Medicolegal evaluation of pontine hemorrhage at autopsy- Highlights from a case and an overview

Abstract

One in ten non-traumatic intracerebral hemorrhages (ICH) is located in the pons with chronic arterial hypertension as the leading etiology. In the forensic context, deaths related to a pontine hemorrhage (PH) are usually encountered in situations of drug abuse, excited delirium, trauma, as well as in sudden natural deaths where some hypertensive catastrophe is the usual underlying mechanism. The clinical presentation of PH may be variable, causing a failure in timely diagnosis that, if presents with unexplainable circumstances, may become the subject of medicolegal concern. The present case relates to a middle-aged man with a long history of hypertension and presents during an afternoon with an abrupt onset of deleterious symptoms. The patient was managed conservatively but succumbed to his illness and expires during treatment. A questionable diagnosis and the case circumstances, however, directed the doctors to inform the police. A medicolegal autopsy was therefore carried out that leads to the discovery of a lethal pontine hemorrhage rupturing into the fourth ventricle and involving the adjacent cerebellar tissues as well. Severe atherosclerosis of the basal arteries constituting Circle of Willis and Vertebrobasilar system was seen along with their hallmark effects that became evident during brain sectioning. Pathological stigmata of well established hypertension were found in the heart and kidneys. A clinic pathological correlation of the physical characteristics and topography of the hematoma to its severity was also carried out, based upon the known CT and autopsy findings. The possibility of a drug related or traumatic and secondary brainstem/Duret hemorrhage was ruled out.