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Ro A.,Tokyo Women's Medical University | Kageyama N.,Tokyo Medical Examiners Office | Takatsu A.,Tokyo Medical Examiners Office | Fukunaga T.,Tokyo Medical Examiners Office
Cardiovascular Pathology | Year: 2010

We report an autopsy case of segmental arterial mediolysis (SAM) of various phases occurring in both the intracranial vertebral artery (IVA) and intra-abdominal arteries. The patient was a 70-year-old male found dead in his house. The cause of death was massive intra-abdominal hemorrhage owing to a ruptured right gastroepiploic artery. Histopathological examination revealed that there was a broad arterial dissection as long as 20 cm in the right gastroepiploic artery associated with SAM in the injurious phase. In addition, SAM in the reparative phase was observed as organized arterial dissections in the left gastric artery. Furthermore, SAM in the reparative phase was detected as an arterial dissection in the right IVA undergoing an organizing process. These three lesions were considered to have developed at different times. SAM occurring in both the intra-abdominal and intracranial vertebral arteries is extremely rare. This coincidence may provide a clue to the relationship between SAM and spontaneous IVA dissection. © 2010 Elsevier Inc.

Ro A.,Tokyo Women's Medical University | Kageyama N.,Tokyo Medical Examiners Office
Journal of Neurosurgery | Year: 2013

Object. Subarachnoid hemorrhage (SAH) due to ruptured intracranial vertebral artery (VA) dissection is a lifethreatening disease. Angiographic and symptomatic prognostic factors for rupture and rerupture have been investigated, but the pathological characteristics have not been fully investigated. The authors aimed to investigate these features by performing a pathomorphometic study of ruptured intracranial VA dissections. Methods. This study included 50 administrative autopsy cases of fatal SAH due to ruptured intracranial VA dissection among 517 fatal nontraumatic cases of SAH occurring between March 2003 and May 2011. Pathomorphometry was performed using serial 5-mm histological cross-sections with elastica van Gieson staining from each 0.2-mm segment around the ruptured intracranial VA. The longitudinal lengths of 4 types of vascular lesions-adventitial ruptures, dilated lesions where the internal elastic lamina (IEL) was ruptured with adventitial extension, intimal tears where the IEL was ruptured, and medial defects-were calculated based on the numbers of the slides in which these lesions were continuously detected (minimum 2 adjoining slides). The distance from the vertebrobasilar junction to the center of adventitial rupture was also calculated in 37 cases. Results. All cases showed one adventitial rupture with a mean length of about 1.9 ± 1.1 mm. The center of the adventitial rupture was located 5.0-26.8 mm (mean 14.6 ± 5.5 mm) from the intracranial VA bifurcation. Adventitial ruptures existed in the centers of dilated lesions, where the adventitia was highly extended. Other vascular lesions were serially observed surrounding the adventitial rupture. The mean lengths of dilated lesions, intimal tears, and medial defects were 9.4 ± 4.8 mm, 13.2 ± 6.3 mm, and 15.6 ± 7.2 mm, respectively. The lengths between proximal lesions and distal lesions from the center of the adventitial rupture for both medial defects and intimal tears were significantly longer at proximal lesions than at distal ones (chi-square test, p 0.01). Conclusions. Every ruptured intracranial VA dissection has a single point of adventitial rupture where the adventitia was maximally extended, so dilation appears to be a valuable predictive factor for hemorrhagic intracranial VA dissections. The adventitial ruptures were as small as 2 mm in length, and clinically detectable dilated lesions were about 9 mm in length. However, vascular vulnerability caused by IEL ruptures and medial defects existed more widely across a length of VA of 1.3-1.5 cm. Comparatively broader protection of the intracranial VA than the clinically detected area of dissection might be desirable to prevent rebleeding. Broader protection of proximal lesions than distal lesions might be effective from the viewpoint of site distribution of vascular lesions and blood flow alteration to the pseudolumen caused by the dissecting hematoma. Medial defects are the most widely seen lesions among the 4 types of vascular lesions studied. Medial degenerative disease, known as segmental arterial mediolysis, is suspected in the pathogenesis of intracranial VA dissections. © AANS, 2013.

Ro A.,Tokyo Women's Medical University | Kageyama N.,Tokyo Medical Examiners Office
Legal Medicine | Year: 2014

We aimed to establish an objective indicator for differential diagnosis between traumatic rupture of the intracranial vertebral artery (TRIVA) and nontraumatic rupture from intracranial vertebral artery dissection (NIVAD). We investigated 19 intracranial vertebral artery (IVA) samples, including three from TRIVA, seven from NIVAD and nine non-IVA rupture cases using 0.2-mm serial histological sections through the IVA. The internal elastic lamina (IEL)-adventitia ratio for each slide was calculated as the ratio of the traced length of the adventitia to the length of the IEL as measured by digital photomicrography. NIVAD cases showed a significant peak in the IEL-adventitia ratio around the area of rupture, whereas TRIVA and non-rupture cases showed no specific increase or decrease in IEL-adventitia ratios throughout the IVAs. All NIVAD cases had a significantly higher average IEL-adventitia ratio across 10 slides at the site of the rupture lesion than at the site furthest from the rupture. In contrast, two out of three TRIVA cases showed no significant difference between the two points. The other TRIVA case showed a significantly lower IEL-adventitia ratio at the point nearest the rupture compared with that at the point farthest from the rupture. Other histological characteristics considered specific to either TRIVA or NIVAD were observed. Our results indicate that measuring and comparing IEL-adventitia ratios at ruptured and non-ruptured sites of the IVA could be a useful practical indicator for differential diagnosis between TRIVAs and NIVADs. © 2014 Elsevier Ireland Ltd.

Inoue K.,Aichi University | Fukunaga T.,Tokyo Medical Examiners Office | Okazaki Y.,Tokyo Metropolitan Matsuzawa Hospital
Journal of Forensic Sciences | Year: 2012

There were more than 30,000 suicides in 1998 in Japan, and since then, the numbers have remained high. In 2009, the number of suicides per a day was c.90. This phenomenon constitutes a major social problem. One of the major reasons for the rapid increase in the number of suicides appears to be the worsening economic problems. It is therefore necessary to research the relationship between economic issues and suicide. In this study, we examined the relationship between the value of the Nikkei Stock Average and suicide rates in Japan. The value of the Nikkei Stock Average may be related to suicide among men. On the basis of the results, relevant researchers and organizations should understand the factors that relate to suicide to better carry out specific suicide prevention measures. © 2012 American Academy of Forensic Sciences.

Fukunaga T.,Tokyo Medical Examiners Office
Nihon rinsho. Japanese journal of clinical medicine | Year: 2012

Tokyo Medical Examiner's Office has approximately 13,000 inquest cases and 3,000 autopsies per year. Usually the winter season has much number of inquest cases owing to the elder' s death. In summer of 2007 and 2010, however, a number of inquest and autopsy cases increased rapidly and conspicuously. The cause was the increase of heat stroke death caused by intense heat. We often appealed "the prevention of the heat stroke" for the ministries and agencies from the standpoint of medical examiners. In the present paper, the situation of heat stroke deaths in Tokyo metropolitan area and the findings and diagnosis of heat stroke death were introduced.

Suzuki H.,Tokyo Medical Examiners Office | Tanifuji T.,Tokyo Medical Examiners Office | Abe N.,Tokyo Medical Examiners Office | Fukunaga T.,Tokyo Medical Examiners Office
Journal of Epidemiology | Year: 2014

Background: Annually, about 400 cases of sudden unexpected death are attributed to cancer in Tokyo, Japan. These individuals may have been undiagnosed, or their medical conditions may not have been carefully evaluated before death. We examined medical consultations, cancer diagnoses, and economic status of all cancer deaths investigated by medical examiners in 2009. Methods: Among cases handled by the Tokyo Medical Examiner's Office in 2009 (N = 12 493), records for all cases of cancer death (n = 400) were reviewed to determine the extent of medical care provided, diagnosis before death, and economic status of the decedent. Results: Most of the decedents (n = 232; 58%) had received a diagnosis of terminal/advanced cancer during a medical consultation. Most did not receive such medical consultations at home, despite their very weak physical condition. However, nearly one quarter of decedents (24%; 95/400) had not received a cancer diagnosis before death. The proportions of decedents who had been indigent, received no medical consulting, and had colon cancer were significantly higher among undiagnosed cases than among diagnosed cases. Indigent persons were the largest subgroup (n = 19; 43%) among those who had never received a medical consultation (n = 44). In addition, the proportion of those who had discontinued or received no medical consultation was higher among indigent persons than among non-indigent persons. Conclusions: The quality of medical services for cancer patients could be improved by educating general practitioners about terminal care, expanding efforts to monitor and diagnose cancer, especially among indigent patients, and increasing participation rates for colorectal cancer screening. © 2014 Hideto Suzuki et al.

Suzuki H.,Tokyo Medical Examiners Office | Shigeta A.,Tokyo Medical Examiners Office | Fukunaga T.,Tokyo Medical Examiners Office
Legal Medicine | Year: 2014

Acute leukemia causes hemorrhage in various sites throughout the body, such as the brain parenchyma, resulting in serious complications. Here, we present an autopsy case where the patient succumbed to a ruptured mesenteric hematoma caused by acute leukemia.A 58-year-old man, without a significant past medical history, was found dead at his workplace. An external examination showed subcutaneous hemorrhage on the left upper extremity. Macroscopic autopsy findings revealed a massive hemoperitoneum (1000. mL) and extensive hematoma in the mesentery. Histopathological findings showed monotonous cell proliferation not only in the mesentery, but in many organs, such as the liver, spleen, and kidney; aggregates of the infiltrating cells were also observed in the microvessels of various organs. Immunohistochemical staining indicated that the infiltrating cells showed variable myeloperoxidase positivity, and the cells were strongly positive for CD68 (PG-M1). From the autopsy findings and the immunohistochemical staining, we concluded that the underlying cause of death was acute myeloid leukemia (M5).This case was not only a rare presentation of acute leukemia, but provides a lesson to forensic pathologists regarding noting underlying hematological disease, particularly when a case of massive hemorrhage of unknown etiology is encountered. © 2014 Elsevier Ireland Ltd.

Suzuki H.,Tokyo Medical Examiners Office | Hasegawa I.,Tokyo Medical Examiners Office | Hoshino N.,Tokyo Medical Examiners Office | Fukunaga T.,Tokyo Medical Examiners Office
Legal Medicine | Year: 2015

In this report, we describe two autopsy cases of death due to upper gastrointestinal hemorrhage (Case 1: Gastric ulcer, Case 2: Aortoduodenal fistula). Postmortem computed tomography (CT) images from both cases revealed pooling of gastric fluid, which contained high attenuation areas, although these images also mirrored the different sources of the gastrointestinal hemorrhage. Fluid collection was observed in the small intestine for both cases, although the high attenuation areas were only remarkable in Case 2. The autopsy in Case 1 revealed a peptic ulcer, with small vessels exposed on the surface of the ulcer. Melena was also observed throughout the intestine, although clotting was only observed inside the stomach. The autopsy in Case 2 revealed diffuse massive clotting from the stomach to the upper portion of the ileum, which was due to a primary aortoduodenal fistula. Given our autopsy findings, the extent of the high attenuation areas in the digestive tract during postmortem CT scanning may be correlated with the speed of the gastrointestinal hemorrhage before death. Carefully evaluating the radiodensity of the gastrointestinal contents during postmortem CT scanning may indicate the primary site of the hemorrhage before the autopsy, thereby facilitating the accurate identification of the cause of death during forensic autopsy. © 2015 Elsevier Ireland Ltd. All rights reserved.

Suzuki H.,Tokyo Medical Examiners Office | Shigeta A.,Tokyo Medical Examiners Office | Fukunaga T.,Tokyo Medical Examiners Office
Legal Medicine | Year: 2013

Older individuals are susceptible to accident, such as falls, some of which are fatal. In such cases, autopsies and toxicological analysis may be deemed unnecessary, especially if the critical injuries and manner of death can be determined conclusively based on information at the scene and an external investigation. Here, we report the results of two autopsies performed on elderly individuals who died accidentally under the influence of chlorpheniramine. These autopsies revealed valuable additional information.Case 1: A woman in her 70s, who was living alone, was found dead under the stairs in her house. She had no history of a condition that could have led to sudden death. The autopsy revealed a neck fracture, multiple rib fractures, and a coccyx fracture. The histopathological findings showed fat embolisms in numerous small vessels of the interalveolar septum. Toxicological analysis of blood samples revealed the presence of chlorpheniramine (0.41. μg/ml).Case 2: A woman in her 70s, who was living alone, was found dead in the bathtub in her house. There was no past medical history other than diabetes mellitus and vertigo. The autopsy revealed hyper-inflated lungs and brown-red fluids in the trachea, but there was no evidence of a pathology or injury that could have induced a loss of consciousness. Toxicological analysis of the fluids in the right thoracic cavity revealed the presence of chlorpheniramine (0.57. μg/ml).In both cases, re-examination of the scene after the autopsy revealed the presence of common cold medicine containing chlorpheniramine. The victim may have accidentally overdosed on common cold medicine. This overdose would have been compounded by anti-histamine-induced drowsiness. The present cases suggest that forensic pathologists should always notify physicians/pharmacists of findings pertaining to unexpected drug side effects. Such intervention would prevent many accidental deaths. In addition, each autopsy must be performed in conjunction with a detailed postmortem investigation. Such efforts would also increase the accuracy of the public health record's mortality statistics. © 2013 Elsevier Ireland Ltd.

Hikiji W.,Tokyo Medical Examiners Office | Fukunaga T.,Tokyo Medical Examiners Office
Journal of Forensic and Legal Medicine | Year: 2014

Numerous studies on physician suicide in various countries have been reported but no data from Japan on the issue can be found to date. In this study, physician suicides in the special wards of Tokyo Metropolitan area in 1996-2010 were investigated retrospectively. A total of 87 cases were enrolled. The results suggested that physician suicide has been linked to pre-existing psychiatric illnesses and occupational problems, and that psychiatrists have a relatively higher suicide risk compared to those majoring in other specialities of medicine. A distinctive feature was that 19 cases had used either drugs or devices which were accessible due to their profession some time during the process of committing suicide. Another notable feature was that 4 out of 5 anaesthesiologists enrolled in the study had chosen poisoning for their suicide method, with the drugs frequently used in their speciality. The findings advocate strongly for efficient suicide prevention measures for physicians including an early detection and treatment of psychiatric illnesses, as well as an urgent need for a more effective pharmacy management in applicable institutions together with the implementation of self discipline on each physician. This is the first broad academic study on physician suicide in Japan. © 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

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