Forensic Science International 126 (2002) 4042

Longitudinal brainstem laceration associated with complex basilar 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 parietooccipital 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 hyperextension of the neck from trafc accidents, often accompanying 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 brainstem 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 just under 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 moderately. Conjunctivae were pale without petechiae. Pupils

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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Fig. 1. Incomplete ring fracture of the base of the skull with a longitudinal fracture of the sphenoid bone (arrow).

were round and isocoric (0.5 cm in diameter). There was a contusional laceration (2 cm 5 cm) with a marked abrasion (5 cm 3:5 cm) and a subgaleal hematoma (10 cm 10 cm 0:6 cm) in the parieto-occipital region of the head, a longitudinal fracture of the occipital bone with diastasis of 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

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.

brain was swollen, weighing 1190 g, and had sustained 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 (Fig. 2). There were marked bruises in the shoulder and upper back involving a

Fig. 3. Histological ndings of the pons: marked fresh hemorrhages and edema around the longitudinal laceration of the contusion areas (HE, 200).

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

compression fracture of the body of the 9th thoracic vertebra, 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 laceration associated 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 violent anteroexion 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 consistent with the witnessed circumstantial evidence of a fall from a height of 9.2 m nally facing upward. The centroaxial 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 longitudinal 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 no evidence 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 buldging 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 longitudinal sphenoid bone fracture appeared to have contributed to the fatal injury. References
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