Academic Forensic Pathology

Increased age is a significant risk factor for the development of dementia, predominately Alzheimer disease (AD). Since the fastest growing population sector in the United States is individuals over the age of 85 years, a surge in cases of dementia is expected. The inherent features of dementia mean those affected will eventually be incapacitated and require a high level of medical care. The majority of individuals dying from the complications of dementia will be under the care of a physician. However, dementia is a significant morbidity and demented patients are at risk from dying of non-natural causes (e.g., neglect/abuse or accidental injury) that necessitates the medical examiner/coroner (ME/C) to determine if the individual was incapacitated by a neurodegenerative process. The definitive diagnosis of a specific type of dementia requires a postmortem neuropathological examination. This paper provides a concise description of and a practical neuropathological algorithmic approach to the diagnosis of the most common neurodegenerative diseases.

Epilepsy is a common neurological disorder characterized by an enduring predisposition to generate recurrent seizures. Pathologists may be called upon to evaluate brain tissue from patients with a history of seizures, and it is important to keep in mind the diversity of histopathologic findings associated with this disorder and the limitations imposed by both, limited sampling and neuroanatomy. Review of the literature has shown that the three most common clinicopathological entities in surgically resected medically refractory epilepsy are mesial temporal sclerosis (MTS), long-term epilepsy-associated tumors (LEAT), and malformations of cortical development (MCD) which includes focal cortical dysplasia (FCD). Here, we will review the most common clinicopathological entities seen in surgically resected cases of refractory epilepsy, such as MTS, MCD, LEAT, as well as vascular and encephalitic lesions. We will also touch upon traumatic brain injuries and SUDEP, and the role of the forensic pathologist. A better understanding of the etiopathology, recent classifications, and underlying molecular mechanisms involved in each entity will be helpful in order to identify the cause of death in patients with seizure disorders, candidates who will benefit from tailored surgical resection strategies, as well as to develop new and targeted drug treatment.

When approaching a case in which a decedent's body is on the ground, death investigators collect circumstantial, historical, and clinical (radiographic) information to infer whether the person fell to the ground and sustained a head injury or simply experienced a terminal collapse due to a natural event. We have observed that cases presenting as presumed accidental head trauma, some of which have diagnosed subdural hematomas, are sometimes proven to be of natural causes following autopsy. Autopsies sometimes demonstrate that either 1) the intracranial hemorrhage is intracerebral rather than subdural, 2) the subdural hemorrhage is an extension from an intracerebral hemorrhage, or 3) there is no intracranial hemorrhage at all. In each of these examples, the autopsy established that the manner of death is natural rather than accidental, as originally presumed at the outset of the investigation.

We performed a 5 year retrospective study on cases indicating intracranial hemorrhage in the cause of death statement in order to assess how often the cause and manner of death would have been incorrectly certified without an autopsy. We found that 6% of cases presumed at the time of initial investigation to represent falls with accidental head trauma (specifically, subdural hemorrhage) were proven by autopsy to represent intracranial hemorrhage of natural manner. Conversely, 7% of cases with intracranial hemorrhage that were presumed to be due to natural disease were proven by autopsy to represent accidental trauma.

Proper certification of manner of death has important legal implications which may be of critical importance to family members.

Subarachnoid hemorrhage (SAH) may occur with natural, accidental, homicidal, suicidal, and/or undetermined events. The forensic autopsy and death scene investigation are useful in reconstructing the mechanism of death, as well as the dynamics of the event. Therefore, an accurate forensic evaluation of SAH is crucial. The annual incidence of subarachnoid hemorrhage in the United States is estimated at 1 per 10,000 persons with a median age of 50 years, and a high mortality rate. SAH is the most common indicator of traumatic brain injury (TBI). The majority (80%) of nontraumatic SAH is due to a ruptured saccular aneurysm. Other causes of nontraumatic SAH include arteriovenous malformations, cavernous angiomas, mycotic aneurysms, neoplasms, blood dyscrasias, perimesencephalic hemorrhage and central venous thrombosis. Risk factors for nontraumatic SAH include cigarette smoking, hypertension, cocaine use, heavy alcohol use, and a first-degree relative with subarachnoid hemorrhage. The rate and amount of hemorrhage determine the morbidity and mortality of the lesion. Computed tomography (CT) is considered the study of choice for ante-mortem identification of SAH. In rare circumstances, however, a similar CT appearance may occur in the absence of blood in the subarachnoid space. Such “pseudo-subarachnoid hemorrhage” is confirmed when autopsy shows no subarachnoid hemorrhage in those carrying the premortem CT diagnosis. However, when true SAH is present, dating of the hemorrhage, by both gross and microscopic examination, may aid in the forensic evaluation.

The medicolegal autopsy is part of a death investigation that determines the cause and manner of death and the extent of the testing performed is variable and is directed by the specifics of a particular case. Published studies disagree on the value of routine examination of microscopic sections of internal organs in forensic cases and no studies have specifically reviewed the utility of routine neuropathology microscopic sections. We reviewed the Miami-Dade County Medical Examiner Department and Mayo Clinic computer databases to determine whether routine brain histology is of value in medicolegal autopsies and the impact on the cause and manner of death. Consecutive cases from each institution were analyzed to determine whether the microscopic neuropathological findings revealed a previously unrecognized disease, changed the cause or manner of death, or significantly impacted the death investigation. In the cases in which the immediate cause of death was attributable to central nervous system (CNS) pathology, the cause of death was readily apparent from the gross brain examination. If CNS pathology was the proximate cause of death, contributed significantly to the death, or was a significant part of the death investigation, full appreciation of the neuropathology required microscopic examination and often additional special/immunostains. We conclude that microscopic brain examination is needed in selected medicolegal autopsies to exclude and/or diagnose underlying disease processes, particularly if the gross examination doesn't reveal an obvious explanation of the CNS pathology or the clinical history suggests underlying neuropathology.

Cervical fracture may occur with a high force mechanism of injury such as a motor vehicle crash, or with a low force mechanism of injury such as a ground level fall. To better characterize and understand low force cervical fractures and their significance, case files from the Travis County Medical Examiner's office covering a 5-year time period were retrospectively reviewed for fatal cervical fracture occurring with an accidental ground level fall. Thirty such fatal cervical fractures were identified, all occurring in elderly individuals (>65 years of age), with odontoid type 2 fracture of the C2 vertebra identified as the most frequent type of fracture. Odontoid fracture should be included in the list of craniocervical injury that may result from not only motor vehicle crashes and other high force mechanisms of injury, but also low force mechanisms of injury such as a ground level fall with head impact in an elderly individual.

The report begins with the case of an 18-year-old male who presented to a community hospital with difficulty walking and speaking. His illicit drug use history included smoking heroin. After admission to the hospital, a thorough workup was consistent with toxic heroin related leukoencephalopathy. The young man continued to decline and died approximately 2 months after his initial presentation and diagnosis. An autopsy and a thorough neuropathology examination were completed. Sections through the cerebral hemispheres and the cerebellum revealed diffuse and profound softening and discoloration of the white matter, most prominently in the occipital lobes. Microscopically, there was vacuolization and spongiosis of the white matter. The pathologic findings were consistent with the diagnosis of toxic or heroin related leukoencephalopathy. Toxic leukoencephalopathy is a rare disorder of unknown etiology linked to the smoking of heroin, known as “chasing the dragon.” The exact mechanism of the disorder is unknown, but it is thought that impurities cut into the heroin may become toxic substances upon sublimation, as the disorder is not seen with injected heroin. Currently, therapy is supportive with no effective cures available. The natural history of the disorder is variable, with an approximately 25% mortality rate. The popularity of smoking heroin is growing in the United States, and it is particularly seen with increasing frequency in new heroin users. Thus, this is an important, and likely increasingly common, effect of illicit drug use that should be recognized by forensic pathologists.

The analysis of digital images using computer algorithms to mine digital data directly is an important and increasingly utilized tool in many different fields of medicine. However, despite the clear value of image analysis to forensics, there is little research and no current practical applications of this technology to forensic pathology.

This paper demonstrates the technique of Spatially Invariant Vector Quantization (SIVQ) in the analysis of gross forensic images. SIVQ is a pattern recognition algorithm that can run on a laptop and be utilized by a forensic pathologist with no programming experience. The user merely points and clicks to the feature of interest and SIVQ searches the entire image for the desired feature. The results can be displayed in a variety of formats, both qualitative and quantitative.

Gross forensic images from gunshot wounds, burns and patterned contusions were analyzed by a forensic pathologist using SIVQ. Based on features selected by the user, the algorithm was able to detect both the gunshot wound and its marginal abrasion, calculate the surface area of a gunshot wound defect, distinguish between a thermal burn and the surrounding areas of healing, analyze a patterned contusion, and both identify and calculate the density of gunpowder stippling.

Even though the work is preliminary, it is obvious from these few examples that SIVQ is easily able to identify features of interest in gross forensic images. Additional work needs to be done to fully explore the potential for this application of technology to the practice of forensic pathology.

Personnel employed in medical examiner and coroner offices are involved in the identification of the deceased, the determination of causes of death, and the communication of this information to relevant parties, including the families of the victims, public health authorities and the criminal justice system. Although the mental health needs of other types of emergency workers (i.e., fire, police, emergency medical services) have been well identified and acknowledged in the literature and in planning efforts, the mental health needs of medical examiner and coroner personnel have not received the same attention. The aim of this study was to identify predictors of mental and physical health symptoms among employees of medical examiner and coroner offices. Data was collected from a convenience sample composed of employees of eight medical examiner sites nationwide, attendees of a coroners' conference, and through the web. A total of 395 employees completed a survey evaluating symptoms of depression, posttraumatic stress, anxiety, self-reported health and sleep quality. Results indicated variations among job titles in the intensity of mental and physical health symptoms, with investigators, clerical and administrative staff, and coroners reporting the highest levels of symptoms. Work-related stressors associated with increased levels of psychological symptoms included: exposure to cases involving the accidental death of infants, as well as stress associated with interacting with the families of the deceased and concerns about bringing home infection or illness. The results have implications for the development of intervention strategies designed to prevent work-related illness in medical examiner personnel.

Adult polyglucosan body disease (APBD) is a rare neurodegenerative condition characterized by typical onset in middle age, progressive neurological impairment that is heterogeneous between cases, and death within 1-14 years of diagnosis. The histopathologic hallmark of the disease is massive deposition of corpora amylacea (designated polyglucosan bodies in this context) in the central nervous system, and variable deposition of similar material in other sites. While the cause of the disease is as yet unknown, recent research has identified mutations in proteins involved in glycogen metabolism in a subset of cases. In this paper, we present a case of unexpected death wherein APBD was diagnosed at forensic autopsy. This represents the first report of an unexpected death due to this disease reported in the medical and forensic literature.

Subcortical band heterotopia (SBH), also known as double cortex syndrome, is a rare congenital abnormality seen almost exclusively in women. Affected individuals present with seizures, decreased cognitive ability, and behavioral problems, all of which may be expressed with variable severity. The diagnosis is considered with the characteristic MRI findings coupled with the neurologic features and appropriate family history.

The rarity of this disorder combined with the typically early presentation with seizures and the characteristic imaging findings make initial diagnosis in a forensic setting unlikely. Therefore, to our knowledge, SBH has not been described in the forensic literature. This case demonstrates a case of sudden death in a woman with known epilepsy, without further clinical history available at the time of autopsy.

Endosulfan is a highly toxic agricultural pesticide that has been banned in many countries due to its significant neurotoxicity and environmental persistence. Accidental or intentional ingestion by humans induces severe neurological symptoms, which frequently culminate in coma or death. Forensic evaluation of suspected endosulfan toxicity cases can be challenging, given that endosulfan residue may not be detectable in the blood or tissues at the time of death. As such, evaluation of the case history in the context of the reported literature becomes extremely important. Although acute endosulfan toxicity in adults has been well documented, pediatric cases are rare within the literature. Here we present the case of a toddler who accidentally ingested an unknown quantity of endosulfan from an unmarked water bottle on his family farm. The child developed rapid-onset neurological symptoms, including vomiting and seizures, followed by coma. Despite medical intervention, the child was eventually pronounced brain dead and taken off life support. Autopsy revealed massive cerebral edema and its sequelae (sutural diastasis, pituitary necrosis, and dural venous thromboses), and pulmonary thromboemboli. Endosulfan was detected in the bottle from which the child drank. As endosulfan was not detectable in postmortem blood, the cause of death was certified based upon the totality of available information including history, consistency of the case history with the clinical presentation, and the autopsy findings.