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Longitudinal brainstem laceration associated with complexbasilar skull fractures due to a fall: an autopsy case

Bao-Li Zhu*, Li Quan, Kaori Ishida, Mari Taniguchi, Shigeki Oritani,Masaki Q. Fujita, Hitoshi Maeda

Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, Osaka 545-8585, Japan

Received 13 June 2000; received in revised form 11 May 2001; accepted 29 January 2002

Abstract

This report describes an autopsy case of a rare longitudinal brainstem laceration associated with complex basilar skull

fractures. The victim was a 40-year-old male who died immediately after falling from a roof (9.2 m in height) of a factory onto a

concrete oor. The postmortem examination revealed an incomplete ring fracture of the base of the skull with longitudinal

fractures of the sphenoid (clivus of the dorsum sellae turcicae) and occipital bones, cerebral contusions in the frontal and

temporal poles, a longitudinal brainstem laceration at the posterior median sulcus of the pons accompanied with multiple

contusional hemorrhages in the brainstem and corpus callosum. Related blunt-force injuries were observed in the parieto-

occipital region of the head, shoulder and upper back involving the fractures of the cervical and thoracic vertebrae, and sternum

and ribs, indicating a huge impact to the occiput and subsequent impression of the vertebral column into the base of the skull due

to violent anteroexion of the neck, which caused the complex basilar skull fractures, contusions and longitudinal laceration of

the brainstem. # 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Forensic pathology; Ring fracture of the base of the skull; Brainstem injury; Fall

1. Introduction

Brainstem lesions can occur in relation to downward

displacement due to a huge centro-axial impact to the head

[1,2]. Traumatic ponto-medullary and/or cervico-medullary

avulsion can be caused by violent posterior or lateral hyper-

extension of the neck from trafc accidents, often accom-

panying ring fractures of the base of the skull [36]. Other

various mechanisms have been suggested for ring fractures[412], which may be accompanied by a variation of brain-

stem injuries. However, there is no report of a longitudinal

brainstem laceration.

This report describes a rare autopsy case of a longitudinal

brainstem laceration associated with complex basilar skull

fractures due to a fall.

2. Case report

2.1. Case history

A 40-year-old workman was working with two colleagues

on a roof (9.2 m in height) of a factory for the repair. With a

crack of the roof slate, where he had been standing, he

suddenly disappeared. His colleagues found that he had

fallen, lying down on his back on the concrete oor justunder a large opening of the broken roof slate. His death was

conrmed 14 min later at the hospital. Police investigation

proved the fall from the broken roof. To exclude the possible

contribution of alcohol, drugs or diseases, a forensic autopsy

was performed about 8 h after death.

2.2. Autopsy ndings

The body was slender: 164 cm in length weighing 51 kg.

Slight dark red-purplish postmortem hypostasis was

observed on the back. Postmortem rigidity developed mod-

erately. Conjunctivae were pale without petechiae. Pupils

Forensic Science International 126 (2002) 4042

* Corresponding author. Tel.: 81-6-6645-3767;

fax: 81-6-6634-3871.

E-mail address: baolizhu@med.osaka-cu.ac.jp (B.-L. Zhu).

0379-0738/02/$ see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.

PII: S 0 3 7 9 - 0 7 3 8 ( 0 2 ) 0 0 0 2 9 - 4

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were round and isocoric (0.5 cm in diameter). There was a

contusional laceration (2 cm 5 cm) with a marked abra-

sion (5 cm 3:5 cm) and a subgaleal hematoma (10 cm

10cm 0:6 cm) in the parieto-occipital region of the head,

a longitudinal fracture of the occipital bone with diastasisof the sagittal suture, bilateral transverse fractures in the

middle cranial fossa and an incomplete ring fracture of the

base of the skull with longitudinal fractures of the sphenoid

bone (clivus of the dorsum sellae turcicae) (Fig. 1). The

brain was swollen, weighing 1190 g, and had sustained

contusions in the frontal and temporal poles, a longitudinalbrainstem laceration at the posterior median sulcus of the

pons accompanied with multiple contusional hemorrhages in

the brainstem and corpus callosum (Fig. 2). There were

marked bruises in the shoulder and upper back involving a

Fig. 1. Incomplete ring fracture of the base of the skull with a

longitudinal fracture of the sphenoid bone (arrow).Fig. 2. Longitudinal brainstem laceration (arrow) at the posterior

median sulcus of the pons accompanied by multiple contusional

hemorrhages in the brainstem and corpus callosum. The posterior

parts (A) and a cross section (B) of the pons.

Fig. 3. Histological ndings of the pons: marked fresh hemorrhages and edema around the longitudinal laceration of the contusion areas

(HE, 200).

B.-L. Zhu et al. / Forensic Science International 126 (2002) 4042 41

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compression fracture of the body of the 9th thoracic verte-

bra, fractures of the spinous processes of the 6th and 7th

cervical and the 3rd8th thoracic vertebrae, fractures of the

sternum and ribs and pulmonary contusions. Alcohol was

not detected in the blood. A drug screen of the serum and

urine was negative.

2.3. Histological ndings

There were marked hemorrhages and edema around the

longitudinal brainstem laceration of the pons and contusion

areas (Fig. 3). Otherwise, no pathological evidence other

than congestion was found.

3. Discussion

In the present case, the cause of death was determined as

brainstem injuries involving contusions and a lacerationassociated with an incomplete ring fracture of the base of

the skull and a longitudinal fracture of the sphenoid bone

from a blunt-force impact to the occiput. Causal mechanisms

for ring fractures of the base of the skull have been described

as traction of the head by hyperextension [48] or by

anteroexion [911], shearing effect [10,11], torsion due

to rotation [10], wedge effect against the frontal bone [10]

and impression of the vertebral column into the base of the

skull [11,12]. The localization and distribution of the head

and upper back injuries indicated a head-rst fall causing a

huge impact to the occiput and subsequent impression of the

vertebral column into the base of the skull due to violentanteroexion of the neck and back, which was suggested by

a compression fracture of the 9th thoracic vertebra. These

injuries localized at the occiput and upper back were con-

sistent with the witnessed circumstantial evidence of a fall

from a height of 9.2 m nally facing upward. The centro-

axial force can explain the causal mechanism of the complex

fractures of the base of the skull and brainstem contusions.

The rst impact to the occiput may have caused the long-

itudinal occipital bone fracture, and then, impression of the

vertebral column into the base of the skull may have

produced the longitudinal sphenoid bone fracture and

incomplete ring fracture, which ended at the right margin

of the longitudinal occipital bone fracture. There was noevidence of any other impact to cause these skull fractures.

Thus, the skull base fractures were considered to be a

variation of an incomplete ring fracture due to impression

of the vertebral column. The longitudinal laceration of the

pons appeared to be caused from compression by the buld-

ging edges of longitudinal fracture of the sphenoid bone

(clivus of the dorsum sellae turcicae). Substantial hemorrhage

and edema without an inammatory response in the reticular

formation around the laceration suggested peracute death.

In conclusion, an autopsy case of a rare longitudinal

brainstem laceration associated with complex basilar skull

fractures has been reported. Buldging edges of the long-

itudinal sphenoid bone fracture appeared to have contributed

to the fatal injury.

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