents display cardiac injuries in 25% of the cases, the number of traumatic heart lesions inflicted in persons in aircarft accidents is three times as high, a fact which may be attributed to the far higher speeds of the aircraft at the moment of impact with resultant forces of deceleration. Causes and mechanisms of the development of cardiac lesions as well as necessary recommendations for the improvement of the health protection of aircraft occupants are discussed.     

Dilemmas concerning the diffuse axonal injury as a clinicopathological entity in forensic medical practice

Dilemmas and discussions concerning the diffuse axonal injury (DAI) and still existing in forensic medical practice are as it follows: 1. Whether the occurrence of DAI can indicate the type of traumatic event that has caused the head trauma, 2. Whether the presence of axonal damage in cases of hypoxia, ischaemia and other pathological conditions casts a shadow on the post-mortem pathological diagnosis of DAI and totally negates it, or there are certain clues in the findings that can point to the aetiology of the axonal damage. This paper discusses our findings based on neuropathological examination of 60 forensic cases of closed head injury. The neuropathological examination included: a macroscopic examination of the coronal sections and a microscopic examination involving an immunohistochemical method with antibody against β-amyloid precursor protein. Our findings indicate that DAI, as a clinicopathological entity, is undoubtedly an acceleration-deceleration injury, predominant in road traffic accidents as it is classically outlined, and cases of falling from a considerable height. Our findings point to a certain difference between the features of traumatic and ischaemic axonal damage. In this paper we also investigate the correlation between pathological grades of DAI and the impairment of the brain function before death.     

Lethal rupture of post-traumatic aneurysm of the vertebral artery case report

Traumatic aneurysms or dissections of the vertebral artery have been reported in patients who have suffered minor craniofacial injuries in traffic accidents.A case is reported of ruptured traumatic vertebral artery aneurysm due to closed head injury without without penetrating injuries or skull fractures.The macroscopic and histological findings relevant to the vertebral wall were compatible with post-traumatic aneurysm; the rupture of the wall was assumed to be caused by sepsis and local infiltration of inflammatory cells.     

The occurrence of acute subdural haematoma and diffuse axonal injury as two typical acceleration injuries

Closed head injuries have already been classified into contact injuries and acceleration–deceleration injuries. Two typical acceleration–deceleration injuries and at the same time, the two worst head injuries are acute subdural haematoma (ASDH) and diffuse axonal injury (DAI), and that is where they got their medico-legal importance. Using experiments, it has been shown that acceleration with an impact time of more than 20–25 min (which occurs in traffic accidents in real life) causes DAI, whereas an impact time of 5–10 min is more likely to produce acute subdural haematoma. The aim of this research is to show that not all, but some types of traffic accidents are more typical for the occurrence of DAI, as well as that the ASDH is not a common feature for all types of fall. The analysis conveyed covered 80 cases of closed head injuries (traffic accidents, falls and assaults) where a complete forensic medical autopsy has been undertaken, followed by a complete forensic–neuropathological examination. For the purpose of diagnosing DAI, immunohistochemistry using antibody against β-amyloid precursor protein has been involved. Results show that ASDH is more likely to occur in cases of simple fall, assaults and cyclists and DAI is more typical for vehicular traffic accidents and cases of falling from a considerable height. The paper also comprises discussion about some open questions regarding the diagnosis of DAI in the medico-legal practice.     

Forensic mental health evaluations of military personnel with traumatic life event,in a university hospital in Ankara,Turkey

IntroductionThe definition of psychological trauma has been rephrased with the DSM-5. From now on, witnessing someone else's traumatic event is also accepted as a traumatic life event. Therefore, the psychiatric examination of forensic cases gains importance for not overlooking a psychiatric trauma. This research aims to discuss the psychiatric examinations of military personnel who had a traumatic life event and to reveal psychiatric states of soldiers after trauma.Materials and methodsThe forensic reports prepared at Gulhane Military Medical Academy (GMMA), Forensic Medicine polyclinic between January 1, 2011 and November 30, 2014 were examined, and among them the cases sent to GMMA Psychiatry polyclinic for psychiatric examination were analyzed retrospectively.ResultsThere were a total of 2408 cases who applied for the arrangement of a judicial report and 167 of them required a psychological examination. Among 167 cases, 165 were male and 2 were female, and the mean age was 25.6 years. Anxiety disorder (53.9%) was the most common diagnosis as a result of the psychiatric examination, following posttraumatic stress disorder (PTSD) (18.6%), and 3.6% had no psychopathology. It was determined that injuries caused by firearms (38.3%) and explosive materials (26.3%) had caused psychological trauma the most. On the other hand, 11 (6.6%) cases were determined to have undergone a psychological trauma on account of being a witness to their friends' injuries during the conflict without experiencing any physical injury. There were not any statistically significant relationships between the severity of physical injury and being PTSD or anxiety disorder.DiscussionDevelopment of PTSD risk is directly correlated with the nature of trauma. The trauma types of the cases in our study were in the high-risk group because of the military population. Our study is of importance in terms of putting forward the psychiatric disorders seen in the military population with traumatic life history associated with war (combat-related). In this research, 26.1% of the cases followed up due to combat-related trauma were diagnosed with PTSD. Interestingly, this ratio was lower than the studies that have larger case numbers. There is still the need to conduct studies that will involve larger participants.     

Renal immunohistochemical investigation for the differentiation of the cause of multiple trauma fatalities

In fatalities with multiple traumatic injuries, it is important to determine the severity of trauma, the main damaged organ, and the antemortem pathophysiological condition. We examined 63 cases within 48 h of the postmortem interval, which included assaults, slips and falls and falls from heights, traffic accidents, and sharp instrumental injuries. Immunohistochemically, each kidney was stained against hemoglobin (Hb), myoglobin (Mb), superoxide dismutase (SOD), 8-hydroxy-2'-deoxyguanosine (8-OHdG), 150 kDa oxygen regulated protein (ORP150), pulmonary surfactant A (SP-A), and liver-type fatty acid binding protein (L-FABP). Bleeding or circulatory failure induced ORP150, 8-OHdG, and L-FABP in the kidney. Statistical analysis of the immunoreactivity revealed that in battered and/or abused cases, Hb could be considered a specific marker. Hb and Mb were observed in the cases with general severe trauma, such as slips and falls and falls from heights. In traffic accidents, ORP150 could reflect general circulatory failure with bleeding. SP-A was observed in the cases with severe thoracic injuries, such as lung injuries and multiple thoracic fractures. L-FABP appeared in cases with renal circulatory failure as well as renal injury. These findings suggest that immunohistochemical observation of the kidneys could be a useful tool in determining several key factors, such as the severity of injury, the specific damaged organ, and the pathological condition after injury.     

Intracartilaginous haemorrhagic lesions in strangulation?

This case control study was designed to investigate if laryngeal haemorrhages occur in cases of strangulation and whether these lesions are specific to strangulation. In the study 30 larynges from victims of fatal strangulation were examined (7 cases of manual strangulation, 12 cases of ligature strangulation, 11 cases of combined manual and ligature strangulation). The control group comprised 40 cases of death without any neck injuries and another group consisted of 5 cases of death caused by trauma with findings of non-strangulation neck injuries. In all the groups, only four solitary haemorrhages (two cases, one control, one non-strangulation neck injury) were observed that did not occur in the proximity of areas of blood accumulation. The results of our investigation suggest that histological evidence of blood accumulation or of haemorrhages in thyroid cartilage is not a reliable criterion to distinguish between haemorrhagic lesions due to strangulation and other types of blood accumulation or artefacts.     

Urinary phenylacetylglutamine as a possible biomarker for central nervous system disorders in forensic autopsy cases

Phenylacetylglutamine (PAG) is a metabolite that is excreted in human urine. Phenylalanine is metabolized to phenylacetic acid, which is then amide-bonded to glutamine to form PAG. We are currently studying PAG as a urinary biomarker in forensic autopsy cases.Materials and MethodsUrine samples were collected from 188 forensic autopsy cases and the urinary PAG concentration was analyzed quantitatively using GC-MS. Urinary creatinine (Cr) concentration was also analyzed by GC-MS. For statistical analysis, the JMP Pro 15.0.0 software program was used. The relationship between urine PAG/Cr (the ratio of each concentration), sex, age, postmortem interval (PMI), survival duration, and cause of death was statistically analyzed.Results and DiscussionThe median (range) of PAG/Cr was 0.12 (0.002-3.26). The PAG/Cr ratio showed no significant relationship to sex or survival duration. Regarding the cause of death, traumatic brain injuries had a significantly higher ratio than intoxication (p=0.023). Cerebrovascular disease, such as cerebral hemorrhage and subarachnoid hemorrhage, did not differ significantly from any cause of death group. However, when traumatic brain injuries and cerebrovascular accidents are combined as one cause of death group, the PAG/Cr value of CNS damages was significantly higher than that of intoxication (p=0.062).ConclusionUrinary PAG/Cr might be a biomarker not only for traumatic brain injuries but also for antemortem CNS damages.     

不同等级医院交通事故伤伤员分布特征与结局的比较研究

目的：比较不同医院的车祸伤员分布特点和伤情、抢救水平和疗效．方法：临床流行病学调查与创伤评分相结合，抽取车祸重伤员１９１５例，按医院等级分组，进行创伤评分和统计处理．结果：（１）伤员分布：大医院的伤员解剖损伤和生理紊乱重而生存概率低，二三级医院平均ＩＳＳ＞１６．（２）转诊的影响：重伤员向上级医院转运使院前时间延长５～９小时．（３）死亡因素分析：①评分值：生理评分ＲＴＳ与死亡概率Ｐｓ密切相关；解剖评分ＩＳＳ／ＡＰ与死亡概率Ｐｓ中度相关，ｍａｘＡＩＳ＝５组和院前时间＜６小时组死亡率明显升高．②并发症：死亡组并发症率显著高于生存组．③医院等级：大医院死亡率高于基层医院，但非预期死亡率较低，平均住院日较短．结论：上述结果能反映车祸伤员在各级医院的分布特点．     

Traumatic lesions of adrenal glands in paediatrics: about three cases

Pediatric adrenal injuries, in blunt thoracoabdominal trauma, are rare and usually associated with traumatic liver and kidney lesions. This paper aims to present imaging findings and possible adrenal involvement in blunt abdominal traumas in childhood. We report three cases of thoracoabdominal trauma with adrenal involvement. Two patients were polytraumatised in car accidents. The third case was unusual because of the mild trauma. The adrenals lesions were right-sided in all cases. Post-traumatic adrenal contusion/haematoma may arise not only because of a direct trauma but also as a consequence of a sudden increase in the pressure in the inferior vena cava system-adrenal veins. This is why adrenal haemorrhage is not directly proportional to the trauma: compression of the inferior vena cava leads to increased pressure in the adrenal venous circulation, which supports the parenchymal lesion. The right adrenal gland is more frequently injured than the left gland: it can be easily compressed between the liver, spine and kidney, and its venous drainage flows directly into the inferior vena cava.     

The injury pattern to children involved in lethal traffic accidents in Berlin

A statistical investigation of causes of death of children in Berlin, as well as in the rest of Germany shows, that 'accidents' are the most frequent causes of death in children. Nearly 50% of all child fatalities (0-15 years old) are due to traffic accidents. The reports of 30 children (19 boys, 11 girls) that were investigated in one of the three Institutes of Legal Medicine in Berlin over a period of 5 years were studied. In nearly 40% of all cases the children were pedestrians, in ten cases they died as passengers in cars, five children were bicyclists and in one case the child was a skateboarder. In 60% of all cases the principal injuries were severe injuries of the skull and brain; skull and brain trauma was the most frequent cause of death. In the group pedestrians (n=11), the cause of death in ten cases was the severe head-injury. Over 60% of all injured children died at the scene or in the first 24h after the accident, none of the children survived more than 30 days.     

Forensic pathological evaluation of injury severity and fatal outcome in traffic accidents: five illustrative autopsy cases of clinically unexpected death

In forensic casework, investigation of injury severity in traffic accidents is important for evaluating the mortality, occasionally in terms of the adequacy of clinical management. The present study evaluated 5 cases of clinically unexpected delayed collapse followed by death using the abbreviated injury scale (AIS), injury severity score (ISS), and a clinical trauma care method (trauma and injury severity score, TRISS). In these cases, major injury (AIS = 3–5) was found in the head, chest and/or abdomen at autopsy, and ISS was estimated to be 11–45 (serious to critical but not incompatible with life). By the TRISS method, the probability of survival (P _s) was estimated to be >0.5 for all cases (0.60–0.99), suggesting that these were preventable deaths. However, the present cases showed several common features: (a) fatality due to closed injury/-ies to the thoracic and/or abdominal viscera, (b) alert and poor symptoms/clinical signs, and (c) poor positive findings in diagnostic imaging at early times after injury, and (d) complications of other evident injuries, suggesting difficulties in the clinical diagnosis of potentially fatal injuries, but (e) possibly predictable fatal injury when typical patterns of traffic accident injury were considered.     

Postmortem Multislice Computed Tomography and Magnetic Resonance Imaging of odontoid fractures,atlantoaxial distractions and ascending medullary edema

Non-invasive imaging methods are increasingly entering the field of forensic medicine. Facing the intricacies of classical neck dissection techniques, postmortem imaging might provide new diagnostic possibilities which could also improve forensic reconstruction. The aim of this study was to determine the value of postmortem neck imaging in comparison to forensic autopsy regarding the evaluation of the cause of death and the analysis of biomechanical aspects of neck trauma. For this purpose, 5 deceased persons (1 female and 4 male, mean age 49.8 years, range 20–80 years) who had suffered odontoid fractures or atlantoaxial distractions with or without medullary injuries, were studied using multislice computed tomography (MSCT), magnetic resonance imaging (MRI) and subsequent forensic autopsy. Evaluation of the findings was performed by radiologists, forensic pathologists and neuropathologists. The cause of death could be established radiologically in three of the five cases. MRI data were insufficient due to metal artefacts in one case, and in another, ascending medullary edema as the cause of delayed death was only detected by histological analysis. Regarding forensic reconstruction, the imaging methods were superior to autopsy neck exploration in all cases due to the post-processing possibilities of viewing the imaging data. In living patients who suffer medullary injury, follow-up MRI should be considered to exclude ascending medullary edema.     

Fatal delayed hemopericardium and hemothorax following blunt chest trauma

Cardiac injury following blunt chest trauma is common in motor vehicle accidents due to a crush or blast injury. Severe cardiac trauma is associated with a very high mortality. If a cardiac injury develops several weeks after non-penetrating chest trauma, establishing a causal link between the traumatic event and the cardiac injury becomes complicated. This article reports a case of fatal delayed hemopericardium and hemothorax following a motor vehicle accident including blunt chest trauma 34 days prior to death. The cardiac injury was caused by displacement of a sharp irregular fragment of one of the decedents fractured ribs and the primary defect was sealed by blood clots. Subsequent bleeding occurred when the thrombus was displaced. Since the incidence of blunt high-energy chest injuries is relatively high, heart and large vessel injuries must be taken into account and a comprehensive examination needs to be done in order to prevent the delayed development of fatal complications.