The information obtained at autopsy is important in clinical and forensic practice at four different levels (Keeling 1993):
1. The light it sheds on the cause of death is of inter- est to the family of the deceased and the treating clinicians. It can serve as a quality control of the diagnostic and therapeutic measures taken.
2. It is indispensable for adequate audit of a depart- ment’s policies and practices.
3. It will contribute to regional or national statistics by classifying data derived from postmortem ex- amination.
4. It is important for students and doctors studying the morphology of disease processes and trau- ma.
Neuropathologists deal with disorders of the ner- vous system (NS), i.e., the brain, the spinal cord, the peripheral nerves, and, sometimes, the muscles. The NS extends to all other organ systems of the body as a network, connecting, coordinating, and regulating their functions. The pathology of the NS is therefore also an integral part of the pathology of all organ and tissue systems of the body. At autopsy the neuropa- thologist applies the same criteria that apply to gen- eral autopsy. Yet, in contrast to the clinical neuro- pathologist, the forensic neuropathologist must not only diagnose disease processes of the NS, including tumors, inflammation, and degenerative diseases, but he must also − and predominantly − investigate non-natural, exogenous events leading to injuries and/or death. The forensic neuropathologist is espe- cially confronted with injuries of the head and brain as well as the spine and spinal cord and peripheral nerves, or secondary alterations of the NS which are caused by hypoxia, ischemia, toxic agents, etc.
The present volume deals with the problems of neuropathology for both the forensic and clinical neuropathologist, particularly emphasizing the rel- evance for routine practice. It incorporates recent findings in anatomy, physiology, pathophysiology, molecular biology, nosology, clinical features and sequelae, epidemiology, biomechanics, immunology, and pathology. Part I provides basic information on the tasks of the forensic expert, the cytology of the NS, techniques for dissection of the brain and spinal
cord, and on staining methods. Parts II−IV discuss the various types of physical loadings to the head and central nervous system (CNS), asphyxia-related effects on the brain such as hypoxia and ischemia, and toxic effects on the brain. Part V deals with in- juries in infants and children caused by prenatal and childhood traumatic events. Part VI is devoted to aspects of clinical neuropathology with cases of NS diseases leading suddenly and unexpectedly to death, that have to be considered in differential diag- nosis or that are often additionally observed in cases of unnatural death.
Forensic neuropathology does not intend to sub- stitute for clinical neuropathology. In contrast, the knowledge of general and special clinical neuropa- thology will be a precondition for understanding the present textbook, though the authors have strived to give basic information as well. Incorporating the most recent literature and up-to-date methods, the present textbook covers the main aspects of neuro- pathology with regard to the needs of forensic pa- thologists and specialists in associated fields, such as clinical pathology and neuropathology, neurol- ogy, neurosurgery, pediatrics, law, and criminology.
The authors have attempted to impart basic infor- mation that can be fundamental to further scientific investigations. The concise, direct style is intended to provide the reader with succinct and easy-to-find answers to forensic-pathological and forensic-neuro- logical problems.
The forensic neuropathologist is expected to pro- vide answers regarding: (1) the cause of death, i.e., whether the neuropathological findings are suffi- cient to explain why the death occurred; (2) infor- mation on whether neuropathological changes could have influenced the fatal mechanism, i.e., whether the death was hastened by NS injury or diseases; (3) the victim’s capacity or incapacity to act at a given time point, i.e., whether he was capable of resistance or flight, or could still perceive anything such as pain or danger; (4) the mode of death, i.e., whether death was caused by accident, disease, or was a suicide or homicide (murder, manslaughter, or due to negli- gence). These questions can usually be answered by (5) a plausible and detailed reconstruction of the process and/or events leading to the death inclusive
Introduction
CHAPTER 1
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INTRODUCTIONdating (time course) based on eyewitness accounts, evidence at the scene, analysis of the injuries, medi- cal records, etc.
But why should the nervous system be examined by a forensic neuropathologist at all? Is a textbook dealing with the forensic aspects of only one organ system really necessary?
More than 50% of all cases of death encountered at forensic autopsy are associated with primary or secondary involvement of the NS, especially of the brain. The forensic pathologist must be able to judge or comment on NS injuries and/or diseases in dead as well as sometimes in living subjects. Often patho- logical examinations of the NS are sufficient to de- termine the “mode of death,” sometimes only by rul- ing out a natural process within the NS as the cause of death. The neuropathological investigation can therefore also serve as a form of quality assessment and quality control, and can help to explain discrep- ant diagnoses presented at trial. Peiffer (1996) and Black and Graham (2002) have surveyed the types of cases dealt with by forensic neuropathologists and the sort of problems they pose.
According to the American Trauma Society (in Trauma Facts 1992) an estimated 500,000 Americans are admitted to hospitals as a result of mechanical brain injuries and more than one million children in the world sustain head injuries each year. Such cases should be assessed to determine whether the injuries could have been avoided in order to enhance preven- tion in future. The complexity of such cases and the methods used to examine them consequently war- rant special, more in-depth consideration, possibly in the form of a monograph or textbook.
In-depth coverage can also aid in quality control and accreditation of laboratories. Guidelines and standards for neuropathological examinations must be set, which can be of special value to forensic neu- ropathologists confronted with questions of their own legal liability (Pounder 2002; Tingle 2002).
Equally important are questions of research as they relate to forensic practice. This holds particu- larly true for cases that are encountered only in legal medical institutions, rather than in clinicopatho- logical or cliniconeuropathological institutes. In this regard it is a much appreciated development that fo- rensic neuropathologists are being increasingly pro- vided with their own distinct forums at congresses.
This is happening both at meetings devoted solely to clinical neuropathology (Neuropath Appl Neurobiol 25:27−28, 1999; Kalimo et al. 2004) and at interna- tional congresses on forensic pathology and related fields (Oehmichen 2001).
One of the prime reasons for publishing a text- book on forensic neuropathology and associated neurology is reflected in the statement by Courville (1964) describing his own: “… unhappy experience to learn that all too often a misinterpretation or an
erroneous evaluation of a cerebral lesion has led to a gross miscarriage of justice.” The present textbook also has its roots in many forensic pathologists‘ prac- tice of dissecting and then disposing of the brain after autopsy, without considering minor, though poten- tially important, findings. In such cases the brain is treated like a diffuse parenchymatous organ compa- rable to the liver, specimens being taken at random, fixed in formalin, and examined microscopically.
Because the remaining brain tissue is discarded, it is no longer available for further investigations, pre- cluding any retrospective examinations.
Conscientious forensic pathologists lacking either the knowledge or experience to deal with a particu- lar problem themselves will fix the brain and spinal cord in formalin and hand them over to a clinical neuropathologist for evaluation. Sometimes though, the clinical neuropathologist may have no particu- lar interest in forensic problems, and thus may find it difficult to unravel the true nature of the problem at hand. Moreover, the clinical neuropathologist is often not acquainted with the current forensic lit- erature, or may not be able to differentiate autolytic changes and putrefaction from pathological findings and, when examining the autolytic material, to detect forensically relevant changes. The authors therefore regard expertise training and education in forensic neuropathology as highly desirable. Even though not every institute will need such special investigative techniques and experience, central research labora- tories could be established that would make the neu- roscientists, technicians, and methods needed for such investigations readily available.
The last comprehensive survey of forensic neu- ropathology in a textbook format was published by Leestma in 1988. The volume followed the ex- ample of Courville (1964), who was the first to write a textbook in this field. In the early 1990s Unter- harnscheidt (1992−1994) published a handbook comprised of four monumental volumes in German devoted to mechanical injury of the head and spinal cord giving a review on the investigations, findings, and the literature of the previous 50 years. The nu- merous important findings that have been published since 1990, especially in the fields of molecular biol- ogy and biochemistry of the CNS, make the present volume both justified and necessary.
References
American Trauma Society (1992) Trauma facts. Upper Marlboro, Md.
Black M, Graham DI (2002) Sudden unexplained death in adults caused by intracranial pathology. J Clin Pathol 55:44−50
CHAPTER 1: Introduction
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Courville CB (1964) Forensic neuropathology. Lesions of the brain and spinal cord of medicolegal importance. Callaghan, Mun- delein, Ill.
Kalimo H, Saukko P, Graham DI (eds) (2004) Special issue: forensic neuropathology. Forensic Sci Int 146:71−147
Keeling JW (1993) The perinatal necropsy. In: Keeling JW (ed) Fe- tal and neonatal pathology. Springer, Berlin Heidelberg New York, pp 1−46
Leestma JE (1988) Forensic neuropathology. Raven, New York Oehmichen M (ed) (2001) Brain hypoxia and ischemia. In: Re-
search in legal medicine, vol 24. Schmidt-Römhild, Lübeck Peiffer J (1996) 30 Jahre neurologisch-neuropathogische
Gutachtertätigkeit − Auftraggeber, Fragestellungen, Prob- lembereiche. Med Sachverst 92:116−120
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Tingle JH (2002) Do guidelines have legal implications? Arch Dis Child 86:387−388
Unterharnscheidt F (1992−1994) Pathologie des Nervensystems von Hirn und Rückenmark: Traumatologie von Hirn und Rück- enmark. In: Doerr W, Seifert G (eds) Spezielle pathologische Anatomie, vol 13/VI A,B − 1993; vol 13/VI C − 1994; vol 13/VII
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