ARTIFACTS IN NECK WHILE CONDUCTING AUTOPSY

ARTIFACTS OF NECK RELATED AUTOPSY

1. ARTIFACTS IN NECK Fact or Artifact?—A Retrospective Analysis of Patterns of Postmortem Anterior Neck Muscle Hemorrhages From Hypostasis Versus Strangulation Kaileigh Bingham- Abujasen , Jessicia Schmitt, and Laura Knight. Presentation :Dr. Haneef Shaik Moderator : Dr. Asrarul Haque

2. Outline of presentation Definition Introduction Types of artifacts in the neck Materials and methods Results Discussion References 2

3. Definition something observed in a scientific investigation or experiment that is not naturally present but occurs as a result of the  preparative  or  investigative  procedure. A post-mortem artifact is  any change caused in the body after death that is likely to lead to misinterpretation of medically significant antemortem findings . It is introduced in the period between death and autopsy or during autopsy. 3

4. Introduction Postmortem Artefacts is any alteration or introduction of new features into the cadaver which is physiologically and pathologically unrelated to its natural state and is likely to cause misinterpretations for the investigators or a layman unfamiliar with this phenomenon. It is imperative for the autopsy surgeons to know the various types of Artefacts, so that erroneous conclusions may be avoided which otherwise may lead to the inquest heading in the wrong direction and may lead to a miscarriage of justice. Rayamane , Anand & Thejaswi , H.T. & Puneeta , Dr & Kalai , Dr & H, Dr & C . ARTEFACTS AND ITS MEDICO-LEGAL PROBLEMS. Journal of Forensic Medicine, Science and Law A Journal of Medicolegal Association of Maharashtra.2013 3(22) p 46. 4

5. The Deceased found hanging in a closed room in lying down position over ground with slightly raised upper half of the body and ligature material tied at the window. Relatives of body noticed discoloration (darkening) over face, front of chest and abdomen and alleged it as a case of poisoning and murder. With great difficulty it was explained to them that the darkening of the body was due to the postmortem staining over dependent parts like face, chest, abdomen and both upper limb Rayamane , Anand & Thejaswi , H.T. & Puneeta , Dr & Kalai , Dr & H, Dr & C . ARTEFACTS AND ITS MEDICO-LEGAL PROBLEMS. Journal of Forensic Medicine, Science and Law A Journal of Medicolegal Association of Maharashtra.2013 3(22) p 46. 5

6. Types of artefacts The five main pitfalls and artefacts encountered in the neck at autopsy can be classified as follows: 1) development of the hyoid bone; 2) triticeous cartilage; 3) Prinsloo-Gordon hemorrhage ; 4) postmortem hypostatic hemorrhage; and 5) resuscitation-related neck injury. 6

7. DEVELOPMENT OF HYOID BONE The hyoid is divided up into a horizontal component known as the body of the hyoid, which is present in the ventral aspect of the neck. T wo greater cornua , which project posteriorly and slightly superiorly in the neck. T wo lesser cornua (which are often very poorly visualized at autopsy) emerge from the body of the hyoid bone and project inferiorly. The greater cornua and the body of the hyoid bone in early development are three separate bony structure which are connected by two synchondrotic joints. The synchondrotic joints are composed of fibrous connective tissue, which is heavily collagenized. During the developmental progression of the hyoid bone in adulthood, the synchondrotic joints are progressively ossified. This transforms the three separate bones of the hyoid into one continuous structure. the developmental progression is variable in timing and may not be symmetrical in all people On this basis, the synchondrotic joints may be unfused or partially unfused on one or the other side of the hyoid bone. This can result in mobility and flexibility of the greater cornu at the junction point between the greater cornu and the body of the hyoid. This can be misdiagnosed as a fracture unless the developmental anatomy of the synchondrotic joint is known 7

8. Radiological development of hyoid bone 8

9. Triticeous Cartilage of the Larynx T riticeous cartilages are small pieces of fibrocartilage that are linear or round, in the millimeter-size range. These cartilages are present in the fibrous connective tissues that link the superior horns of the thyroid cartilage to the suspensory ligaments and soft tissues of the superior anterior neck, adjacent to the hyoid bone. The main pitfall associated with triticeous cartilages is the misdiagnosis Of fractures of the superior cornu of the thyroid cartilage This is of great practical relevance because the most common fracture associated with strangulation is fracture of the superior cornu of the thyroid cartilage. Usually such fractures are present at the base of the superior cornua however, sometimes the tips or distal one-third of the superior cornu are fractured in cases of strangulation. the main mainstays of differentiating laryngeal fracture from triticeous cartilages is the presence of hemorrhage. However, if interpretative difficulties persist after careful macroscopic examination, histological examination is often helpful. 9

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11. Radiological finding 11

12. Prinsloo-Gordon Hemorrhage Prinsloo and Gordon called attention to the misinterpretation of extravasation of blood into the soft tissues of the neck, entirely due to dissection, as a mimic of bruising related to trauma. Essentially, handling (blunt dissection) and incising congested blood vessels(sharp dissection) can cause blood to track between and within the strap muscles. 12

13. Postmortem Hypostatic Hemorrhage The postmortem hypostatic hemorrhage is the extravasation of blood into the interstitium when two conditions are met. First, a congested venous plexus is distended with blood due to the gravitational effect of livor mortis. Second, there is a loss of vascular integrity of the venous channels due to autolysis or decomposition. When these two factors operate together, the combined effect is the formation of focal perivascular extravasation of blood or extensive interstitial infiltration of blood. The postmortem hemorrhages that occur in the skin in cases of hanging with pronounced lividity in the lower extremities. These postmortem hypostatic petechial hemorrhages (often known as Tardieu spots) are a typical example of postmortem hypostatic hemorrhages 13

14. Postmortem hypostatic hemorrhages in a 36-year-old female who died of multiple drug intoxication and was found in the prone position Left side of neck and face with extensive postmortem hypostasis Marked diffuse subconjunctival hemorrhage 14

15. C) Hypostatic hemorrhages in the subcutaneous tissues of the left side of the face. D) Hypostatic hemorrhages in the subcutaneous tissues of the left upper neck. 15

16. Materials and methods Type of study : retrospective case-control type Place: Washoe County Regional Medical Examiner's Office (WCRMEO) in Reno, Nevada. Time period : July 2021 to March 2022. All autopsy reports from January 2020 to December 2021 Inclusion criteria : case to have anterior neck hemorrhage documented in the report. Tongue hemorrhages for artifact cases were included if there had been no medical intervention such as intubation, and no overlying bite defects, and it was not described in the evidence of injury section. Exclusion criteria: eliminated factors that could cause the hemorrhage such as medical interventions (such as vascular puncture) in the areas of hemorrhage and traumatic injuries Controls : were selected based on the presence of anterior neck hemorrhage in those strangulation cases. Published in American Journal of Forensic Medicine Pathology 2023;44: 145–149) 16

17. analyzed for the position manner and circumstances of death, age, medical interventions, neck musculature hemorrhage. Data were analyzed in the form of frequency and percentage QUALITATITVE analysis: Fisher exact test was used for neck muscle involvement between the cases and controls, using statistical software SAS 9.4 (Cary, NC). The significance level was set to 0.05. 17

18. Results 10 strangulation cases are taken as controls 18

19. Age Ages ranged from 27 to 77 years, with a mean of 48.5 years in the artifact cases. In terms 19

20. POSITION Control cases were not evaluated for body position Laterality was defined as the hemorrhage, or the majority of the hemorrhage, being located on the left or the right. Two artifact cases did not specify a location, in a prone position so excluded from calculations. Supine cases were statistically significantly more likely to have laterality than prone ( P = 0.0256). 20

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22. Discussion BMI Sample size Errors in pm report 22

23. Ignorance of knowledge of artefacts leads to: a. Wrong interpretation of cause of death. b. Wrong interpretation of manner of death. c. Wrong interpretation about time since death. d. Undue suspicion of criminal offense e. A halt in investigation of criminal death f. Wastage of time and effort as a result of misleading findings It ultimately leads to miscarriage of justice Muthiharan K, Patnaik A K. Modi’s Medical Jurisprudence and Toxicology. Postmortem Artefacts. 23rd ed. New Delhi: Lexis Nexis Butterworths India; 2005. p. 463-69. 23

24. Problems faced by forensic experts due to Artefacts: • Relatives of the deceased create law and order problem. • Relatives in huge numbers often put undue pressure on forensic experts. • Difficult to explain to layman and convince the relatives of the deceased. • Relatives of the deceased threaten forensic experts by not receiving the deceased body or keeping body in front of the hospital and protesting. • Many a time ill-informed media might spread false information due to misinterpretation. • Lawyers may file a case in court due to false interpretation by seeing photographs and alleging involvement of experts for illegal gain.t 24

25. . Remedy for avoiding medicolegal problems by Artefacts. • Conducting meticulous autopsy. • Preserving viscera for FSL and other ancillary investigations such as histopathology etc. • Photography or Video recording of the autopsy should be done. • Detailed description of antemortem and postmortem injuries. • Good communication and convincing relatives may help sometimes. • Train medical officers periodically. • Compulsory rotatory internship postings for interns in Department of Forensic Medicine. • In case of doubt, don’t hesitate to take the opinion of senior colleagues. 25

26. References Rayamane , Anand & Thejaswi , H.T. & Puneeta , Dr & Kalai , Dr & H, Dr & C . ARTEFACTS AND ITS MEDICO-LEGAL PROBLEMS. Journal of Forensic Medicine, Science and Law A Journal of Medicolegal Association of Maharashtra.2013;33(2):42-46. Pollanen MS. Forensic pathology and the miscarriage of justice. Forensic Sci Med Pathol . 2012;8(3):285–289 . Pollanen MS. Pitfalls and artifacts in the neck at autopsy. Acad Forensic Pathol . 2016;6(1):45–62. Prinsloo I, Gordon I. Post-mortem dissection artifacts of the neck; their differentiation from antemortem bruises. S Afr Med J. 1951;25(21): 358–361. Jadav D, Shedge R, Kanchan T, Meshram V, Garg PK, Krishan K. Age-related changes in the hyoid bone: An autopsy-based radiological analysis. Medicine, Science and the Law. 2022;62(1):17-23. 26

27. References Simmons T, Cross PA. Chapter: forensic taphonomy. In: Siegel JA, Saukko PJ, Houck MM, eds. Encyclopedia of Forensic Sciences. 2nd ed. Cambridge, MA: Academic Press; 2013:12–17. Herath JC, Pollanen MS. Chapter: autopsy of asphyxiation, suffocation and neck pressure deaths. In: Madea B, ed. Asphyxiation, Suffocation, and Neck Pressure Deaths. 1st ed. Boca Raton, FL: CRC Press; 2021:355–359. Muthiharan K, Patnaik A K. Modi’s Medical Jurisprudence and Toxicology. Postmortem Artefacts. 23rd ed. New Delhi: Lexis Nexis Butterworths India; 2005. p. 463-69. 27

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