Sudden death

whose deaths are

not expected, who suddenly collapse and die.
Have a history of a serious disease.
die as a result of a chronic or terminal disease,
but who have elected to die at home.
Sudden deaths can be instantaneous; sudden
but not instantaneous, or cases where the
individual is found dead
 instantaneous deaths.
an individual walking along suddenly collapses
and is dead upon hitting the ground. a
ventricular arrhythmia due to coronary artery
disease.
The individual will often show impact abrasions
of the face, indicating that as he was going down,
he was unconscious and was not even able to
put his arm up in front of his face to prevent
impacting the ground
 The sudden, but not instantaneous,
death
Individual who begins to complain of chest
pain, difficulty in breathing,
weakness,sweating, nausea, and vomiting,
and then collapses.
transported To the hospital. On the way to
the hospital, he goes into cardiac arrest and by
the time he reaches the emergency room he is
not resuscitatable.
 If the individual complaining of chest pain and
difficulty breathing survives long enough to
get to the emergency room of a hospital,
where an EKG shows an acute myocardial
infarct and laboratory tests reveal elevated
enzymes, then a diagnosis of myocardial
infarct can be made is not a forensics case.
 Death due to natural death
 Cardiovascular disease
Cardiovascular disease is the most common cause
of death in the United States.
Sudden cardiac death causes between 300,000
and 400,000 deaths a year.
There is a circadian variation in the incidence of
sudden death, with a peak incidence in the early
morning increased activity of the sympathetic
nervous system, known to occur in the morning,
which may predispose to cardiac arrhythmias.
 Coronary Atherosclerosis
In a study of 500 consecutive autopsies of
individuals aged 2099 years who died
suddenly and unexpectedly of coronary artery
disease, only 67 (13.4%) showed acute
thromboses, grossly.
The left coronary artery and its branches
showed a slightly higher incidence of
thrombosis compared with the right.
 What is present in all deaths due to coronary
atherosclerosis is severe atherosclerosis of the
coronary vessels. Significant obstruction of the
coronary artery lumen usually requires 75%
narrowing of the lumen.
In individuals with hypertensive cardiovascular
disease, one often does not see the classical
eccentric narrowing due to plaque formation of
pure coronary atherosclerosis, but rather
concentric thickening of the walls by
atherosclerotic deposits.
 In some individuals, while the epicardial
coronary arteries appear nonoccluded,
microscopic examination of the myocardium
reveals severe, occlusive dysplasia of the
intramural coronary arteries.
The dysplasia is characterized by severe
medial thickening, with smooth muscle
disorganization and marked luminal
narrowing.
 Bridging
the left anterior descending coronary artery
(very rarely the right coronary), instead of
lying in the epicardial fat of the heart, dips
down into the myocardium
In bridging, there is compression of the vessel
during systole with either partial or complete
occlusion of the lumen nearly all coronary
blood flow to the left ventricle occurs during
diastole.
 With tachycardia, however, there is a shortening
of diastolic perfusion This may allow the systoli
compression to become significant.
This would explain the observation that sudden
death in bridging is seen more often in association
with exercise.
The mechanism of sudden death in most
individuals with coronary artery disease is the
sudden onset of ventricular tachycardia, which
either is sustained or, in most cases, progresses
to ventricular fibrillation (approximately 80%).
 Hypertensive Cardiovascular Disease
Sudden death in individuals with hypertension is
usually associated with, and probably in most
instances due to, accompanying coronary
atherosclerosis.
In some individuals with a history of hypertension
who die suddenly and unexpectedly, the autopsy
will reveal only an enlarged heart with marked
left ventricular hypertrophy and minimal or
absent coronary atherosclerosis
 The mechanism of death in these cases is a
cardiac arrhythmia, most likely ventricular
fibrillation.
Deaths Due to Intracranial Lesions
the most common cause of sudden death due
to an intracranial lesion is epilepsy
approximately 34% of all natural deaths
Typically, individuals dying suddenly and
unexpectedly of epilepsy are young and show
either subtherapeutic levels or absence of
epileptic medications on toxicological analysis
 Usually, but not always, such deaths are
unwitnessed, with the victims often found
dead in bed in the morning.
probably because sleep predisposes to
epileptic attacks and, in fact, is used as a
provocative diagnostic technique.
Sleep has also been found to affect cardiac
vulnerability to arrhythmia in that sudden
death secondary to arrhythmias often occurs
in the morning, immediately before or at the
time of awakening.
 Diagnosis of death due to epilepsy is, for the
most part, a diagnosis of exclusion.
At autopsy, there are no pathonomonic
findings
25% of the cases, a bite mark of the tongue
might indicate a seizure, but seizures as a
terminal event can occur in other entities.
 Nontraumatic Subarachnoid
Hemorrhage
The second most common cause of sudden
unexpected death due to natural disease of
the brain is nontraumatic subarachnoid
hemorrhage
Berry aneurysms are the most common cause
of subarachnoid hemorrhage, followed by
intracerebral hemorrhages and, to a lesser
degree, rupture of arteriovenous
malformations.
 Berryaneurysms are located, for the most
part, at the point of bifurcation and branching
of the cerebral arteries, with approximately
90% found in the anterior cerebral, middle.
Cerebral and internal carotid arteries.
When rupture occurs, there is generally
hemorrhage into the subarachnoid space.
 Intracerebral Hemorrhage
is characterized clinically by an abrupt onset
and rapid evolution.
Hypertension is virtually always present.
The primary sites for intracerebral
hemorrhages are the putamen and adjacent
internal capsule, the thalamus, the cerebellar
hemispheres, the pons, and the white matter