Fatal Intracranial Aneurysms and Dissections Causing Subarachnoid Hemorrhage: An Epidemiological and Pathological Analysis of 607 Legal Autopsy Cases

Forensic neuropathology in the past decade: a scoping literature review

While there has been notable research activity in the field of clinical neuropathology over the recent years, forensic approaches have been less frequent. This scoping literature review explored original research on forensic neuropathology over the past decade (January 1, 2010, until February 12, 2022) using the MEDLINE database. The aims were to (1) analyze the volume of research on the topic, (2) describe meta-level attributes and sample characteristics, and (3) summarize key research themes and methods. Of 5053 initial hits, 2864 fell within the target timeframe, and 122 were included in the review. Only 3-17 articles were published per year globally. Most articles originated from the Europe (39.3%) and Asia (36.1%) and were published in forensic journals (57.4%). A median sample included 57 subjects aged between 16 and 80 years. The most common research theme was traumatic intracranial injury (24.6%), followed by anatomy (12.3%) and substance abuse (11.5%). Key methods included immunotechniques (31.1%) and macroscopic observation (21.3%). Although a number of novel findings were reported, most were of preliminary nature and will require further validation. In order to reach breakthroughs and validate novel tools for routine use, more research input is urged from researchers across the world. It would be necessary to ensure appropriate sample sizes and make use of control groups.

Fusiform aneurysms of anterior cerebral artery: center experience and systematic literature review

Fusiform aneurysms of the anterior cerebral artery (ACA) are uncommon, and the natural history of this entity is poorly characterized. Along with our center experience, we conducted a systematic literature review to help shed light on the clinical course of ACA fusiform aneurysms. We queried our institutional database to identify cases with fusiform aneurysms of ACA. In addition, following the PRISMA algorithm, we identified all reported cases published in the English literature from the inception of PubMed until December 2022. We categorized clinical presentations into three categories: (i) traumatic/iatrogenic, (ii) spontaneous symptomatic ruptured/unruptured, and (iii) spontaneous asymptomatic aneurysms. We utilized descriptive statistics. We identified seven cases from our center along with 235 patients from published literature. Blunt trauma was responsible for the development of 19 aneurysms. Sixty-three percent of these aneurysms tend to rupture within 2 weeks from the initial trauma, and despite treatment, only 74% of these patients had good clinical outcomes. Spontaneous symptomatic presentation occurred in 207 patients and was often associated with previous/concomitant ACA dissection. Subarachnoid hemorrhage from ruptured aneurysms was the most common presentation. Spontaneous symptomatic fusiform aneurysm is rapidly evolving lesions, and treatment is necessary. Three of our own cases were treated with an endovascular flow diverter (pipeline) stenting with good outcomes. Spontaneous asymptomatic aneurysms were reported in nine patients. These lesions are often associated with other vascular abnormalities. Treatment included surgical clipping with good clinical outcomes. Instead, four patients from our center database were managed conservatively with equally good outcomes. Our study demonstrates good clinical outcomes when fusiform aneurysms of ACA, especially when symptomatic, are treated promptly with either reconstructive or deconstructive therapies.

Acute hemicranial pain accompanied with a pearl and string type dissection of intracranial vertebral artery: Consideration for the time when to finish the medical observation

The International Classification of Headache Disorder (ICHD) clearly guides the suspicion of intracranial vertebral artery dissection (ICVAD) in headache patients, but guidelines on how observational or imaging studies should be performed to detect dangerous progression early are unclear. Fifty-six cases with pearl and string type intracranial vertebral artery dissection were divided into 3 groups: 39 in the headache group, 6 in the infarction group, and 11 in the hemorrhagic group. Clinical and angiographic data were analyzed and compared. Most headaches resolved within 2 weeks and did not exceed 8 weeks. Of the 33 patients (84.6%) who underwent continuous follow-up imaging, 18 (54.5%) returned to normal, but 3 (9%) had deteriorated. All the patients survived without subsequent bleeding or infarction. Image changes started before 3rd month and ended after 6 to 7 months. In acute ICVADs, image changes occur at the same time as the headache resolves and continue for several months after the headache has subsided. Since the dissection is likely to worsen even after the headache disappears, the image changes continue over several months, and prediction of rupture of unruptured ICVAD is unpredictable, it is desirable to conduct continuous imaging studies regularly after the initiation of dissection until stabilization is confirmed.

Growth of unruptured aneurysms: A meta-analysis of natural history and endovascular studies

The growth of unruptured intracranial aneurysms (UIAs) is a strong predictor of rupture. Clinical observations suggest that some UIAs might grow faster after endovascular treatment than untreated UIAs. There are no head-to-head comparisons of incidence rates of UIAs thus far.

METHODS

We searched PubMed, Embase and Google Scholar for relevant articles from the inception of the databases to March 2020. We pooled and compared the incidence rates for the growth of aneurysms from natural history studies and endovascular treatment studies. Generalized linear models were used for confounder adjustment for the prespecified confounders age, size and location.

RESULTS

Twenty-five studies (10 describing growth in natural history and 15 reporting growth after endovascular therapy) considering 6325 aneurysms were included in the meta-analysis. The median size of aneurysms was 3.7 mm in the natural history studies and 6.4 mm in endovascular treatment studies (p = 0.001). The pooled incidence rate (IR) of growth was significantly higher in endovascular treatment studies (IR 52 per 1000 person-years, with a 95% confidence interval (CI) 36-79) compared to natural history studies (IR 28 per 1000 person-years, 95% CI 17 - 46, p-value < 0.01) after adjustment for confounders.

CONCLUSION

Our results suggest that the incidence rate of cerebral aneurysm growth might be higher after endovascular therapy than the incidence rates reported in natural history studies. These results should be viewed in light of the risk of bias of the individual studies and the risk of ecological bias.

Associations between socioeconomic status and place of residence with survival after aneurysmal subarachnoid haemorrhage

OBJECTIVES

This study aims to understand early (< 24 h post ictus) and late (up to 12 months) survival post aneurysmal subarachnoid haemorrhage (aSAH), with a focus on rurality and socioeconomic status.

METHODS

A statewide population-based cohort of aSAH cases in Tasmania, Australia, was established from 2010-2014 utilising multiple overlapping sources. Clinical data were collected from medical records and the Tasmanian Death Registry, with area-level rurality and socioeconomic status geocoded to participants' residential address.

RESULTS

From a cohort of 237 (70% women, 36% disadvantaged, 38% rural) individuals over a 5-year period, 12-month mortality was 52.3% with 54.0% of these deaths occurring within 24 h post ictus. In univariable analysis of 12-month survival, outcome was not influenced by socioeconomic status but rural geographical location was associated with a non-significant increase in death (HR 1.22 95% CI 0.85-1.75) along with hypertension (HR 1.78 95% CI 1.07-2.98) and hypercholesterolemia (HR 1.70 95% CI 0.99-2.91). Multivariable analysis demonstrated a statistically significant increase in death to 12 months after aSAH for both hypertension (HR 1.81 95% CI 1.08-3.03) and hypercholesterolemia (HR 1.71 95% CI 1.00-2.94) but not socioeconomic status or geographic location.

CONCLUSION

We found high early death in this population-based aSAH Australian population. Survival to 12 months after aSAH was not related to either geographical location or socioeconomic status but modifiable risk factors increased the risk of death. This article is protected by copyright. All rights reserved.

Spontaneous Subarachnoid Haemorrhage as a Cause of Out-of-Hospital Death

BACKGROUND

There are no recent studies on the incidence rate of out-of-hospital death due to spontaneous subarachnoid haemorrhage (SAH). The primary aim of this study was to determine how often SAH was the cause of out-of-hospital death. The secondary aim was to determine if decedents had contacted any health care services within the last 72 h prior to the time of death.

METHODS

This was a retrospective cohort study. The reports of all autopsies carried out at the Department of Forensic Medicine in the Capital Region of Denmark in a ten-year period were read. Police records and Emergency Medical Services (EMS) telephone records were searched for health care contacts within the last 72 h prior to the time of death. Descriptive statistics were used, and to analyse the incidence rates for trend Poisson regression was used.

RESULTS

In total, 6,903 decedents underwent autopsy. Out-of-hospital SAH was the cause of death in 58 decedents, resulting in an average incidence rate of 0.34 per 100.000 persons per year. No significant change in the incidence rate over time was found (p = 0.52). No EMS data were available for eleven decedents in the first part of the study period. Of the remaining 47 decedents, 2 (3.5%, 95% CI: 0.4-11.9) had called the EMS, and in regards to 27 of the 58 decedents, the police records contained information on health care system contacts. Five (8.6%, 95% CI: 2.9-18.9) patients had contacted a general practitioner and three (5.2%, 95% CI: 1.1-14.4) patients had been admitted to hospital but were discharged again within 72 h prior to their death.

CONCLUSION

The incidence rate of out-of-hospital death from SAH was 0.34 per 100.000 persons per year and remained stable across the years 2009-2018. Several patients had sought medical attention shortly before their death, emphasizing the vital importance of recognizing the early symptoms of SAH.