Fatal subarachnoid haemorrhages in relation to minor injuries in Denmark from 1967 to 1981

doi:10.1016/0379-0738(84)90152-X

Forensic Science International

Volume 24, Issue 1, January 1984, Pages 57-63

https://doi.org/10.1016/0379-0738(84)90152-X Get rights and content

Abstract

Twenty cases of fatal subarachnoid haemorrhage after minor injuries are presented. Thirteen of the cases occurred during scuffles, four in traffic accidents and in the remaining three cases the traumatic source was not definitely elucidated. In the majority of cases the deceased was under the influence of alcohol when the haemorrhage occurred. In 10 cases (50%) the haemorrhage was due to a rupture of a normal vertebral artery and in eight cases (40%) a fracture of the transverse process of the atlas was demonstrated. It is underlined that especially injuries to the side of the upper cervical spine are particularly apt to cause these haemorrhages.

References (24)

S. Wilks
Sanguineous meningeal effusion
Gay's Hosp. Rep.
(1859)
Saathoff
Beitrag zur Pathologie der Arteria basilaris
Dtsch. Arch. klin. Med.
(1905)
P. Fraenckel
Tod in Boxkampf
Dtsch. Z. Ges. Gerichtl. Med.
(1922)
W. Munck
Den subarachnoidale Blødning og dens retsmedicinske Betydning
Hospitalstidende
(1926)
K. Sand
Den retsmedicinske bedømmelse af intracranielle blødninger hos voxne individer, som har vaeret udsat for stump vold, der har ramt hovedet
Ugeskr. Laeg.
(1926)
P. Fraenckel
Gedeckte traumatische Zerreissung der gesunden Arteria Basilaris
Dtsch. Z. Ges. Gerichtl. Med.
(1927)
K. Sand
Om små traumer som dødsårsag
Bibl. Laeger.
(1927)
K. Wolff
Traumatische Zerreissung der gesunden Arteria vertebralis an der Hirnbasis
Dtsch. Z Ges. Gerichtl. Med.
(1928)
F. Harbitz
Om Aneurysmer på Basis Cerebri
Norsk. Mag. Laegevidensk.
(1933)
E. Fritz
Abreissung einer Arteria Vertebralis von der Basilaris ohne Schädelverletzung
Beitr. Gerichtl. Med.
(1935)

H. Schmidt

Meningeale Apoplexie infolge traumatischer Zerreissung des Ramus communicans anterior, ohne Gefässerkrankung und ohne Knochenbruch

Beitr. Pathol. Anat.

(1942)

R. Ford

Basal subarachnoid hemorrhage and trauma

J. Forensic Sci.

(1956)

Cited by (38)

Post-traumatic aneurysmal rupture involving the circle of Willis affected by fibromuscular dysplasia. A case report and systematic review
2020, Legal Medicine
The fatal rupture of a saccular aneurysm at the junction between the left anterior cerebral artery and anterior communicating artery affected by fibromuscular dysplasia (FMD) is a rare condition. Here is reported the case of a subject involved in a road traffic accident a few minutes before the death, which opened the debate on the real cause of death in a forensic setting.
By autopsy, the examination of the brain revealed subarachnoid haemorrhage with flooding of the ventricles due to the breached saccular aneurysm of the junction between the left anterior cerebral artery and anterior communicating artery, in FMD mainly affecting the circle of Willis arteries. A spontaneous aneurysmal rupture was excluded on the basis of probabilistic analysis, in the presence of alternative hypotheses that could explain the facts. The passenger’s delayed loss of consciousness may be explained as much by a hypertension-linked rupture of the aneurysm triggered by the emotional stress experienced, as by the traumatic shaking/impact of the aneurysm against the bony skull structures, in a subject predisposed to aneurysm frailty due to FMD.
Overall, the concausal role of both the road traffic accident, typified by high kinetic energy, and the presence of a pre-existing aneurysmatic weakness due to FMD is fully recognized.
The identification of anatomical variants, jointly with uncommon diseases at the examination of the brain base arteries in any case of isolated basal subarachnoid haemorrhage, may avoid wrong legal consequences even when the cause of death seems to be obviously of simple traumatic origin.
Deaths: Trauma, Head and Spine - Pathology
2015, Encyclopedia of Forensic and Legal Medicine: Second Edition
This chapter summarizes the differences between impact and acceleration and ‘focal’ and ‘diffuse’ head and brain injuries. Two areas that give rise to conceptual difficulties are explored; traumatic’ axonal injury and its relationship to ‘diffuse’ axonal injury; the nature of traumatic spinal injuries. A series of forensic neuropathological ‘syndromes’ and their allied findings are provided as an aid to directing an autopsy in which neuropathological findings are expected.
The source of haemorrhage in traumatic basal subarachnoid haemorrhage
2015, Journal of Forensic and Legal Medicine
Citation Excerpt :
This notion has been described by others5,6 and relates directly to the method used in the examination of the head and neck. Some case reviews have revealed a preponderance of extracranial sites of injury, however these studies placed high levels of significance on upper cervical vertebral malformations and fractures as a mechanism of rupture and thus may have overlooked intracranial sites.1,2,11 At present the aetiology of TBSH is somewhat unclear.
Traumatic basal subarachnoid haemorrhage (TBSH) following trauma to the head, face or neck is well-established as a cause of death; however it remains a heavily disputed topic as the site of vascular injury is difficult to identify. Whilst many regions within the vasculature of the head and neck have been proposed as more susceptible to rupture, the vertebral artery remains the focal point of many investigations. We present a retrospective case review of TBSH in our forensic centre at Forensic and Scientific Services in Brisbane, Australia, from 2003 to 2011. Thirteen cases of TBSH were found, one case excluded due to vasculopathy. All decedents were male, the majority of which were involved in an altercation receiving blows to the head, face, or neck and were unconscious at the scene. All victims were under the influence of alcohol, drugs, or a combination thereof. External examination revealed injuries to the head, face, and neck in all cases. Various combinations of further examination techniques were used during the post-mortem examination including brain and/or cervical spine retention, CT imaging, and angiography. Vascular injury was identified in eight of the twelve cases, all of which occurred intracranially, with seven involving the vertebral artery. Histology was most reliable in identifying the rupture site and angiography failed to reveal a rupture site. The added benefits of histology over angiography are the ability to identify the microscopic architecture of the tear and to diagnose vasculopathy that may have rendered the individual more susceptible to TBSH.
Pathomorphological differentiation between traumatic rupture and nontraumatic arterial dissection of the intracranial vertebral artery
2014, Legal Medicine
Citation Excerpt :
Isolated traumatic subarachnoid hemorrhage (SAH) is a rare but serious outcome of head or neck injury [1–4].
We aimed to establish an objective indicator for differential diagnosis between traumatic rupture of the intracranial vertebral artery (TRIVA) and nontraumatic rupture from intracranial vertebral artery dissection (NIVAD). We investigated 19 intracranial vertebral artery (IVA) samples, including three from TRIVA, seven from NIVAD and nine non-IVA rupture cases using 0.2-mm serial histological sections through the IVA. The internal elastic lamina (IEL)–adventitia ratio for each slide was calculated as the ratio of the traced length of the adventitia to the length of the IEL as measured by digital photomicrography. NIVAD cases showed a significant peak in the IEL–adventitia ratio around the area of rupture, whereas TRIVA and non-rupture cases showed no specific increase or decrease in IEL–adventitia ratios throughout the IVAs. All NIVAD cases had a significantly higher average IEL–adventitia ratio across 10 slides at the site of the rupture lesion than at the site furthest from the rupture. In contrast, two out of three TRIVA cases showed no significant difference between the two points. The other TRIVA case showed a significantly lower IEL–adventitia ratio at the point nearest the rupture compared with that at the point farthest from the rupture. Other histological characteristics considered specific to either TRIVA or NIVAD were observed. Our results indicate that measuring and comparing IEL–adventitia ratios at ruptured and non-ruptured sites of the IVA could be a useful practical indicator for differential diagnosis between TRIVAs and NIVADs.
Traumatic dissection of the vertebral artery in a toddler following a short fall
2012, Forensic Science International
Citation Excerpt :
Several works have also shown that SAH has been caused by rupture of the vertebral artery in connection with fracture of the transverse process of the atlas [22–24]. Many of the subjects were under the influence of alcohol [10,16]. According to Deck and Jagadha alcohol contributes in this process by slowing the response of voluntary muscles [25] and, stated by a number of authors, causing vasodilatation of the vessels [5,23,26].
Spontaneous subarachnoid haemorrhage (SAH) in children is uncommon, but is sometimes seen after rupture of aneurysms, and in different disorders. Traumatic SAH is common after serious accidental head injury, but is also reported after child abuse with vigorous shaking. To avoid unnecessary accusations of innocent care givers, it is important not to misinterpret the findings as abusive head trauma in small children with SAH.
In the presented case, a nearly two-year-old girl was brought to the hospital after a fall witnessed by her father. The girl was unconscious, with elevated intracranial pressure, SAH and bilateral retinal haemorrhage (RH). She was pronounced dead after 9 h. Premortem angiography revealed a dissection of the right vertebral artery, and postmortem examination revealed a traumatic lesion deep in the neck, at the base of the skull. Cerebral edema, in combination with SAH and RH, is highly suggestive of abusive head trauma. However, no external lesions, no skeletal lesions, especially no long bone metaphyseal lesions, or subdural haematomas occurring at the same time as SAH, were found. There was no report of previous child abuse in the family. Based on the radiological and postmortem findings, we believe that an accidental fall caused a blunt force trauma with a subsequent dissection of the right vertebral artery.
To our knowledge, accidental tear of one of the vertebral arteries, leading to SAH in a toddler, has previously not been described. Child abuse is an important exclusion diagnosis with serious legal implications.
Cerebellar contusions as a possible cause of traumatic basal subarachnoid hemorrhage: A case report
2010, Legal Medicine
Citation Excerpt :
TBSAH is known as fatal massive SAH, originating from a vascular tear without cerebral injury, caused by hyperextension or rotation of the head due to apparently minor trauma to the head, face or neck [1–19]. The contribution of preexisting vascular pathology or anomaly of the cervical vertebrae to the vascular injury has been also suggested [10,20,21]. In the present case, however, no vascular lesion could be detected in the intra- and extracranial vertebro-basilar vessels, but hemorrhagic contusions at the base of the cerebellum were identified as the source of SAH.
Traumatic basal subarachnoid hemorrhage (TBSAH) is infrequent but of forensic neuropathological importance because of its high mortality and complex causal mechanisms. The source of the hemorrhage is most frequently identified in the vertebro-basilar arteries but often cannot be identified in these arteries. We present a case of TBSAH possibly originating from hemorrhagic cerebellar contusions due to fist blows to the neck. A 35-year-old woman, who was punched on the right side of the neck, became unconscious about 20 min later and died. Autopsy demonstrated a massive subarachnoid hemorrhage at the base of the brain, with blood clots attached to the right lower surface of the cerebellum. No tear was detected in the vertebro-basilar vessels, but there were hemorrhagic cerebellar contusions beneath the blood clots as a possible source of TBSAH. The site of impact to the neck suggested the cerebellar contusions to be a coup injury due to hard blows.

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Original paperFatal subarachnoid haemorrhages in relation to minor injuries in Denmark from 1967 to 1981

Abstract

Sanguineous meningeal effusion

Gay's Hosp. Rep.

Beitrag zur Pathologie der Arteria basilaris

Dtsch. Arch. klin. Med.

Tod in Boxkampf

Dtsch. Z. Ges. Gerichtl. Med.

Den subarachnoidale Blødning og dens retsmedicinske Betydning

Hospitalstidende

Den retsmedicinske bedømmelse af intracranielle blødninger hos voxne individer, som har vaeret udsat for stump vold, der har ramt hovedet

Ugeskr. Laeg.

Gedeckte traumatische Zerreissung der gesunden Arteria Basilaris

Dtsch. Z. Ges. Gerichtl. Med.

Om små traumer som dødsårsag

Bibl. Laeger.

Traumatische Zerreissung der gesunden Arteria vertebralis an der Hirnbasis

Dtsch. Z Ges. Gerichtl. Med.

Om Aneurysmer på Basis Cerebri

Norsk. Mag. Laegevidensk.

Abreissung einer Arteria Vertebralis von der Basilaris ohne Schädelverletzung

Beitr. Gerichtl. Med.

Meningeale Apoplexie infolge traumatischer Zerreissung des Ramus communicans anterior, ohne Gefässerkrankung und ohne Knochenbruch

Beitr. Pathol. Anat.

Basal subarachnoid hemorrhage and trauma

J. Forensic Sci.

Original paper
Fatal subarachnoid haemorrhages in relation to minor injuries in Denmark from 1967 to 1981