Sudden Natural Deaths
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

Possible causes should be considered, depending on the age, sex, and the past medical history
of the deceased.
Around 80% of routine autopsy load consists of Sudden Natural Deaths.
The following is only a summary, classified according to the systems of the body. – Some
causes are common while others are rare -
CVS
a) Coronary artery Disease
 Coronary atheroma occurs in two major types
o Diffuse stenosis
o Interrupted plaques

Atheromatous plaques will reduce coronary blood flow by :
o
o
o
o
The stenosis it self
Rupture of the plaque
Sub–intimal hemorrhage
Coronary thrombosis


Common sites of coronary occlusion (Please see diagram)
Coronary artery disease may lead to:
o Cardiac arrhythmias
o Myocardial Infarction

MI – Two main types.
o Laminar infarct –
(Sub – endocardial region of whole LV, occupying up to 2/3 of the thickness
of the LV wall)
o Regional infarct (more common. Due to the blockage of a major branch of a coronary vessel)


Morphology of MI
o Naked eye appearance
o Microscopy (with time)
(Read Pathology Notes)
Complication of MI – (Read Path/Medicine Notes)
b) Hypertensive Ht. Disease
(Read Path Notes)
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c) Cardio myopathies
 Definition. - Read
 Types
- HOCM
- Dilated/Congestive CM
- Restrictive CM
HOCM – Read Path
Histological appearance
Dilated C.M. – Chronic Alcohol Abuse
Post-Partum CM
d) Coronary Artery anomalies
* Coronary a. spasm (Prinzmetal Angina)
* Muscular Bridging of C.A.
* Acute C.A. dissection
*
Congenital anomalies
i.
Hypoplasia
ii.
Single coronary Artery
iii.
(L) CA arising from (R) sinus of valsalva and vice-versa etc.
e) Valvular Ht Disease
1.
2.
3.
MVP. (Floppy MV syndrome)
Calcific aortic stenosis
Endocarditis
Infective
Non-Infective
f) Myocarditis
 Inflammation of the myocardium by infections, toxins, inflammatory conditions or
connective tissue disorders
- Infectious myocarditis(mainly viral)
- Hypersensitivity
- Giant cell myocarditis (granulomatous degeneration of Ht muscle due to
auto-immune condition (SLE, thyrotoxicosis)
g) Natural Diseases of Aorta
 Aneurysms

Atheromatous
Syphillitic
Acute Aortic Dissection
h) Cardiac Ion channelopathies
Eg: Long QT syndrome, Brugada syndrome etc.
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CNS
a) Intra Cerebral Hemorrhage
Causes:
 HTN
 Amyloid Angiopathy
 Av maltormations
 Tumors
 Bleeding Diathesis
 Drugs (cocaine, Amphytamine)
 Cerebral vasculitis




The most common site
External capsule (Artery of cerebral hemorrhage /
charcots’ Artery)
= Lenticulo-striate Br. Of middle cerebral artery
Though the bleed is in the external capsule, the pressure effects commonly involve the internal
capsule leading to a contra lateral stroke.
Thus, the Basal ganglia and the capsular areas are most frequently affected by hypertensive
hemorrhages.
Can also occur in cerebellum, Thalamus, Mid Brain & Pons.
Brain stem
Pontine H’ges
Read: How to differentiate a primary Brain system Hemorrhage from a secondary Brain
system Hemorrhage.
b) Cerebral Infarction
4 main causes:
i.
Large vessel Disease:
Thrombosis or Embolism of large cerebral Arteries.

ii.
Small vessel Disease:
- Arteriosclerosis of small Penetrating vessels with in Basal ganglia and
pons.
- Often due to HTN and DM.
- Results in “Lacunar Infracts”
iii.
iv.
Global Ischaemia.
Venous Infarcts.(Very rare)
A cerebral Infarct may appear as a small area of softening.
may become cystic and brown in colors.
c) Non Traumatic SAH
o Ruptured Berry aneurysm.
o Bleeding AV malformations.
(Read notes on Head Injuries)
(See Diagram of Circle of Willis)
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Later,
d) Epilepsy
o Usually in young pts.
o Most of the time
A negative autopsy
 Bite wounds on tongue
 Sclerosis of Ammon’s Horn in Brain may be seen.
e) Meningitis
o In all age groups
o Causative Organism (Read)
o Meningococcalmia (with or without meningitis) can be rapidly fatal
Waterhouse Friderichsen syn.(Petechaea, Purpura, B/L adrenal Hemorrhages)
f) Primary Brain Tumors
o Commonest (>50%) Astrocytoma glioblastoma category
o Also, oligoderdroglimas, meningiomas, colloid Cysts, medulloblastomas etc.

Even benign tumors can be rapidly fatal due to pressure effects.
g) Hydrocephalus
ed
Volume of CSF in the cranial cavity.
Internal H.C.

External H.C.
Communicating H.C.

Non-communicating HC
 Compensatory HC
Causes of Hydrocephalus – (Read)
e.g.: Meningitis
D.W.S.
A.C.M.
h) Psychiatric Disorders
e.g. Schizophrenia
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Resp. System:
a. Pul. Thrombo Embolism

DVT is encouraged by Trauma, Immobility, Debilitating illnesses, OCP, old age,
Pregnancy, Surgery, Intercurrent diseases etc.
o Ante-mortem thrombus vs. P.M. clot. (how to differentiate)
AM Thrombus:
 Reddish grey
 Dull in luster.
 Firm and Not Friable
(Can be handled without breaking)
 Side branches do not correspond to branches of pul. Artery.
 Surface is dull and contains wavy lines (of Zahn) due to deposition of fibrin and
platelets.
 Often coiled.
 No “chicken fat on current gelly” appearance.
b. Other pul. Emboli
 Amniotic fluid
 Air
 Bone marrow
 Fat etc.
c. Bronchial Asthma.
Hyper expanded, puffy, pale lungs with abundant mucous plugging of bronchii.
d. Pneumonias
e. Tuberculous Pneumonitis
f. Acute Epiglotitis
g. Massive Haemoptysis
Causes:
o Neoplasm or inflammatory cession of Naso pharynx
o CA Bronchus eroding in to pul. Artery.
o Cavitating TB
o Cavitatory lung Abscess
o Bronchiectasis
o Aortic Aneurysm
Bronchus
Haemoptysis
Oesophagus
Haematemesis
Erosion in to
h. Spontaneous Pneumothorax
 Rupture of emphysematous bullae
NB. – PM X Ray
- PM technique of demonstration (read)
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GIT
i.
Hematemesis
 oesophageal Varices
(Portal HTN
pre Hepatic
Hepatic
causes (read)
Post Hepatic

Mallory- Weiss syndrome
ii.
Massive upper GI Hemorrhage
Eroded gastric/ duodenal ulcers.
iii.
Strangulated Hernia
Bowel infarction
iv.
gangrene
peritonitis
sepsis
Hemorrhagic Pancreatitis
 Mostly alcohol related
 Death is due to fluid and electrolyte imbalance
Diabetes Mellitus
Most reliable indicator for ante-mortem hyperglycaemia is vitreous humour glucose lavels
(>200 mg/dl)
v.
Hepatic Disorders:


Alcoholic liver Disease (-fatty change – advanced cirrhosis)
Massive liver cell necrosis (Read causes)
Adrenal Disorders:
 Pheochromocytoma
Adrenal medullary tumor.
(minor trauma, Surgery, abdominal examination etc
Adrenal crisis
cardiac stimulation
death)
 Addison’s Disease (chronic adrenal insufficiency)
sudden catecholamine release
Splenic Disorders


Splenic Rupture (leukemia, IMN)
Absence of spleen
Pneumoccocal Infection
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septicaemia
B/L Ad. Hemorrhages
Other causes:
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Sickle cell trait.
(Infection, Hypoxia, Dehydration can precipitate sick ling)
Ruptured Tubal pregnancy
Ruptured Cystic ovarian Tumors.
Hemorrhage corpus lentium
Undiagnosed malignant tumors
Read : Sudden Unexpected Deaths In Children
Prepared for the Medico-legal Module-21st Batch
July 2014
DR. SANJAYA HULATHDUWA
MBBS. DLM. MD. DMJ(Path)Lond. DMJ(Clin)Lond. Dip.Crim, MFFLM(UK)
Senior Lecturer, Consultant Forensic Pathologist
Dept. of Forensic Medicine
FMS/USJP
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