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Abstract: This article presents a case of severe CPR-related injuries leading to diagnosis of vascular Ehlers-Danlos syndrome. The subject is a 36-year-old female with a past medical history of a 10-mm aneurysm of the right internal carotid artery discovered on imaging 3 years prior to death. Major autopsy findings included subarachnoid hemorrhage in the base of the brain, bilateral hemothoraces, hemopericardium, laceration of the interatrial septum, laceration of the left pulmonary artery, and changes secondary to chronic alveolar hemorrhage in the lungs. The autopsy findings and subsequent unremarkable toxicology studies led to the suspicion of an underlying and clinically undiagnosed connective tissue disorder. Broad genetic exome testing revealed a mutation consistent with vascular Ehlers-Danlos syndrome. An overview of this disease, its diagnosis, and differential are further described herein, along with recommendations for forensic pathologists., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: An accurate diagnosis of peripheral lung and pleural lesions using image-guided transthoracic biopsy procedure becomes a good diagnostic performance protocol., Purpose: To examine the difference between ultrasonography (USG)-guided versus computed tomography (CT)-guided transthoracic biopsy for pleural and peripheral lung lesions by pooling data from published studies., Material and Methods: PubMed, CENTRAL, Scopus, Web of Science, and Embase were searched for comparative studies up to 20 February 2023 irrespective of the language of publication. The outcomes were adequacy of the sample and complications (pneumothorax and hemothorax)., Results: Two randomized controlled trials (RCTs) and eight non-RCTs were eligible. The total sample size was 1618. Meta-analysis showed that there was no difference in the adequacy of the sample obtained by USG- or CT-guided biopsies; however, an analysis of only non-RCTs indicated better adequacy with USG. On pooled analysis of any pneumothorax, there was a lower risk associated with USG-guided biopsies, but the risk of pneumothorax requiring interventional treatment was not different in the two groups. Similarly, the pooled analysis also demonstrated a reduced risk of hemothorax with USG-guided biopsies., Conclusion: While there seems to be no difference in the adequacy of the sample obtained with either imaging modality, retrospective data show that USG guidance offers better diagnostic yield compared to CT guidance for peripheral lung and pleural biopsies. The risk of pneumothorax and hemothorax is also significantly lower with USG-guided biopsies. Results should be interpreted with caution owing to selection bias among studies. There is a need for large-scale RCTs to enhance current evidence., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Pediatric chest wall tumors are unusual and can arise from bone structures or from adjacent soft tissues. Osteochondroma is a benign cartilaginous tumor arising from the metaphysis of bone; however, it is more common in extremity rather than in membranous bone. Although benign, osteochondroma of the rib may lead to fatal complications such as pneumothorax, hemothorax, fractures, and pleural or pericardial effusion. Therefore, some form of surgical management becomes necessary to treat these lesions. We present a case of 7-year-old female child with solitary osteochondroma of the rib. The tumor was surgically excised and the child is asymptomatic on follow-up., Competing Interests: None

The current standard technique for cardiopulmonary resuscitation (CPR), initially described in the early 1960s, has quickly become the expected response for all persons found without a pulse or respiration. Despite the potentially lifesaving properties of external cardiac massage, the mainstay of resuscitation, it consists of repeated blunt force trauma to the chest, which can lead to extensive traumatic skeletal and nonskeletal injuries. Numerous autopsy-based studies have documented the incidence and patterns of rib and sternal fractures associated with attempted CPR, but there is relatively little data on the incidence and severity of nonskeletal CPR-related injuries. We reviewed reports from 1878 autopsies performed between September 2017 and December 2019 (inclusive), for documentation of CPR-related injuries. Among these cases, there were 93 cases with resuscitation-related nonskeletal injuries. The most common type of injury identified were visceral contusions, documented in 57.0% of cases. These contusions predominantly involved the heart, lungs, neck soft tissue, and surrounding structures. Resuscitation-related lacerations were seen in 17.2% of the cases, most predominantly involving the pericardium, heart, and liver. Statistical analysis of the data demonstrated that lacerations were more likely to be seen in females and with associated sternal fractures. Additionally, hemothoraces were present in 34.4% of cases and hemopericardium was seen in 8.6% of cases. This study provides additional documentation of the range, severity, and incidence of various types of resuscitation-related visceral injuries to better assist autopsy pathologists in distinguishing these injuries from other antecedent traumatic injuries., (© 2021 American Academy of Forensic Sciences.)

Spontaneous hemothorax is a rare disorder characterized by pleural fluid hematocrit greater than 50% of the peripheral blood hematocrit without natural or iatrogenic trauma to the lungs or pleural space. Since the first case of COVID-19, more than 85 million cases have been confirmed and most patients have sustained symptoms after more than six months of acute infection. This paper reports the case of a 38-year-old woman without signs of endometriosis and a history of COVID-19 infection who developed spontaneous hemothorax after oocyte retrieval. Three months before undergoing assisted reproductive technology (ART) treatment, the patient had a symptomatic COVID-19 infection with a negative PCR test and a positive IgG test four weeks after the onset of symptoms. Controlled ovarian stimulation and oocyte retrieval were conducted uneventfully. Two hours after oocyte retrieval, the patient developed nausea and mild hypogastric pain. Ten hours after the procedure, the patient went to the emergency department with abdominal pain. Chest computed tomography scans revealed moderate right pleural effusion and laminar left pleural effusion. Since the patient had respiratory symptoms, the choice was made to drain the pleural fluid. Fluid analysis confirmed the patient had right hemothorax (400 mL). After drainage, the patient's clinical and imaging signs improved gradually without complications. The patient was asymptomatic one week after the procedure.

The motion-activated system (MAS) employs vibration to prevent intraluminal chest tube clogging. We evaluated the intraluminal clot formation inside chest tubes using high-speed camera imaging and postexplant histology analysis of thrombus. The chest tube clogging was tested (MAS vs. control) in acute hemothorax porcine models (n = 5). The whole tubes with blood clots were fixed with formalin-acetic acid solution and cut into cross-sections, proceeded for H&E-stained paraffin-embedded tissue sections (MAS sections, n = 11; control sections, n = 11), and analyzed. As a separate effort, a high-speed camera (FASTCAM Mini AX200, 100-mm Zeiss lens) was used to visualize the whole blood clogging pattern inside the chest tube cross-sectional view. Histology revealed a thin string-like fibrin deposition, which showed spiral eddy or aggregate within the blood clots in most sections of Group MAS, but not in those of the control group. Histology findings were compatible with high-speed camera views. The high-speed camera images showed a device-specific intraluminal blood "swirling" pattern. Our findings suggest that a continuous spiral flow in blood within the chest tube (MAS vs. static control) contributes to the formation of a spiral string-like fibrin network during consumption of coagulation factors. As a result, the spiral flow may prevent formation of thick band-like fibrin deposits sticking to the inner tube surface and causing tube clogging, and thus may positively affect chest tube patency and drainage., (© 2020 International Center for Artificial Organs and Transplantation and Wiley Periodicals LLC.)

Hemothorax cannot always be treated by thoracic surgeon. Rapidly improved interventional pulmonology broadens the application of medical thoracoscopy. We attempt to share our experiences of medical thoracoscopy for hemothorax and discuss the value of medical thoracoscopy in pleural diseases. We reported a 76-year-old male with hemothorax who was cured by medical thoracoscopy under local anesthesia together with argon plasma coagulation. Moreover, final pathological diagnosis was acquired as pleural sarcomatoid carcinoma. The unusual manifestation under medical thoracoscopy of such a relative rare disease was also described in this paper. The medical thoracoscopy could be used successfully for hemothorax instead of treating with surgeon, especially for those who cannot tolerate procedure of operation or surgical thoracoscopy., Competing Interests: None

Hemothorax is a serious medical condition that can be life-threatening if left untreated. Early diagnosis and timely treatment are of great importance to produce favorable outcome. Although currently available diagnostic techniques, e.g., chest radiography, ultrasonography, and CT, can accurately detect hemothorax, delayed hemothorax cannot be identified early because these examinations are often performed on patients until noticeable symptoms manifest. Therefore, for early detection of delayed hemothorax, real-time monitoring by means of a portable and noninvasive imaging technique is needed. In this study, we employed electrical impedance tomography (EIT) to detect the onset of hemothorax in real time on eight piglet hemothorax models. The models were established by injection of 60 ml fresh autologous blood into the pleural cavity, and the subsequent development of hemothorax was monitored continuously. The results showed that EIT was able to sensitively detect hemothorax as small as 10 ml in volume, as well as its location. Also, the development of hemothorax over a range of 10 ml up to 60 ml was well monitored in real time, with a favorable linear relationship between the impedance change in EIT images and the volume of blood injected. These findings demonstrated that EIT has a unique potential for early diagnosis and continuous monitoring of hemothorax in clinical practice, providing medical staff valuable information for prompt identification and treatment of delayed hemothorax., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Lin Yang et al.)

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.

Obstetric and gynecologic pleural effusions may occur in the setting of different diseases and conditions, early and appropriate recognition of the different etiologies of these effusions will aid in appropriate treatment management. In this paper we will give an overview of the different pleural effusion etiologies that may be encountered including catamenial hemothorax, ovarian hyperstimulation syndrome, the different Meigs' syndromes and benign peripartum pleural effusion., (Copyright © 2018. Published by Elsevier Inc.)

Instruments that create stab wounds are required to possess tips of sufficient strength and rigidity to breach the integrity of the skin. Knives, the most common weapons used to create stab wounds, have cutting edges that cleave the skin, leaving unabraded margins. On rare occasions, blunt objects are driven with sufficient force to pierce the skin and become impaled within the body. The morphologic differences between the cutaneous injuries and wound tracks of stab wounds from sharp objects and impalement with blunt ones provide clear delineation of the two. However, elements from the scene and obscuring hemorrhage can make initial differentiation difficult. The authors report the death of a 59-year-old woman found near the entryway steps of her home with a stab wound to her chest. Law enforcement did not discover any weapons. Investigation focused on blood around and on a broken rose bush planted near the steps with the belief that the decedent had fallen upon the vegetation. When presented with information that conflicts with autopsy findings, careful consideration of proposed weapons and thorough examination of the wound are required to discount confounding material.

Intercostal artery injury during transthoracic puncture is rare but is accompanied by high rates of morbidity and mortality. We report a case with metachronous double primary esophageal cancers and development of multiple lung nodules. Tissue proof for the lung nodules is required to guide the following treatment protocol. Our patient died soon after computed tomography-guided lung tumor biopsy was performed, as a result of procedure-related massive and uncontrolled hemothorax. The cause is likely intercostal artery injury related to the transthoracic puncture. After review of our case and the wide variation in intercostal artery courses, we identify several considerations that should be included in procedural planning to further decrease the risk of intercostal artery injury during transthoracic puncture, including avoiding choosing target lesions at the posterior lung, keeping the puncture needle as close to the superior rib margin as possible, and checking the density of new pleural fluid. In addition, it is important to inform clinical doctors when the risk of periprocedural vascular injury is high., (© 2018 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Pneumopericardium (PPC) describes the collection of gas in the pericardial sac. In tension Pneumopericardium (tPPC), this collection of gas may lead to cardiac tamponade. PPC following blunt trauma is considered a rare finding, as reflected by the low number of case reports on the topic. We analyzed the prevalence and pathophysiology of PPC and the associated trauma in 44 cases of falls from height. We retrospectively analyzed postmortem CT data and autopsy reports of fatal falls in the period March 2014-2017. A valid estimation of the height of the fall and a documented impact on an even and hard surface were inclusion criteria. A total of 44 cases were included in the study. We identified PPC in 18 of the 44 cases, and it was associated with an increased height of the fall, alongside aortic, pericardial, and myocardial ruptures. All cases with PPC also presented with bilateral pneumothorax. Five cases presented with a "ballooning" pericardium, indicating tPPC. PPC is a common finding in cases of falls from great heights. Due to a significant correlation with height and thus impact severity, PPC may be used as a reconstructive element in medico-legal investigations. Association with trauma makes PPC a sign of severe thoracic injury in postmortem and clinical radiology.

Objectives: Aortic dissection (AD) can be a challenging diagnosis. At autopsy, the aorta may not be dilated and intimal tears may be missed or found without obvious rupture or haemorrhage. We report our experience of AD at a tertiary referral centre with review of 32 cases and discuss 2 unusual complications., Methods/results: 32 cases of which 12 females and 20 male and 18 out of 32 cases were aged below 40. All of the cases were examined macroscopically and microscopically. 30 out of 32 cases (93%) died due to rupture associated with the AD. Two unusual complications were proximal extension of AD into left coronary artery (CA) with intramural haematoma blocking the vessel and AD involving the ostium of the right CA resulting in avulsion of the right CA from the aorta. Mode of death in both these cases were myocardial ischemia. Sections of the aorta in all cases confirmed extensive cystic medial degeneration with disorganisation, fragmentation and disappearance of the elastin fibres with increased collagen and smooth muscle nuclear degeneration., Conclusion: Pathologists should be thorough when examining the aorta, the aortic valve and root in AD. When a rupture site cannot be found it is important to look for unusual complications involving the CAs. Histology plays an important role to corroborate the cause of death., (Copyright © 2018. Published by Elsevier Ltd.)

Acute subclavian artery dissection (SAD) is a rare entity which is usually associated with several vascular abnormalities and traumatic events. Spontaneous SAD remains exceptional and often affects the left artery. We report the autopsy case of a 29-year-old female who died suddenly following a spontaneous dissection of the right subclavian artery.

Pleural epithelioid haemangioendothelioma (EHE) is a rare tumour that originates in the vascular endothelium with an intermediate degree of malignancy between haemangioma and angiosarcoma. Smoking and asbestos exposure are unproven risk factors and diagnosis is usually confirmed by thoracoscopy, since pleural fluid (PF) cytology is often not conclusive. Immunohistochemistry can also help to confirm the diagnosis. We report an 85-year-old patient with bilateral pleural EHE diagnosed by thoracoscopy, who debuted with a spontaneous bilateral haemothorax, the second described so far, and we conducted a thorough review of the literature to describe the clinical, radiological and prognostic features, as well as the PF, of this rare tumour., (© 2016 John Wiley & Sons Ltd.)

Purpose: In this paper we present a case report of two people who were found dead in a holiday cottage after a fire. The cause of death in these cases was clarified by the presence of blood in the left pleural cavity in both bodies., Methods: An inspection of the bodies at the scene of the fire and subsequent examination by a medical examiner suggested the deaths were accidental., Results: An autopsy showed that the bodies were those of a man and a woman with severe carbonization of the skin, soft tissues, brain, and some organs of the thoracic and abdominal cavities. There were also isolated stab injuries to the chest, as well as injuries to skeletal structures and intrathoracic organs. The accumulated blood in the pleural cavity had protected the internal organs against thermal destruction and preserved the traumatic findings., Conclusion: To the best of our knowledge this is the first description of the protective effect of hemothorax against thermal damage of the intrathoracic organs.

Intrathoracic extracardiac hemangiosarcoma (HSA) is rare in dogs. This report describes three dogs with acute onset dyspnea due to hemorrhagic pleural effusion resulting from intrathoracic extracardiac masses, which were confirmed as HSA by histopathology. The dogs were stabilized with thoracocentesis and intravascular fluid resuscitation. Computed tomography identified intrathoracic masses, which were not originating from the heart or pulmonary parenchyma. Surgical exploration was performed in all cases. Case 1 was euthanized intraoperatively as the tumor could not be dissected from the aorta. In cases 2 and 3, hemostasis and resection of the tumors was successful. Case 2 was euthanized 1 mo after surgery and case 3 was alive at the time of writing, 5 mo postoperatively. Intrathoracic extracardiac HSA should be considered as a differential for nontraumatic hemothorax and surgical treatment can be palliative.

The results of examination and treatment of 36 injured persons with complicated penetrating thoracic woundings in tertiary centres were analyzed. Own experience of the pulmonary woundings surgical treatment, using application of videothoracoscopic and welding-coagulating equipment, was summarized.

The results of examination and treatment of 71 patients for pleural exudates (PE) of various origin were analyzed. The efficacy of application of a one-ported thoracoscopy in diagnosis and treatment of a PE in patients with noncomplicated course of intrathoracic pathological processes was proved. The reduction of the PE quantity by (15 ± 4)% and duration of exudation by (15 ± 9)% was noted after performance of a one-ported thoracoscopic interventions, reduction of operative trauma and subjective sensation of pain, as well as best cosmetic effect.

This case report describes the clinical, ultrasonographic, pathological and histological findings in a two-year-old Swiss Braunvieh cow with granulosa cell tumor and metastases in the abdomen and thorax. The cow was ill and had tachycardia, coughing, increased breath sounds, positive reticular foreign body tests and a tense abdominal wall. Ultrasonography revealed a massive accumulation of hypoechoic fluid in the thorax and abdomen, and abdomino- and thoracocentesis yielded red fluid indicative of abdominal and thoracic haemorrhage. Because of a poor prognosis, the cow was euthanized and examined postmortem. Multiple nodular lesions were seen in the omentum, liver, spleen and lungs. The left ovary was grossly enlarged and nodular in appearance. Histological examination of the lesions revealed granulosa cell tumour of the left ovary and metastases in the omentum, liver, spleen and lungs.

In a forensic setting, haemothorax is usually seen in cases of trauma. The main non-traumatic cause for haemothorax is an intrathoracic rupture of an acute aortic dissection or an aortic aneurysm that is almost always fatal. Here we present one such case of sudden natural death caused by rupture of an acute aortic dissection. The deceased was a middle-aged, unidentified male who was subjected to autopsy at the Department of Forensic Medicine, M.S. Ramaiah Medical College, after having been brought in dead to the hospital. It is a type III DeBakey dissection as it originates in the descending aorta and it is quite unusual that a rare retrograde extension was also observed., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

The article presents the case of a 73-year-old female injured in a bicycle accident, who was diagnosed with a left hemothorax. Initially, a chest drain was inserted and the pleural hematoma was evacuated. Then a thoracotomy was performed. A hematoma debridement and decortication with a subsequent tissue biopsy was carried out and a final diagnosis of spindle cell sarcoma was made. There is a brief discussion on the differential diagnosis of spontaneous hemothorax and its management.

A 30-year-old man was found dead in a pool of blood inside his office room in the morning. Autopsy revealed a small contusion at the lower anterior part of neck, laceration on the left common carotid artery, hemothorax and a laceration over the nose with underlying fracture. On investigation, it was found that on the previous night the victim had been assaulted by his domestic help with an iron rod over head and neck. The blunt trauma to the neck resulted in laceration on the left common carotid artery and subsequently bled, causing fatal hemothorax. The authors report this case owing to the rarity of such patterns of injury leading to fatal outcomes, which may be overlooked due to the simple nature of external injuries.

Fatal lawn mower related injuries are a relatively rare occurrence. In a forensic setting, the primary aim is to reconstruct the injury mechanism and establish the cause of death. A relatively rare, but characteristic type of injury is a so-called projectile or missile injury. This occurs when the operator or a bystander is impacted by an object mobilized from the grass by the rotating mower blades. This type of injury often leaves only modest external trauma, which increases the risk of overlooking an entry wound. In this paper we present a case of a fatal lawn mower related projectile injury which was initially overlooked, later interpreted as a possible gunshot homicide, and finally identified as a lawn mower related projectile injury when autopsy revealed a piece of metal thread in the main bronchus to the right middle lobe, hemopericardium, and right-sided hemothorax. To our knowledge, this injury mechanism has not previously been reported as a cause of death. This case illustrates the importance of postmortem radiological imaging and interdisciplinary cooperation when establishing manner and cause of death in unusual cases.

Spontaneous hemothorax is a well-known yet seldom-reported entity in forensic literature. While trauma-related hemothorax is frequently encountered in a medicolegal setting, non-traumatic and spontaneous hemothorax are relatively uncommon entities. The wide range of causes that can trigger fatal intrathoracic bleeding include thoracic aortic dissection, followed by vascular malformations, various oncological diseases, and connective tissue abnormalities. In rare instances, extramedullary hematopoiesis, ectopic pregnancy, congenital heart defects, amyloidosis, or parasitic diseases may constitute a source of bleeding. This etiological heterogeneity may, as a result, cause diagnostic difficulties during post-mortem elucidation of hemothorax. It should be borne in mind that hemothorax after low-energy trauma does not exclusively indicate traumatic hemorrhage, hence, the non-traumatic origin of bleeding must be taken into consideration. In this paper, we present a systematic review of the relevant literature enriched by the results of our observations to investigate the etiologies and recommendations for the post-mortem diagnosis of spontaneous hemothorax in an attempt to better delineate the possible medicolegal considerations. It is important that forensic pathologist as well as clinicians are aware of the diseases that could potentially give rise to fatal hemothorax., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Traffic accidents have increased in the last decade, pedestrians being the most affected group. At autopsy, it is evident that the most common cause of pedestrian death is central nervous system injury, followed by skull base fractures, internal bleeding, lower limb haemorrhage, skull vault fractures, cervical spinal cord injury and airway compromise. The attribution of accident responsibility can be realised through reconstruction of road accident dynamics, investigation of the scene, survey of the vehicle involved and examination of the victim(s). A case study concerning a car accident where both humans and pets were involved is reported here. Investigation and reconstruction of the crime scene were conducted by a team consisting of forensic pathologists and forensic veterinarians. At the scene investigation, the pedestrian and his dog were recovered on the side of the road. An autopsy and a necropsy were conducted on the man and the dog, respectively. In addition, a complete inspection of the sports utility vehicle (SUV) implicated in the road accident was conducted. The results of the autopsy and necropsy were compared and the information was used to reconstruct the collision. This unusual case was solved through the collaboration between forensic pathology and veterinary forensic medicine, emphasising the importance of this kind of co-operation to solve a crime scene concerning both humans and animals., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Aortic arch blunt injury has highly lethal nature. Because the physical examination findings are subtle, immediate medical evaluation is very important. The case was a 72-year-old woman. Massive haemorrhage in the left haemotorax, contusion area in the left lung and a traumatic transection of the distal aortic arch was observed during autopsy. We described intersting autopsy case of aortic arch blunt injury.

We report a case showing delayed hemothorax superimposed on extrapleural hematoma after blunt chest injury. The patient was a 56-year-old man with a medical history of alcoholic hepatopathy who presented with a chief complaint of dyspnea on exertion. One month prior to presentation, he had sustained a fall that had resulted in left simple rib fracture. A chest radiograph taken at the time of injury showed notable reduction in the permeability of the left lung field along with high pulmonary collapse as well as rightward deviation of the shadow of the inferior mediastinum. Chest CT images showed a region of low absorption in the thoracic cavity with septi. Thoracic drainage was performed (1,300 mL total) and hemothorax was diagnosed. Thoracoscopic examination was then performed. When the inside of the thorax was observed, what had been presumed to be the septi of a multilocular fluid collection was found to be actually the parietal pleura, and a hematoma was confirmed inside the extrapleural cavity. The hematoma inside the extrapleural cavity was managed with lavage and drainage, and drainage tubes were placed inside both the thoracic cavity and extrapleural cavity at the end of the procedure. The patient's postoperative course was uneventful, and he was discharged on postoperative day 4.

Procedures involved in grooming, bathing, and other pet services can often lead animals to death. Of the necropsies of 1391 animals carried out at a private diagnostic laboratory in Sao Paulo, Brazil from 2004 to 2009, 94 were dogs that died during the above-mentioned procedures. Young male dogs and small breeds like Poodle Miniature, Yorkshire Terrier, and Lhasa Apso were most frequently observed. Blunt-force trauma was responsible for the deaths of 31% of the animals, with a higher incidence of trauma to the head, characterized chiefly by fractures and nervous tissue lesions. In the other 69% of cases, the animals showed signs of stress, and died due to pulmonary edema and hemorrhage. As we cannot rule out the intentional character in some situations, this article provides veterinary forensic support for veterinarians and pet owners, especially in lawsuits, helping in finding the cause of animal's death in such pet services., (© 2013 American Academy of Forensic Sciences.)

In the literature, only a few cases of deaths related to the use of atypical firearms are present and even more rare are cases of suicide due to multiple lesions.In the present case, the authors report a rare occurrence of suicide due to 4 speargun shots, 3 to the chest and 1 to the head.A complete forensic approach led to attribute the death to acute cardiac failure due to hemopericardium after the injury of the left coronary artery.Scene investigation and autoptic findings allowed authors to hypothesize that injury to the head was a last attempt of suicide, elapsed during the progression of cardiac tamponade.With this report, the authors would like to share knowledge with the forensic community about speargun-related lesions distinguishing them from the very similar ones produced by cold steels.It also shows how it is possible to survive for some time after being shot by such a weapon.

Seat belts have been shown to decrease the incidence of lethal lesions to the head, chest, and abdomen. Since the introduction of seat belts, it is reported that the incidence of traumatic lesions in these body parts is reduced. In the meantime, the characteristic lesions to the chest and abdomen caused by the use of seat belts are described (J Trauma. 2007;62(6):1473-1480).Reported is a peculiar case of an oblique front-to-rear car collision, in which overloading of the rear seat with packages pushed forward the passenger front seat in an abnormal way, causing fatal thoracic and abdominal lesions.The authors underline that the seat belt protection device is defeated if front seats are damaged by heavy unanchored bags on the rear seat or on the rear parcel shelf of a motor vehicle.

A 65-year-old man collapsed suddenly, while on an escalator. Despite intensive cardio-pulmonary resuscitation, the subject died 1h later. Post-mortem magnetic resonance imaging and post-mortem computed tomography angiography demonstrated rupture of an ascending aortic aneurysm, with haemorrhage into the pericardial cavity and the uncommon associated finding of haemorrhage into the left hemi-thorax through a small left-sided pericardial defect. The cause of death was thus attributed to the rupture of thoracic aortic aneurysm, and traditional autopsy was not performed. The circumstances of the case will be discussed, followed by a discussion of the imaging findings, mechanism of death, and explanation of the findings in this case. Finally, on the basis of this case report, we suggest that in selected cases, post-mortem imaging can be used as a screening tool for conducting hypotheses on the cause and mechanism of death before autopsy., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Dissecting intramural hematoma of the esophagus (DIHE) is a rare condition in which intramural hemorrhage can lead to submucosal dissection of the esophageal wall. DIHE is generally considered a benign disease, and the only mortality associated with DIHE has been due to operative intervention or to the presence of another underlying, life-threatening condition. We report, however, a case of sudden death due to the spontaneous rupture of a DIHE that occurred in a 32-year-old woman, affected by neurofibromatosis type 1. She was admitted to the local emergency room, presenting a 24-hour history of sudden onset, severe central chest and interscapular pain associated with dysphagia, odynophagia and vomiting. Her condition worsened and proved fatal within a 6-hour period. A complete autopsy was then conducted, showing a complete dissecting intramural hematoma with laceration of the third superior of the esophagus. We can hypothesize that abnormal variations of gastro-esophageal pressure during ingurgitation and during bolus movement could be predisposing factors in the pathogenesis of the dissection. On the other hand angular kyphoscoliosis deformity may have had play a role as precipitating factor while vomiting in the subject's medical history can then be interpreted as the likely activation phenomenon., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Patients with concomitant injuries to the thorax and thecal sac requiring chest tube drainage are at risk for cerebral herniation caused by overdrainage of cerebrospinal fluid (CSF)., Case Description: A 40-year-old man presented to the trauma service awake, alert, and oriented with an isolated gunshot wound to the midaxillary line through the tenth intercostal space and a complete spinal cord injury at T12. The patient was stabilized and intubated. A chest tube was placed, and he was transferred to the neurologic intensive care unit. The patient was found to be comatose with complete absence of brainstem reflexes 3 hours after admission., Results: Magnetic resonance imaging (MRI) and autopsy revealed diffuse cerebral edema, occlusion of the bilateral posterior cerebral arteries, and tonsillar herniation extending several centimeters below the foramen magnum, with petechial hemorrhages and absence of gliosis., Conclusions: To the authors' knowledge, this case represents the first report of cerebral herniation secondary to chest tube drainage of a CSF leak caused by traumatic injury to the thecal sac., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Though rare occurrences, fatal falls from bicycles are generally linked to the absence of a protective helmet and/or a collision with another vehicle. The case presented here is exceptional due to its circumstances and the consequences of the accident: a fall with no obstacle at a low speed that brought about multiple traumas and the death of a cyclist wearing a protective helmet. Comparing this against a review of cyclist accidentology literature, this case is unique. The increased use of autopsy in terms of forensic accidentology is to be encouraged so as not to misunderstand the possibility of such lesion-based consequences following a simple fall from a bicycle., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

The patient, MSM, a 69-year-old man, sought medical care due to left dorsal and right lower limb pain. The chest x-ray showed mediastinal enlargement. He was undergoing examination when he lost consciousness and went into shock. Subcutaneous emphysema was observed in the left hemithorax, as well as abolition of breath sounds at auscultation. Tracheal intubation was performed with draining of blood-tinged fluid from the left hemithorax. Echocardiography showed left ventricle with 44/29 mm; septum, 12 mm; posterior wall, 13 mm; mild aortic root dilation, dissection of the lamina and periaortic hematoma. The valves and pericardium were normal. The patient was transferred to Instituto do Coraçao - InCor. Physical examination (21 Oct 2004: 10:45) showed that the patient was sedated with tracheal intubation, pale, heart rate at 90 bpm, blood pressure 130 x 80 mmHg, bloody drainage in the chest tube. Electrocardiogram - frequency 90 bpm, sinus rhythm, low voltage in the frontal plane and decreased voltage in left leads (Fig. 1). Computed tomography showed bilateral subcutaneous emphysema, thoracic aorta with inaccurate borders in its descending portion (from the subclavian artery to the middle portion), collapsed left lung and extensive collection of hematic characteristics in same hemithorax and middle and posterior mediastinum. Small right pneumothorax; small right pleural effusion with underlying parenchymal alterations. The analysis of the heart was impaired by the presence of hemothorax. While undergoing computed tomography, the patient showed no pulse, mydriasis, with asystole unresponsive to resuscitation and died (21 Oct 2011; 15:00 h).

A 72-year-old white woman was admitted to the hospital for mitral valve replacement with a metallic valve. A few days after surgery, the patient experienced a sudden cardiac arrest and died because of the intrapleural rupture of a pulmonary arteriovenous fistula.

Publications report observing tortuosity in the posterior intercostal arteries of elderly patients. Studies also describe the size and course of the collateral intercostal arteries. This information is clinically significant when performing thoracentesis and video-assisted thorascopic surgery. To the best of our knowledge, no studies have examined arterial tortuosity or described collateral artery origins relative to bony landmarks. The purpose of this study was to define a safe surgical zone for thoracic access using palpable external bony landmarks. A total of 348 intercostal spaces (3rd-8th) of 29 male and female embalmed cadavers were dissected from the vertebral body to the mid-axillary line to observe the posterior intercostal artery and its collateral branch. The origins of the collateral intercostal arteries relative to the midline of thoracic spinous processes were measured. Mild to moderate tortuosity (arterial curves covering 25- -50% of the intercostal space) was observed in at least one posterior intercostal artery in the majority of cadavers. The origins of the collateral intercostal arteries were variable relative to the midline. Additional collateral intercostal arteries distal to the primary collateral branch were observed, most commonly in the 5th intercostal space, which is used in video-assisted thorascopic surgery and thoracentesis. Tortuosity is common in the 3rd to the 8th posterior intercostal arteries, especially in individuals over the age of 60 years. Given the findings of this study, we recommend that any procedure involving placement of a surgical instrument into these intercostal spaces does so at least 120 mm lateral to the midline of the spinous processes. We also recommend pre-procedure ultrasound (intercostal scan) of the posterior and collateral intercostal arteries when performing non-emergent thoracentesis and video-assisted thorascopic surgery, particularly in patients over 60 years of age.

We report a rare case in which hemothorax occurred in addition to hemoperitoneum due to spontaneous rupture of hepatocellular carcinoma (HCC) originating from the caudate lobe of the liver. The case pertains to a 56-year-old female who was transported to our hospital for impaired consciousness due to hemorrhagic shock. Computed tomography (CT) demonstrated ruptured HCC originating from the caudate lobe and accompanying hemoperitoneum and right hemothorax. Hemostasis was carried out by transcatheter arterial embolization (TAE), and surgery was conducted approximately one month after TAE. In the present case, no lesions as possible sources of bleeding were observed inside the pleural cavity, and, moreover, the diaphragm had no abnormalities in the intraoperative findings, suggesting that blood from the ruptured tumor may have traversed the intact diaphragm to enter the right pleural cavity soon after the HCC rupture. However, to the best of our knowledge, no similar cases of HCC have been reported to date, and this case is thus believed to be very rare. This unusual phenomenon may therefore be strongly associated with the location of the ruptured tumor and the formation of a hematoma inside the omental bursa. We discuss the mechanism causing hemothorax in the present case and also review the previously reported cases of ruptured HCC complicated by hemothorax.

A healthy man in his 30s was working on the balustrade of stairs on the second floor. He suddenly fell downstairs without saying anything. On emergency hospitalization, chest echogram showed left hemothorax. Cardiac echogram showed a floating mass from the mitral valve in the left ventricle and severe mitral regurgitation. Surgery for hemothorax and pulmonary contusion was immediately undertaken. However, bleeding from pulmonary contusion could not be controlled and he underwent cardiopulmonary arrest. Autopsy showed a white, elastic, pendulous mass in the left atrium and a white mass in the lower lobe of the left lung. Tumor histology showed a reticular pattern, Schiller-Duval bodies, eosinophilic hyaline globules, and positive staining for α-fetoprotein. We diagnosed primary lung yolk sac tumor with metastatic intracardiac yolk sac tumor, a rare and highly malignant germ cell tumor. It usually arises in the ovaries and testes, and intracardiac yolk sac tumor is rare. Intracavitary tumors induce obstruction of inflow into and outflow from the ventricular cavity. The most common clinical presentation is dyspnea and syncope. In the present case, metastatic cardiac yolk sac tumor might have disturbed cardiac outflow and affected hemodynamics, probably causing syncope. Unfortunately, he was in a high place at that time and fell to receive pulmonary contusion that led to death. Autopsy may sometimes reveal latent diseases which might be related to the cause of death. We should perform autopsy thoroughly to diagnose not only the cause of death but also the factors leading to death.

A homicidal shooting with an air gun is reported. The history, mechanisms of action, and crime scene implications of air guns are discussed. The wounds produced by air guns are compared to those produced by powder firearms.

Percutaneous tube thoracostomy (PTT) remains the most widely performed procedure to manage blunt or penetrating chest traumas. This life-saving manoeuvre can be frequently associated with complications. We present the case of a 76-year-old man, admitted to a peripheral hospital after a car accident and treated by PTT, who died shortly after the withdrawal of the chest tube. At autopsy, the victim was found to be affected by an extensive haemothorax resulting from the perforation of a subpleural angiomatoid lesion. The histopathological characteristics and the pathogenesis of the iatrogenic injury involving the vascular abnormality, along with its causal role in determining the fatal haemothorax, are critically discussed under both clinical and forensic points of view.

Some of the fatally injured car occupants could have had both blunt rupture of thoracic aorta with great amount of intrapleural blood, and pontomedullar laceration of brain-stem as well, with both injuries being fatal. The aim of this study was to answer if all intrapleural bleeding in these cases was antemortem, or the bleeding could also be partially postmortem. We observed the group of 66 cases of blunt aortic rupture: 21 case with brain-stem laceration, and 45 cases without it. The average amount of intrapleural bleeding in cases without brain-stem laceration (1993 ± 831 mL) was significantly higher than in those with this injury (1100 ± 708 mL) (t = 4.252, df = 64, P = 0.000). According to our results, in cases of the thoracic aorta rupture with concomitant brain-stem laceration, the amount of intrapleural bleeding less than 1500 mL, should be considered mostly as postmortem in origin, and in such cases, only the brain-stem injury should be considered as cause of death.