Classic but unexpected: a case of Jefferson fracture.

A man was found lying dead next to a ladder, with only a laceration surrounded by an abrasion visible upon external examination. No skull fractures were palpable. A CT scan and MRI showed a Jefferson fracture of the atlas, associated to a posterior displacement of the skull, a fracture of the dens of the axis, and fractures of the bodies of C5 and C6. Jefferson fractures typically result from a blow to the apex of the skull. In such cases, forensic pathologists should suspect the existence of a Jefferson fracture, particularly when no severe injuries are visible externally.

Imaging mass spectrometry of elements in forensic cases by LA-ICP-MS.

Laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS) was performed to map elements in thin formalin-fixed paraffin-embedded tissue sections of two forensic cases with firearm and electrocution injuries, respectively. In both cases, histological examination of the wounded tissue regions revealed the presence of exogenous aggregates that may be interpreted as metallic depositions. The use of imaging LA-ICP-MS allowed us to unambiguously determine the elemental composition of the observed aggregates assisting the pathologist in case assessments. To the best of our knowledge, we demonstrate for the first time the use of imaging LA-ICP-MS as a complementary tool for forensic pathologists and toxicologists in order to map the presence of metals and other elements in thin tissue sections of post-mortem cases.

Fatal Cervical Spine Injury From Diving Accident.

Spinal cord injuries result after diving into shallow water, often after incautious jumps head first into water of unknown depth during recreational or sport activities. Mortality is generally due to upper cervical trauma. The authors present a case of a diving-related death in a young woman who underwent medicolegal investigations. The measured water depth at the supposed dive site was 1.40 m. Postmortem radiology and autopsy revealed fractures of the body and the posterior arch of the fifth cervical vertebra, a fracture of the right transverse process of the sixth cervical vertebra and hemorrhages involving the cervical paraspinal muscles. Neuropathology showed a posterior epidural hematoma involving the whole cervical region and a symmetric laceration of the spinal cord located at the fourth and fifth cervical vertebra level, surrounded by multiple petechial hemorrhages. Toxicology revealed the presence of ethanol in both blood and urine samples. The death was attributed to cervical spine fracture (C5-C6), spinal cord contusion, and subsequent drowning. This case highlights the usefulness of postmortem radiology, examination of the deep structures of the neck, toxicology, neuropathology, and a detailed research of signs of drowning to formulate appropriate hypotheses pertaining to the cause and mechanism of death.

Hidden lesions: a case of burnt remains.

One of the many challenging cases that forensic pathologists, anthropologists, and forensic imaging experts have to face are burnt human remains. Perpetrators frequently attempt to hide/destroy evidence and make the body unidentifiable by exposing it to fire. We present a case of a partially burnt body found in an apartment after an explosion. First, multidetector computed tomography (MDCT) images and the following autopsy revealed several lesions on the cranium. Forensic anthropologists were involved in order to specify the aetiology of the lesions observed on the cranium. Through an interdisciplinary approach bringing together MDCT scans, 3D surface scans, and anthropological analysis, it was possible to answer the questions raised during the autopsy. Analyses demonstrated that there were signs of blunt force trauma on the cranium vault that the perpetrator likely attempted to hide by exposing the body to fire. This case demonstrates the importance of close collaboration between forensic anthropologists, imaging experts, and forensic pathologists. This multidisciplinary approach allows for a better, more complete reconstitution of forensic cases. Key points: The analyses of burnt human remains are one of the many challenging tasks that forensic pathologists and anthropologists have to face.We present an occurrence of a partially burnt body after an explosion and forensic anthropologists were asked whether the nature of the lesions observed on the cranium could be further specified.Anthropological analyses of the skull were consistent with the radiological and autopsy report. It was possible to reconstruct the various lesions on the dry bone.The case demonstrates the importance of an interdisciplinary approach and the close collaboration between forensic anthropologists, imaging experts, and forensic pathologists.

Clitoral neuroma after female genital mutilation/cutting: a rare but possible event.

INTRODUCTION: Female genital mutilation/cutting (FGM/C), in particular, type III, also called infibulation, can cause various long-term complications. However, posttraumatic neuroma of the clitoris is extremely rare; only one case was previously reported in the literature. AIM: The aim of this study was to describe the case of a patient presenting a clitoral neuroma post-FGM/C in detail and her successful multidisciplinary treatment. METHODS: We report the case of a 24-year-old woman originating from Somalia presenting a type III a-b FGM/C who attended our outpatient clinic at the Geneva University Hospitals complaining of primary dysmenorrhea and a post-mutilation painful clitoral mass. The mass was clinically diagnosed as a cyst and surgically removed. Histopathological analysis revealed that it was a posttraumatic neuroma and a foreign body granuloma around the ancient surgical thread. Our patient was also offered a multidisciplinary counseling by a specialized gynecologist on FGM/C, a sexologist, and a reproductive and sexual health counselor. RESULTS: One month after surgical treatment, the vulvar pain was over. CONCLUSIONS: This is the second case of clitoral neuroma after FGM/C reported and the first with complete clinical, as well as histopathological documentation and multidisciplinary care. Considering the high frequency of clitoral cysts in case of infibulation, clitoral neuroma should be considered in the differential diagnosis. In this case, if symptomatic, the treatment should be surgery, clinical follow-up, and counseling. If necessary, appropriate sexual therapy should be offered too.

Modern post-mortem imaging: an update on recent developments.

Modern post-mortem investigations use an increasing number of digital imaging methods, which can be collected under the term "post-mortem imaging". Most methods of forensic imaging are from the radiology field and are therefore techniques that show the interior of the body with technologies such as X-ray or magnetic resonance imaging. To digitally image the surface of the body, other techniques are regularly applied, e.g. three-dimensional (3D) surface scanning (3DSS) or photogrammetry. Today's most frequently used techniques include post-mortem computed tomography (PMCT), post-mortem magnetic resonance imaging (PMMR), post-mortem computed tomographic angiography (PMCTA) and 3DSS or photogrammetry. Each of these methods has specific advantages and limitations. Therefore, the indications for using each method are different. While PMCT gives a rapid overview of the interior of the body and depicts the skeletal system and radiopaque foreign bodies, PMMR allows investigation of soft tissues and parenchymal organs. PMCTA is the method of choice for viewing the vascular system and detecting sources of bleeding. However, none of those radiological methods allow a detailed digital view of the body's surface, which makes 3DSS the best choice for such a purpose. If 3D surface scanners are not available, photogrammetry is an alternative. This review article gives an overview of different imaging techniques and explains their applications, advantages and limitations. We hope it will improve understanding of the methods.

Understanding scuba diving fatalities: carbon dioxide concentrations in intra-cardiac gas.

INTRODUCTION: Important developments in the diagnosis of scuba diving fatalities have been made thanks to forensic imaging tool improvements. Multi-detector computed tomography (MDCT) permits reliable interpretation of the overall gaseous distribution in the cadaver. However, due to post-mortem delay, the radiological interpretation is often doubtful because the distinction between gas related to the dive and post-mortem decomposition artifactual gases becomes less obvious. METHODS: We present six cases of fatal scuba diving showing gas in the heart and other vasculature. Carbon dioxide (CO2) in cardiac gas measured by gas chromatography coupled to thermal conductivity detection were employed to distinguish decomposition from embolism based on the detection of decomposition gases (hydrogen, hydrogen sulfide and methane) and to confirm arterial gas embolism (AGE) or post-mortem offgasing diagnoses. A Radiological Alteration Index (RAI) was calculated from the scan. RESULTS: Based on the dive history, the intra-cadaveric gas was diagnosed as deriving from decomposition (one case, minimal RAI of 61), post-mortem decompression artifacts (two cases, intermediate RAI between 60 and 85) and barotrauma/AGE (three cases, maximal RAI between 85 and 100), illustrating a large distribution inside the bodies. CONCLUSION: MDCT scans should be interpreted simultaneously with compositional analysis of intra-cadaveric gases. Intra-cadaveric gas sampling and analysis may become useful tools for understanding and diagnosing scuba diving fatalities. In cases with short post-mortem delays, the CO2 concentration of the cardiac gas provides relevant information about the circumstances and cause of death when this parameter is interpreted in combination with the diving profile.

Measurement of ß-tryptase in postmortem serum in cardiac deaths.

Mast cells are well known for their role in hypersensitivity reactions. However, there is increasing evidence that they might also participate in both developing and weakening atherosclerotic plaques, potentially causing plaque instability. Some clinical studies have therefore postulated the existence of relationships between blood ß-tryptase levels and acute coronary syndromes. In this study, we investigated postmortem serum ß-tryptase levels in a series of 90 autopsy cases with various degrees of coronary atherosclerosis that had undergone medico-legal investigations. ß-tryptase concentrations in these cases were compared to levels observed in 6 fatal anaphylaxis cases following contrast material administration. Postmortem serum ß-tryptase concentrations in the anaphylactic deaths ranged from 146 to 979 ng/ml. In 9 out of 90 cases of cardiac deaths, ß-tryptase levels were higher than clinical reference values of 11.4 ng/ml and ranged from 21 to 65 ng/ml. These results indicate that increased postmortem serum ß-tryptase levels can be observed, though not systematically, in cardiac deaths with varying degrees of coronary atherosclerosis disease, thereby suggesting that mast cell activation in this disease cannot be ascertained by postmortem serum ß-tryptase measurements.

Anatomopathological causes of death in patients with advanced cancer: association with the use of anticoagulation and antibiotics at the end of life.

BACKGROUND: Anatomopathological studies that described the immediate causes of death of patients with advanced cancer were first published approximately 20 years ago. OBJECTIVE: Our objective was to analyze if causes of death changed with a wider use of broad spectrum antibiotics and prophylactic anticoagulation. METHODS: We conducted a retrospective study of all patients with an advanced cancer hospitalized in the Division of Palliative Medicine at the University Hospital Geneva from 2004 to 2010 who had an autopsy. RESULTS: Two hundred forty patients were included (130 men, mean age: 74±13). Main causes of death discovered at the autopsy were pulmonary infection (n=131; 55%), advanced cancer (n=39; 16%), pulmonary infection together with pulmonary embolism (PE) (n=27; 12%), PE alone (n=22; 9%), cardiac complications (n=19; 5%) and others (n=2; 1%). In a logistic regression model, with adjusting for age, gender, main diagnosis, comorbidities, blood count, corticosteroids, and antibiotics, there were no independent factors associated with pulmonary infection at autopsy. In a similar model, with adjusting for age, gender, main diagnosis, comorbidities, and anticoagulation, the only independent factor associated with PE at autopsy was the history of thrombo-embolic disease and therapeutic anticoagulation. CONCLUSION: The results of this retrospective study demonstrate that causes of death did not change with the modification of our practice. The high rate of pulmonary infection and embolism in this population, including in patients who received broad spectrum and prophylactic anticoagulation should encourage us to pursue other prospective studies to actually demonstrate the benefit of these treatments in this population.