Korean J Leg Med.  2019 Feb;43(1):23-27. 10.7580/kjlm.2019.43.1.23.

Traumatic Rupture of the Middle Cerebral Artery Followed by Acute Basal Subarachnoid Hemorrhage: Tailored Approach in Forensic Pathology by Aid of Post-mortem Angiographic Findings

• Park S
• Lee S
• Yang KM
• Kim D
• Lee H
• Cha JG

• KMID: 2440395
• DOI: http://doi.org/10.7580/kjlm.2019.43.1.23

Abstract

We present the case of a 23-year-old man who suddenly collapsed during a physical altercation with his friends while in a drunken state. The post-mortem computed tomography (CT) with angiography revealed acute basal subarachnoid hemorrhage with rupture of the left middle cerebral artery. On autopsy, the head, face, mandible and neck showed multifocal hemorrhages with fracture of the hyoid bone, and the pathologic findings of the brain was consistent with CT findings. However, the vascular rupture site was not observed macroscopically. On histologic examination, a microscopic focal rupture was identified at the proximal portion of the middle cerebral artery, and possibility of arteriopathy was considered. This case illustrates that other parts of intracerebral arteries (other than the vertebral arteries) can be the culprit of rupture in the case of traumatic basal subarachnoid hemorrhage, and the post-mortem angiographic findings can be helpful in targeting the site of vascular injury. Furthermore, meticulous sampling of intracranial vessels could help find the vascular rupture site and identify any histologic findings suspicious of arteriopathy. Therefore, we suggest that post-mortem angiography can be an effective and adjunctive tool for a tailored approach in finding the vascular injury, and that histologic examination of both the intracranial and extracranial arteries be important to medicolegally ensure the death of traumatic basal subarachnoid hemorrhage and to examine presence of arteriopathy as a predisposing factor.

Keyword

Forensic pathology; Autopsy; Postmortem; Traumatic subarachnoid hemorrhage; Computed tomography angiography

MeSH Terms

Angiography
Arteries
Autopsy
Brain
Causality
Forensic Pathology*
Friends
Head
Hemorrhage
Humans
Hyoid Bone
Mandible
Middle Cerebral Artery*
Neck
Rupture*
Subarachnoid Hemorrhage*
Subarachnoid Hemorrhage, Traumatic
Vascular System Injuries
Young Adult

Figure

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  Fig. 1. The postmortem computed tomography angiography revealed focal contrast extravasation from proximal segment of left middle cerebral artery suggestive of vascular rupture.

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  Fig. 2. Multiple contusions were observed on the head and neck.

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  Fig. 3. Acute basal subarachnoid hemorrhage was observed at the base of the brain.

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  Fig. 4. The rupture site was not visible on gross examination. The arrow indicates the proximal segment of left middle left middle cerebral artery where postmortem computed tomography angiography demonstrated the profuse contrast leakage.

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  Fig. 5. A microscopic focal rupture was observed with thrombus (arrow). Adjacent wall revealed fibromuscular disorganization with focal mediolysis (asterisk), suspicious of angiopathy (H&E, ×40).

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