Two Autopsy Cases Assessing the Association of Rare Tumors
Case 1
80-year-old female, who consumed alcohol in a bar, fell down the stairs upon returning home and was later found deceased. A postmortem CT did not confirm the presence of a tumor. An autopsy confirmed diffuse subarachnoid hemorrhage and a tumor, with a white surface covered by microvasculature pressing on the optic chiasma. The cause of death was traumatic subarachnoid hemorrhage due to an injury to the head while under the influence of alcohol. However, given the formation of a tumor pressing on the optic nerve, a possible causal relationship between the epidermoid cyst and the head injury cannot be excluded.
Case 2
60-year-old male, discovered dead in his own home. The autopsy confirmed subarachnoid hemorrhage around the base of the brain, and there was a hematoma-like tumor connected to the pituitary gland. The cause of death was determined to be pituitary bleeding due to pituitary adenoma. As seen in these cases, it is possible that a tumor at the base of the brain, which is a difficult location for identification, would impact the process of death; therefore, studying the grade of tumor, stage, and its involvement in the cause of death are diagnostically critical in forensic autopsies.
Introduction
Tumors occurring adjacent to the sella turcica not only put pressure directly on the base of the cerebrum, brain stem, and cerebellum but also involve cranial nerves and blood vessels that penetrate the base of the skull. Therefore, in addition to the symptoms caused by pressure on adjacent cranial nerves, symptoms of intracranial hypertension are often the chief complaint. As computed tomography (CT) and magnetic resonance imaging (MRI) became available, diagnosis of tumors in the sella turcica has become more accurate; however, understanding the properties of tumors and their relationship with surrounding tissues to examine the causal relationship with death is extremely important in forensic pathology. There have been only a few reports on confirmed tumors adjacent to the sella turcica in forensic science. In this report, we examined two cases in which tumors were macroscopically confirmed near the sella turcica based on forensic pathological evidence and reviewed past case reports.
Case Reports
Case 1 was an unemployed 80-year-old female, who resided with her brother, sister, and brother-in-law and had a history of hypertension. The case subject returned home after consuming alcohol at a bar. In the early morning of the following day, the subject was found dead at the landing of a staircase lying on her back. The subject was not transferred to an emergency hospital. An autopsy was performed one and a half days after the death.
A post-mortem head CT showed subcutaneous bleeding slightly to the left of the occipital region and a linear longitudinal fracture from the top of the head to the right forehead. The brain showed mild swelling, and a subarachnoid hemorrhage was found around the base of the brain
Case 2 was a male taxi driver in his 60s who lived alone. His medical history included hypertension and insomnia, and they had been on leave for the last several years. He was discovered lying in his living room and was estimated to have been deceased for several days.
Postmortem Imaging
In a postmortem CT, a hematoma of 2cm in diameter was discovered in the sella turcica at the base of the brain. Diffuse subarachnoid hemorrhage was confirmed through the cerebrum, centered around the base of the brain (Figures. 4a, and b). There was no fracture of the skull. There were multiple parallel fractures on the outer parts of the right dorsal ribs, and pneumothorax was present on the right side.
Discussion
The cause of death in Case 1 was determined to be traumatic subarachnoid hemorrhage due to a contusion to the occipital region. Since the Case 1 subject was highly inebriated, there is a high likelihood that alcohol was involved in her death, but the epidermoid cyst found in this case was located at the chiasmatic groove and pressing on the optic nerve; therefore, it is possible that the subject was experiencing visual field impairment. Epidermoid cysts comprise about 1% of brain tumors and have only been reported in eight autopsies published in international journals. The ages of the subjects in these reports range from 4-66 years (median: 36 years), which is relatively young, and there were six males and two females. Only two of the eight cases had a clear and direct connection between the tumor and death. Among the eight reported cases, half of the patients had complications of malignant tumors, and these cases had a history of infections in their medical record. Though the details of a causal relationship between infection and malignant tumors are unknown, there are reports of infections spreading through the cerebrospinal fluid. Among the eight reported cases, the location of the tumor was often at the base of the brain, particularly in the brain stem, and the main clinical symptoms were those of the central nervous system, which were observed even in tumors measuring only about 1 cm in size. The pituitary gland adenoma in Case 2 was an extrasellar extension that protruded from the sella turcica according to the radiological diagnostic classification, and diffuse bleeding had spread from the pituitary adenoma at the base of the brain. On the other hand, injuries on the back included multiple rib fractures, lung contusion, and pneumothorax, but the thoracic cavity was not open to the air, and there were no subcutaneous emphysema or injuries to large vessels. In addition to the delayed death that Case 2 presents, the lung contusion was also localized. Macroscopically, the lung contusion did not have valvular findings or extreme mediastinal displacement; therefore, there was no rationale to assert that pneumothorax was the primary condition. The direct cause of death in Case 2 was determined to be pituitary gland bleeding caused by the pituitary adenoma. The lung injury and pneumothorax caused by multiple rib fractures from the contusion to the right side of the back were not the direct causes of death but may have played a role. There was no history of treatment for Cases 1 or 2, and only hypertension was noted in the medical history of both subjects. These two cases resulted in an autopsy due to traumatic findings. However, since the tumors were at the base of the brain, which is difficult to diagnose, they may have played a role in their deaths. Therefore, we consider that examining the malignancy and stages of the tumors, their relationship with surrounding tissues, and their involvement in the death of the subject, in addition to examining possible foul play, is diagnostically important in forensic autopsies.
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