Suicides by Jumping Off Istanbul Bridges Linking Asia and Europe.

AIM: The aim of this study was to determine the injury spectrum and characteristics of people who committed suicide by jumping into water from the July 15th Martyrs Bridge and Fatih Sultan Mehmet Bridges in Istanbul, Turkey. METHODS: This study included all of the jumpers from the July 15th Martyrs Bridge and Fatih Sultan Mehmet Bridge who were autopsied by the Council of Forensic Medicine, Istanbul Morgue Department, between 2000 and 2013. All of the data were collected from archived case files. Trauma scores were calculated from the traumatic findings of the autopsy reports using the New Injury Severity Score (NISS). RESULTS: A total of 80 jumping suicides were identified. The male-to-female ratio was 9:1, and the mean age was 34.06 ± 9.6 years. Most suicides occurred in 2009. The suicide rates were higher in the winter, particularly in December. The most frequent injuries were skin lesions, rib fractures, and lung lacerations. In 12% of the cases, the trauma was minor (NISS range, 0-14; mean, 7 ± 5.67), and in 88% of the cases, it was major (NISS range, 17-66; mean NISS, 44.5 ± 12.46). CONCLUSION: The sociodemographic features of the jumpers who committed suicide were quite similar to those reported in previous studies. Preventative measures (installation of barriers or banning pedestrian access to bridges) reduced the suicide rate but were not completely effective. Establishing early warning systems and rescue strategies could save the lives of jumpers who have minor trauma.

Cardiac Findings of Pulmonary Thromboembolism by Autopsy: A Review of 48 Cases.

BACKGROUND To identify the overall effects of pulmonary thromboembolism (PTE) on the heart, we evaluated the heart findings and clinical characteristics of deceased patients diagnosed with PTE. MATERIAL AND METHODS PTEs were classified into 2 categories: fatal and contributory. Cases with a history of cardiopulmonary disease or a finding of significant disease at autopsy, including valvular heart disease and coronary artery obstruction >50%, were excluded from the cardiac evaluation. We defined an LV wall ≥1.2 cm thick and an RV wall ≥0.8 cm thick as abnormal. RESULTS Forty-eight cases were included to the study (21 males and 27 females). The mean age was 41.42 ± 16.5 years. Of the 48 cases, 5 were excluded due to cardiopulmonary diseases for determining heart findings. The thicknesses of the LV and RV walls were not measured in some patients. In the 43 cases, cardiac hypertrophy was detected in 28 patients (65.1%). The mean heart weight was 387 ± 83.5 g. The mean thickness of the left ventricle (LV) wall was 1.40 ± 0.41 cm in 40 cases, and the mean thickness of the RV wall was 0.41 ± 0.135 cm in 41 cases. The LV walls of 35 (87.5%) cases and the RV walls of 2 cases met criteria for abnormal wall thickness. There were histopathological findings of heart in 24/43 cases (56%); these findings were necrosis, fibrosis, and hypertrophy. CONCLUSIONS The RV is affected by massive pulmonary embolism; however, the LV may also play a role in the pathogenesis of PTE.

Peroneus quartus: prevalance and clinical importance.

INTRODUCTION: The most common variant muscle of the ankle, peroneus quartus muscle, is located in the lateral leg compartment. In literature there is ambiguous nomenclature of this muscle because of its different origin and insertion sides. It is related to many pathologic conditions in the lateral ankle compartment but also it can be used as a tendon graft for reconstructive procedures. MATERIAL AND METHOD: We dissected 115 cadaver legs and investigated prevalence of peroneus quartus. We also present 2 year result of a patient who had torn superior peroneal retinaculum reconstructed with peroneus quartus tendon. RESULTS: The peroneus quartus muscle, with a number of different attachments, was present in 5.2 % (6/115) of the legs. It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneus. Associated pathologies are longitudinal degeneration and tear in the tendon of peroneus brevis. There is no any association between the prevalence of peroneus quartus and the height of retrotrochlear eminence or presence of peroneal tubercule (p > 0.05). But there is strong relationship between peroneus brevis degeneration and peroneus quartus existence (p: 0.03). We also defined a new type of peroneus quartus with a bifurcated insertion around the peroneus brevis. In literature our case report is unique because we present a patient who has torn superior peroneal retinaculum which is reconstructed with peroneus quartus tendon with 2 year follow up. CONCLUSION: Peroneus quartus may lead to some pathologic conditions (pain, snapping, tear, synovitis, etc.) in the lateral ankle compartment but it may be used to reconstruct some pathologic conditions. Orthopaedics, anatomists and radiologists should be aware of this accessory tendon structure because of its clinical importance.

Morphometry, asymmetry and variations of cerebral sulci on superolateral surface of cerebrum in autopsy cases.

BACKGROUND: The cerebral sulci are known as main microanatomical borders that serve as a gateway and surgical passage to reach the ventricles or to the deeper lesions. It is a matter of curiosity that whether there is a convergence between the morphological asymmetry and the functional asymmetry, and also its significance in surgery. The aim of this study is make morphometric measurements and evaluate asymmetry of several sulci on the lateral aspects of the cerebrum in regard to main sulci and related reference key points. METHODS: A total of 100 cerebral hemispheres from 50 autopsy cadavers were examined. The lengths of several sulci on the superolateral aspect of the hemispheres and the distances between the sulci and nearby sulci and the reference key points were measured. Encountered variations were examined and photographed. RESULTS: Evaluation of the variations: superior frontal sulcus (SFS), inferior frontal sulcus, superior temporal sulcus (STS), precentral sulcus and postcentral sulcus were found to be discontinuous in 60, 46, 41, 84 and 70 % of the hemispheres, respectively. Evaluation of the asymmetry: the distances between SFS posterior end and longitudinal fissure, STS posterior end and lateral sulcus posterior end, as well as lengths of external occipital fissure (EOF), and discontinuous course of STS were significantly different between left and right hemispheres. CONCLUSIONS: There is usually a morphological partial asymmetry between the right and left hemispheres for any individual. Also, some of our measurements were found to be compatible with the ones in the literature, while others were incompatible.

Relationship between the branches of the recurrent laryngeal nerve and the inferior thyroid artery.

OBJECTIVES: The relationship between the recurrent laryngeal nerve (RLN) and the inferior thyroid artery (ITA) is an important and helpful landmark for isolating the RLN and its branches during surgery. In the present study, we aimed to define and classify in detail all of the possible relationships between the two anatomic structures and their branches. METHODS: We examined 100 specimens (200 sides) from cadavers of 76 men and 24 women who were between 16 and 90 years of age at the time of death. After anatomic dissection was performed, the relationship between the RLN and the ITA was noted for each side and documented in the form of high-resolution photographs. RESULTS: The relationships of both structures and their branches were classified into 6 types. Details were verified regarding the relationships between the main trunks, between the trunks and branches, and between the branches, as follows: type A (ITA trunk to RLN trunk); type B (ITA branches to RLN trunk); type C (ITA trunk to RLN branches); type D (ITA branches to RLN trunk and RLN branches); type E (ITA branches to RLN branches); and type F (others). CONCLUSIONS: Despite the various anatomic and surgical studies already performed, in the present study we tried to demonstrate all types of relationships between the RLN and the ITA and their branches and devise a new, detailed classification of the possible relationships between the two structures.

Identification procedures as a part of death investigation in Turkey.

Forensic identification techniques include the examination of ID cards, the decedent's private belongings, fingerprints, footprints, lip marks, dental findings, red blood cell enzymes, performing photograph matching, facial reconstruction, visual identification, and DNA "fingerprinting." As part of forensic examinations, the identification of corpses that are fresh, decomposed, fragmented, or skeletonized as well as individual body parts and human remains can be requested. Identification becomes a challenging task for forensic terms particularly in mass-disaster situations. Each identification case should be considered to its own merit and the way to do that should be based on the effectiveness and cost of each method used. In Turkey, one of the major duties of the medicolegal system on the investigation of deaths is to identify the deceased if unknown.This study is undertaken to investigate the procedures, as well as their validities, used to deal with individualization of dismembered bodies directly sent to the Council of Forensic Medicine, Ministry of Justice, for autopsy and/or visual identification, as well as those received from peripheral districts for forensic identification. According to the Turkish Penal Procedural Law, a positive identification of the deceased is mandatory before performing an autopsy. According to the law, the ID cards are not taken to be sufficient for recognition of the deceased, and the major way of identification in daily practice is visual identification by a relative or any recognizant person to approve the identification to the prosecutor. If visual identification fails, fingerprints, dental x-rays or body x-rays, and DNA "fingerprinting" can be used to establish identity when compared with known records of the individual obtained by law enforcement.This retrospective study was carried out into 421 dismembered bodies, among 3063 autopsies performed in year 2002 by the Department of Morgue at the Council of Forensic Medicine, with particular insight into the identification procedures undertaken and their results. The overall negative identification rate was 30.4%, and in 1% of the cases, the visual identification by relatives were not confirmed by DNA identification and taken as misidentified.

Evaluation of medical malpractice claims in thoracic surgery.

BACKGROUND: Medical malpractice occurs in cases, where a patient experiences damage as a result of the doctor's deviation from the standard practice or care. As in all medical specialties, thoracic surgeons may face medical malpractice claims. METHODS: Among the files reviewed by the First Board of Specialization of the Council of Forensic Medicine between January 01, 2010, and December 21, 2015, cases with malpractice allegations against thoracic surgeons were analyzed retrospectively. RESULTS: Fifty-nine of the cases were male (72.8%), and 22 were female (27.2%). The mean age was 51.13±18.97 years, and the most common age range was >60 years (n=35, 43.2%). Medical malpractice was confirmed in 11 (13.6%) of the cases. A diagnostic error was the most common cause of error (n=7, 63.6%), and the most common cause of a diagnostic error was failure to diagnose a condition on time (n=4, 36.4%). The most frequent diagnosis was 'injuries due to trauma' (n=54, 66.7%), followed by lung cancer (n=9, 11.1%). It was found that 80.2% (n=65) of the doctors intervened with the patient as a consultant. Complications developed in 48 (59.3%) of the cases. The most common complication was pneumonia (n=7, 14.6%). CONCLUSION: This was the first study in Turkey that included cases of medical malpractice claims that involved thoracic surgeons. We think that examining cases with medical malpractice claims will help physicians not only better understand the characteristics of malpractice claims but also develop strategies to prevent malpractice claims.

Forearm bones and sexual variation in Turkish population.

Forensic anthropologists are aware that there are considerable differences between human populations and therefore develop study models for each skeletal population. The purpose of this study was to analyze forearm bones obtained from forensic settings in Turkey. The sample consists of 42 males and 38 females with an average age of 40 and 36 years, respectively. Numerous measurements were taken from the radius and ulna including lengths (in millimeters), midshaft diameters, and epiphyseal breadths (0.01 mm). Individuals with any anomaly and pathology were not included in the investigation. A stepwise analysis, when applied to individual bones, selected only length and midshaft transverse dimension in the radius and length only in the ulna. When the length was excluded from the statistic, head diameter and distal breadth of the radius and distal minimum head and midshaft anteroposterior diameters of the ulna provided the best predicting functions. Classification results were 92% for the radius and 91% for the ulna. For the incomplete bones, the accuracy rates were about 92% and 83%, respectively. In conclusion, a sex determination was made, in different rates of accuracy, in the human skeleton. Correct assessment can vary among populations. Dimorphism in our region forearm bones is greater than American whites. This supported the hypothesis that human variation is diverse, and population difference should be taken into account when osteometric standards are applied to others. Further studies are needed to understand why the forearm is more dimorphic in Turks.

Medical Malpractice in Turkey: Pediatric Cases Resulting in Death.

BACKGROUND: Malpractice in medicine refers to the failure of a physician to meet a standard of diagnosis and treatment, damages/injuries caused by reprehensible ignorance, or negligence of a doctor. METHODS: Allegedly malpractice cases of pediatricians and the cases in which causal link between malpractice and death was confirmed by the decision of the First Board of Specialization of the Council of Forensic Medicine between the dates of Januray 1, 2012 and December 31, 2014 were analyzed retrospectively. RESULTS: The study revealed that in the majority of 286 cases, the infants were 0-28 days old (n = 115; 40.2%) and were hospitalized due to respiratory problems (n = 111; 38.8%). The allegations of malpractice cases were most frequently seen in private hospitals (n = 120; 42%). Malpractice was found in 17.5% of the cases (n = 50), in which the majority of cased were proved to be diagnostic errors (n = 24; 48%). The most common diagnostic error was the misdiagnosis of "healthy child" in medical malpractice cases (n = 11, 22%). CONCLUSIONS: In conclusion, it is considered to be important for the pediatricians to maintain prope communication with the relatives of the patients while monitoring their health condition, and pediatricians are expected to be more careful-especially in the diagnostic phase-in the cases involving 0-1 age group as children are most likely to be diagnosed as healthy in this age group.

Abnormal proximal musculotendinous junction of the peroneus brevis muscle as a cause of peroneus brevis tendon tears: a cadaveric study.

Abnormal musculotendinous distal extension of the peroneus brevis has been implicated as a possible cause of peroneus brevis tendon tears. We investigated this relationship in 58 (46 male) fresh human cadavers. Torn lesions were classified according to Sobel et al. Musculotendinous distal extension of the peroneus brevis was measured in each ankle as the vertical distance from the musculotendinous junction of the peroneus brevis to the tip of the fibula. Tendons with and without tears were compared by sex, age at death, height, musculotendinous distal extension of the peroneus brevis, the common sheath bifurcation-fibular tip distance, the peroneus brevis and longus width at the musculotendinous junction, fibular groove depth, peroneal tubercle height, superior-inferior peroneal retinaculum wideness, and the presence of the peroneus quartus or an accessory peroneal muscle. Of 115 evaluable tendons, 15 (13%) had tears. All came from men. The average distance from the musculotendinous junction to the tip of the fibula was 27.0 mm in tendons with tears and 16.4 mm in tendons without (P = .04) Male sex (P = .03), age at death (P = .03), height (P = .04), and fibular groove depth (P = .003) were also related to the presence of tears. Our results do not support a relationship between abnormal musculotendinous distal extension of the peroneus brevis and peroneus brevis tendon tears; rather, proximal extension of the peroneus brevis musculotendinous junction may be related to peroneus brevis tendon tears.

Air bag-mediated fatal craniocervical trauma: a case report.

This case report describes a four-year-old girl (102 cm, 17 kg) who sustained fatal craniocerebral injuries as a result of an inflating automobile air bag. The car struck the lid of the sewer system, which was 15 cm above the ground level, at a low speed, and both the driver and passenger air bags inflated. Despite the fact that air bag usage has lessened both the possibility and severity of occupant injuries in frontal collisions, case reports of serious injuries and even deaths especially in children due to air bag deployment, particularly during low speed impacts, highlight the need for changes in both system design and possibly the threshold speed of air bag deployment.

A preliminary study, using electron and light-microscopic methods, of axon numbers in the fornix in autopsies of patients with temporal lobe epilepsy.

Our objective was to show morphological changes of the fornix in autopsies of patients with temporal lobe epilepsy, which may potentially serve for post-mortem diagnosis. Epileptic and non-epileptic autopsy brains were obtained from the council of forensic medicine between the years 2005 and 2007. In both non-epileptic and epileptic autopsies the mean cross-sectional areas and fiber densities of the right and left fornices were calculated and analyzed. The numbers of myelinated and unmyelinated fibers, and the total number of fibers forming each fornix were counted. The total number of fibers in the right fornix was always greater than in the left fornix, in both epileptic and non-epileptic autopsies. The mean total number of fornix fibers was significantly reduced in epileptics compared with non-epileptics, in both the right (p = 0.043) and left (p = 0.043) sides. The electron-microscopic sections showed that myelinated axons outnumbered unmyelinated axons in both epileptic and non-epileptic autopsies. However, the reduction in the number of unmyelinated fibers was only statistically significant for the right fornix in right epileptic autopsies (p = 0.021). Although the reduction in the number of myelinated fibers was not statistically significant, electron-microscopic evaluations showed myelin degeneration of the myelinated fibers in the right fornix of the right temporal lobe in epileptic autopsies. In conclusion, our results suggest that unmyelinated fiber loss is functionally important, and may have functional consequences of diagnostic value.

Evaluation of the functional effects of anterior cruciate ligament bundles: a cadaveric experiment.

The influence of isolated deficiency of the anteromedial or posterolateral bundles of the anterior cruciate ligament (ACL) on knee kinematics has not been fully investigated. Thirty-two cadaveric knees were studied. The fibers of the anteromedial and posterolateral bundles were resected arthroscopically in alternating order in right and left knees. Before and after each arthroscopic cut, laxity tests were performed. Positive results on anterior drawer tests were specific only to the anteromedial bundle-cut knees. Pivot shift tests were positive only in the posterolateral bundle-cut knees. In addition, anterior tibial translation was measured with KT-1000 in response to different external loading conditions. Anterior translation measured with KT-1000 at 67 N and 89 N draw forces at 20 degrees and 40 degrees of flexion may be used in evaluating the integration of each bundle of ACL, both separately and as a whole.

The coracoacromial ligament: the morphology and relation to rotator cuff pathology.

We dissected 80 shoulders from 44 fresh cadavers to define variants of the coracoacromial ligament and their relationship to rotator cuff degeneration. The shapes and the geometric data of the ligaments were investigated, and the rotator cuffs of the cadavers were evaluated macroscopically. Five main types of coracoacromial ligaments were found: Y-shaped, broad band, quadrangular, V-shaped, and multiple-banded. The Y-shaped ligament was the most frequent type, with a frequency of 41.3%, and the V-shaped ligament (11.2%) has not been previously reported. Of the cadavers that were dissected bilaterally, 64% showed the same type of ligament. There was no statistical significance between rotator cuff degeneration and the type or geometric measurement of the ligament. However, the coracoacromial ligaments with more than 1 bundle showed significant association with rotator cuff degeneration with a longer lateral border and larger coracoid insertion.

Sudden death due to congenital pericardial defect: an autopsy case.

Pericardial defects are rare in childhood and outcome is usually benign. Patients may be asymptomatic, but chest pain, emboli, arrhythmia, and sudden death have been described in the literature. We report the case of a 12-year-old boy who suddenly died after mild exercise. A left-sided pericardial defect with a diameter of 8 cm was detected on medico-legal autopsy.

Soccer related sudden deaths in Turkey.

Regular physical exercise is recommended by the medical community, because it offers the potential to reduce the incidence of coronary events. On the other hand, vigorous exertion may act as a trigger of acute myocardial infarction and sudden cardiac death in susceptible individuals. Death during sports activities differs among sports disciplines and countries. In Turkey, soccer attracts more spectators than any other sports activity and the attention of the press and media, and is preferred over other sports by many young and middle-aged individuals. As autopsy-based studies are infrequent in literature and there is a lack of data detailing sudden death during physical activity in Turkey, we present a Turkish series of sudden deaths that occurred during soccer games based on data provided by the Morgue Specialization Department of the Council of Forensic Medicine. We identified 15 male cases of soccer-related sudden death aged from 10 to 48 years. Coronary artery disease was identified as the cause of sudden death in 11 cases. Key pointsThis study is one of the largest series of soccer related SD with reported 15 cases.In our series, CAD is the most common cause of SCD also in very young athletes in contrast with international literature.In autopsy, detailed cardio-vascular system evaluation and toxicological analysis including doping agents are essential to determine precise cause of exercise induced SD.Medical screening is important for all people interested in sport, not only for athletes, as a powerful means of prevention.

Forensic medical evaluation of deaths resulting from inhalation of cigarette lighter refill fuel in Turkey.

Voluntary inhalation/abuse of volatile substances is an important public health problem which especially affects adolescent and young populations worldwide and may be encountered in all socioeconomic and cultural levels. Lighter gas abuse-related death is still an important health problem in Turkey. In this study, 25,265 case files and final reports submitted to the Institute of Forensic Medicine of the First Specialization Board between January 2011 and December 2015 were evaluated retrospectively. In 56 of these cases, lighter gas inhalation (n-butane, propane, isobutane) was recorded as the cause of death. All subjects were male with a mean age of 16.8years. According to eyewitness and crime scene investigation reports, in 48 (85.7%) of the cases, a lighter refill container was found at the scene. It was determined that 21.4% of the cases used a plastic bag to increase the effects of lighter gas and 76.8% inhaled the lighter gas via their mouth and nose. The toxicological analysis of the samples taken while hospitalized showed no lighter refill components (n-butane, propane, isobutane) in 66% of the cases, n-butane in 32.1% of the cases, and n-butane+propane+isobutane in 1.9% of the cases. The importance of lighter gas inhalation-related deaths in Turkey has been increasing. Strict measures against the abuse of these very dangerous substances should be undertaken by the mutual efforts of medical specialists and legislators.

Deaths due to corrosive ingestion: a 10-year retrospective study.

OBJECTIVES: Evaluation of the substances used, macroscopic and microscopic autopsy findings, and the manner of corrosive ingestion deaths in Istanbul are aimed in this study. METHODS: The autopsy records of the corrosive ingestion cases in Istanbul, Turkey, between 1992 and 2001 are investigated in our retrospective descriptive study. RESULTS: The cause of death was determined as "corrosive injury" in 23 (0.089%) cases among 25,763 autopsy cases. Among these cases one was in the child age group and the corrosive substance ingestion was accidental, whereas all the other cases were adults and the ingestion was for suicidal intent. Sixteen (69.6%) of the cases were female. Nitric acid was the most frequent agent with 13 cases (56.5%). Necrosis of esophagus was determined in 19 cases (82.6%) and perforation of stomach in 11 cases (47.8%). CONCLUSION: Guidance and education are important tools for prevention from corrosive injuries, but we believe that the best weapon is to restrict easy access to corrosive agents by prohibiting the free commercialization of these most potent agents.

[Evaluation of medical malpractice in emergency and elective general surgery cases resulting in death]. / Ölümle sonuçlanan acil ve elektif genel cerrahi olgularinda tibbi uygulama hatasinin degerlendirilmesi.

BACKGROUND: General surgery is one of the branches in which the distinction between complication and malpractice is difficult to distinguish. In this study, presentation of the main forensic medical parameters considered for the evaluation of medical malpractice in cases of general surgery deaths in which medical malpractice has been alleged and discussing related concepts through the literature are aimed. METHODS: Allegations of medical malpractice against general surgery physicians sent to the First Forensic Expertise Board of the Council of Forensic Medicine between January 1, 2012 and December 31, 2013 for which the relation of casuality between medical malpractice and death had been determined were retrospectively evaluated. RESULTS: Medical malpractice was ruled in 21.9% (n=23) of 105 cases. The most common primary disease diagnoses were trauma-injury (n=32, 30.5%), cholecystitis (n=25, 23.8%) and appendicitis (n=8, 7.6%). When treatment types were compared according to malpractice decision, rate of malpractice in medicine-only treatment was found to be significantly higher compared to surgery + medical treatment (p=0.003, p<0.01). No statistically significant difference was found regarding the rate of malpractice between cases of emergency and elective surgery (p>0.05). When incidence of medical malpractice was compared between cases with clinical diagnosis and diagnosis determined by autopsy, a statistically significant difference was found (p=0.031, p<0.05). Malpractice was ruled at a significantly lower rate in cases in which diagnosis was confirmed with autopsy (p=0.028, p<0.05). DISCUSSION: It can be concluded that physicians are as successful in emergency conditions as in elective conditions and correct administration of medical treatment is of vital importance. Moreover, the Council of Forensic Medicine considers the clinical follow-up data as well as the autopsy data in medical malpractice evaluation.

Non-ruptured hydatid cyst can lead to death by spread of cyst content into bloodstream: an autopsy case.

Hydatid disease is a parasitic infestation caused by a tapeworm of the genus Echinococcus, and it is common in Mediterranean regions. Cystic lesions cause symptoms via compressing adjacent organs or may be totally silent. Morbidity is usually secondary to free rupture of the echinococcal cyst with or without anaphylaxis, infection of the cyst or dysfunction of affected organs. The cyst of Echinococcus granulosus is commonly located in the liver and frequently causes no symptoms. Anaphylactic reactions as a result of cyst perforation generally occur during interventions such as needle aspiration or open surgery; however, the spillage of cyst fluid with intravascular spread resulting from trauma may also trigger anaphylaxis, and rare case reports of this kind are present in the literature. We report the case of a 17-year-old man who was admitted to the public hospital with a sudden onset of nausea, vomiting and fainting. After a short period of intervention in the emergency department he died. As the cause of his sudden death was unknown, a forensic autopsy was carried out by the Forensic Council of Turkey. The autopsy revealed a macroscopically non-ruptured hydatid cyst in the liver and laryngeal oedema. In histopathological examination, two scolices in the pulmonary artery and inflammatory infiltration mainly composed of mast cells in the larynx were detected. Sudden death in this case was attributed to anaphylactic shock caused by intravascular spread of the cyst contents.