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The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.
Compare and contrast the etiologies and clinical presentations of epidural, subdural, subarachnoid, basal ganglionic, and lobar hemorrhages.
Competency 2: Organ System Pathology; Topic NSC: Nervous System--Central Nervous System; Learning Goal 7: Ischemia of the Brain.
Discuss the key components of the death certificate; differences among immediate, intermediate, and underlying (proximate) cause of death based on disease process; and the role of mechanisms of death on a death certificate.
Competency 3: Diagnostic Medicine and Therapeutic Pathology; Topic AU: Autopsy; Learning Goal 2: Death Certificate.
A 47-year-old female with a medical history of migraine headaches, with migraine pain controlled by codeine, is found dead on the floor of her secured residence. No outward signs of trauma or foul play were identified at the scene of death. Given her relatively young age and minimal medical history, an autopsy was requested and performed by the county medical examiner. Following resection of the skull and dura, the following intracranial finding was identified (Figure 1). The pathologist reports that this collection cannot be wiped from the surface of the brain. The hemorrhage appeared to be concentrated at the base of the brain. The circle of Willis was dissected and showed the abnormality identified by the arrow (Figure 2).
The photograph shows subarachnoid hemorrhage. A subarachnoid hemorrhage is confined by the arachnoid layer and cannot be wiped or rinsed away from the brain. Radiographically, subarachnoid hemorrhage would be demonstrated by thin layers of blood overlying structures, such as the sylvian fissure, intrahemispheric fissure, or basal cisterns. Subdural hemorrhage consists of blood filling the potential space beneath the dura, but outside the subarachnoid space. At gross inspection, subdural blood would be able to be wiped or washed away from the surface of the brain and not retained within the cell layer of the subarachnoid space. CT imaging generally shows a crescentic shaped area of hemorrhage outside the brain parenchyma, beneath the skull. Intraparenchymal hemorrhages, such as those related to hypertension or tumors, would be centered within and usually surrounded by brain parenchyma; however, these areas of hemorrhage may expand to communicate with the subarachnoid, subdural, or intraventricular space. CT imaging of intraparenchymal hemorrhage demonstrates blood within the brain itself.
Ruptured berry (saccular) aneurysm, trauma, ruptured arteriovenous malformation, extension of intraparenchymal hemorrhage, hematologic disorders, and coagulopathies.1 Of these entities, the most common cause of clinically significant subarachnoid hemorrhage is due to a ruptured berry aneurysm.1
Ruptured berry (saccular) aneurysm.
Statistics vary, but up to 50% of patients die within 1 month of an intracerebral aneurysmal rupture and hemorrhage.1 Similar to this patient, at least 10% of patients die prior to hospitalization for the first bleed.1 If a patient survives, major morbidity manifests as delayed ischemic complications related to vasospasm, rebleeding, seizures, hydrocephalus, and hyponatremia.1
The cause of death is the injury or disease process that resulted in a patient’s death. Manner of death is defined by public health parameters and is a selection of natural, accident, suicide, homicide, or undetermined. A death certificate should tell the whole story of a patient’s history and should work backward from the underlying cause of death to the immediate cause of death. Care should be taken to ensure that the death certificate is specific, concise, and avoids nonspecific mechanisms of death that are universal to all deaths, such as the phrase cardiorespiratory arrest. As such, the first disease process that occurred in this patient’s case was the rupture of the berry aneurysm leading to the subarachnoid hemorrhage. Both of these processes are natural diseases; therefore, the death certificate should be completed as follows:
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.