Biventricular false tendons

False chordae tendineae or false tendons (FTs) are fibrous or fibro-muscular structures and sometimes also conduction tissue, blood vessels, and Purkinje cells that cross the ventricular cavities without connections to the valve cusps.1 Typically, they connect the free wall of the left ventricle or the papillary muscles and the ventricular septum, although they can also be found in the right ventricle.2 FTs must be distinguished from other entities, such as thickened ventricular trabeculae or ventricular masses. Most FTs are transverse and located at the apex; however, they may also be located in the apical, middle, or basal third in a diagonal or longitudinal orientation. They can be simple, with 1-2 insertion points, or branched with 3 or more insertion points.3 The exact prevalence of FTs in the general population varies widely, ranging from 0.4% to 83%.3 FTs appear to be higher in the pediatric age group.4 FTs are generally considered benign anatomic variants; however, they may be associated with varied entities, including precordial murmurs, repolarization abnormalities, preexcitation, mitral regurgitation, ventricular arrhythmias, and abnormal cardiac remodeling with systolic and diastolic dysfunction and dilatation of the left ventricle.3-5 FTs may be associated with electrocardiographic changes, especially in young sportspersons.6 Regarding ventricular arrhythmias, it has been suggested that they may be triggered by stretching the ventricular septum by FTs, resulting in increased automaticity. In this setting, it is suggested that FT may contain elements that are part of the cardiac excitation conduction system or cause excessive tension of Purkinje fibers in the cardiac septum. In addition, abnormal electrical impulses and re-entry circuits may be caused by fibrous tissue in FTs.6 However, the exact etiopathological mechanism of FT-induced cardiac changes remains unclear.3 Figure 1 shows the heart of a 48-year-old Caucasian European man in good health, a bricklayer by trade, who died suddenly at home. At autopsy, the body measured 170 cm and weighed 65 kg (BMI 22.5 kg/m2). The heart was of normal shape, weighed 405 g, had a longitudinal diameter of 10.5 cm, a transverse diameter of 12 cm, and an anteroposterior diameter of 5 cm. No pathologic findings were noted in the epicardium or in the parietal and valvular endocardium. At the heart opening, the valves appeared normal, without vegetation or deformities. Specifically, the circumferences were as follows: at the mitral valve 3.2 cm, tricuspid valve 3.8 cm, aortic valve 2.2 cm, and pulmonary valve 2 cm. No signs of stenosis or valvular insufficiency were noted. Mild dilatation of the left ventricle with concomitant slight hypertrophy was observed. The thickness of the free wall of the left ventricle was: proximal third, 1.4 cm; middle third, 1.5 cm; distal third, 1.4 cm; and apex, 1.4 cm. The thickness of the septum was as follows: proximal third, 1.5 cm; middle third, 1.5 cm; and distal third, 1.4 cm. The maximum thickness of the right ventricle was 0.7 cm in the middle third. The myocardium was brownish, with discernible muscle fasciculations and normal consistency. In addition, numerous FTs were observed between the tip of the superior papillary muscle and the endocardial surface of the septal wall of the left ventricle, as well as additional irregularly arranged FTs foci in both ventricles. Finally, the coronary ostia and coronary arteries were free of obstruction and had intact walls. Figure 1 A - Macroscopic view of the heart, fixed in formalin and dissected. Anterior and posterior walls of the left ventricle are shown with evidence of numerous and diffuse foci of false tendons; B - Detail of the postero-lateral wall of the left ventricle with evidence of multiple false tendons that are predominantly transverse, have a branched morphology, and attach at multiple sites; C - Detail of a branched false tendon between the posterior papillary muscle and the endocardial surface of the left ventricle septal wall; D - Macroscopic view of the right ventricle, also characterized by the presence of multiple and diffuse foci of false tendons.: Microscopically, the fibromuscular nature of the FTs was evident, with no other pathologic findings, neither in the heart nor the remaining viscera. At the end of the autopsy, death was attributed to an arrhythmic cardiac event. This case was deemed of interest because the only finding was the presence of multiple biventricular FTs. These findings are rarely observed and reported in the literature and have been described almost exclusively by diagnostic imaging in the clinical setting. However, in this brief report, explanatory macroscopic images of FTs still in situ are reported, helping to fill a gap in the literature. Also, from another perspective, references in the literature to the significance of FTs sometimes need to be revised. Our case was a normal-weight white European male (BMI 22.5 kg/m2) with a heart of normal shape and weighing 405 g, characterized by multiple biventricular FTs foci, mild dilatation of the left ventricle, and slight hypertrophy. There were no other pathologic findings, either macroscopic or microscopic. The mild dilatation of the left ventricle was a finding consistent with the presence of multiple FTs, as reported in the literature.3,5 The left ventricular hypertrophy was of low intensity and was consistent with the man's physical activity as a bricklayer. The weight of the heart deserves special attention. Although it was slightly over 400 g, this weight is within the normal range for Caucasian men, given the height and BMI. These data were compared with the forensic study that examined the weight of organs in 684 autopsies of Caucasian adults, excluding all individuals who showed macroscopic signs of disease or histological abnormalities.7 It was found that the heart weight in the general population of healthy Caucasian men was 365 g +/- 71. With a height of 165-175 cm, the heart weight was 360 g +/- 75; with a BMI between 22 and 24, the heart weight was 370 g +/- 75. Thus, this case was not an enlarged heart. We faced a situation where no evidence could be interpreted as a definite cause of death. As already reported, the association of multiple FTs, left ventricular dilatation, and sudden arrhythmic events were acknowledged in the literature. It is noteworthy that in our case, there were no other pathological conditions that could trigger cardiac arrhythmias, such as valvular dysfunction, cardiomyopathies (including obesity-related diseases), cardiac thrombi, myocardial fibrosis, and heart failure, were ruled out. Notably, the extent of left ventricular dilatation observed was inconsistent with heart failure. Numerous reports suggest that FTs significantly impact cardiac electromechanical events.2 All of this has led us to believe that the FTs in the present case most likely played an active role in the death and thus were not mere bystanders. However, to date, no robust population-based evidence of an association between FTs and increased cardiac morbidity and mortality.3 This gives rise to an apparent paradox that poses considerable interpretive difficulties in situations like our case, where there were no other pathological findings and plausible causes to explain the death. This criticality can be overcome by considering that very few studies on this subject do not allow uncritical generalization. Therefore, precisely because of the possible clinical implications, each case in which FTs are documented should be analyzed individually while waiting for further research to help shed light on this exciting and still partially unexplored phenomenon

Sudden death associated with lipoma of the cerebellopontine angle

Intracranial lipomas are rare benign tumors considered exceptional when localized in the cerebellopontine angle (CPA), with an incidence of 0.1% of the total number of expansive processes located in this area. We present a case of the sudden death of a 26-year-old young woman in which an unencapsulated neoformation of 0.8 cm was documented at the right cerebellopontine angle and was histologically characterized as intracranial lipoma. The cause of death was then identified as a cardiocirculatory failure secondary to supratentorial (uncal right) herniation caused by the lipoma of the pontocerebellar angle with high-grade diffuse cerebral edema

Fatal pulmonary thromboembolism associated with uterine carcinosarcoma

Uterine carcinosarcoma (USC), also known as malignant mixed Müllerian tumor, is a rare and high-grade endometrial cancer composed of epithelial and mesenchymal elements.1 UCS accounts for 4.3% of all uterine corpus cancer, with a worldwide annual incidence of 0.5-3.3 cases per 100.000 women.1 Common risk factors include obesity, nulliparity, chronic endogenous or exogenous hyperestrogenism exposure, older age (with a median age of 70 years), African-American ethnicity, genetic predisposition, tamoxifen therapy, and prior pelvic irradiation.2 Typical UCS-related symptoms, unfortunately, associated with an already advanced stage of the disease, are large masses occupying the abdominal cavity, postmenopausal metrorrhagia, and abdominal pain. One of the most important complications of endometrial tumors, especially in UCS, is venous thromboembolism (VTE), with an incidence of 8.1%.3-4 It may also involve pulmonary arteries and is usually associated with aggressive tumor characteristics and poor patient health.3-4 While Trans-Vaginal Sonography (TVS) is the first-line method for the assessment of UCS, as it can detect neoformations of the myometrium, diagnosis can usually be made by the histopathological examination of targeted endometrial biopsies, possibly associated with hysteroscopy.5-6 Magnetic resonance imaging (MRI) is the best imaging modality for staging. Furthermore, it shows a typical high enhancement with a “spotty” distribution, which may suggest bleeding and is a distinct hallmark of carcinosarcoma.6-7 Depending on the histopathologic assessment of the tumor (depth of invasion and presence or absence of metastases) and clinical presentation,8 the management of UCS requires a multimodality treatment comprised of surgery, systemic therapy, and radiotherapy. The estimated 5-year survival rate ranges from 33 to 39%, but the recurrence rate remains high.2,8 Figure 1 refers to a 61-year-old woman found dead in her flat, dressed in a sanitary napkin and a nightgown. Because the woman lived alone and had no family members, no health information could be achieved. An autopsy was performed to determine the cause of death. The body was in a good state of preservation; it weighed 85 kg and was 158 cm long (BMI = 34 Kg/m2 - Class I obesity). The sanitary napkin was smeared with a yellow-green-blackish creamy material upon external examination,. At dissection, both branches of the pulmonary artery trunk were occupied by red-brownish clots with multiple whitish streaks extending along the intraparenchymal course of the dividing branches of the pulmonary arteries (Figure 1A). They appeared to adhere tenaciously to the intimal surface, replicating the shape of the vascular lumen as a mold. All these characteristics were confirmed upon slicing, and a friable consistency was noted. On the abdominal incision, abundant yellow-green-blackish material of pasty consistency and purulent appearance was noted near the pelvic notch and between some intestinal loops. The uterus (longitudinal diameter = 18 cm, transversal = 11 cm, anteroposterior = 5 cm) appeared to be increased in volume, and the wall had a wall thickness of 1.5 cm. Inside the uterine cavity, a vegetative neoformation was detected (longitudinal diameter = 6 cm, transversal = 5 cm, anteroposterior = 4 cm), almost occluding the lumen. It was associated with abundant material resembling in color and consistency that was found in the abdomen. This neoformation adhered to the lateral walls and fundus of the uterus, extending almost to the cervix (Figure 1B). The ovaries were unscathed. Figure 1 A - Macroscopic view of lungs showing red-brownish clots in the pulmonary artery trunk extending along the intraparenchymal branches (scale bar= 8 cm); B - Macroscopic view of the uterus after dissection with a vegetative neoformation almost occluding its lumen, in association with abundant yellow-green-blackish material of pasty consistency (scale bar= 7 cm); C - Photomicrograph of the endometrial tumor with remnants of neoplastic glandular epithelial component and of residual glandular pseudo-lumen with multi-layered epithelium and cellular atypia (H&E, 200x); D - Photomicrograph of the endometrial tumor with sarcomatous component partly with fused cellularity, partly in the form of compact bundles with marked nuclear atypia and partly with a myxoid-like structure with foci arranged in bundles associated with a scattered cell neoplastic component (H&E; 100x).: Histopathologic examination of the mass revealed features of carcinosarcoma consisting almost entirely of a sarcomatous component and small foci of endometrioid- type adenocarcinoma, with neoplastic embolization of the intraparietal venous vessels. An inflammatory infiltrate associated with marked tumor necrosis was also noted (Figures 1C and 1D). With this background, the abdominal findings were interpreted as purulent discharge and necrosis following the adjoining uterine cancer. At the end of all investigations, the cause of death was identified as massive pulmonary arterial thrombosis in a subject with uterine carcinosarcoma. For completeness, we also considered peritonitis and sepsis as possible co-participation in the cause of death. However, we considered this hypothesis unlikely based on the macroscopic and microscopic findings. Specifically, the peritoneum, abdominal viscera, and serosa were shiny, without fibrinous deposits, and of normal consistency. The purulent-looking material appeared free and not adherent to the abdominal wall and intestinal loops, as would be the case with recent extravasation, and was not organized. The histologic findings confirmed these considerations, which revealed no evidence of septic embolism. Overall, there were no postmortem findings suggestive of peritonitis and sepsis. Had the massive and acutely fatal pulmonary arterial thrombosis not occurred, local or systemic septic complications most likely could have developed. The case was considered of interest because of the rare neoplasm, its size, and the very advanced stage of the disease. Another peculiarity was that one of the most lethal direct complications of this neoplasm, pulmonary arterial thrombosis, was observed. Unfortunately, the absence of family members and health information does not allow further clinical considerations, but the severity of the disease found is glaringly the result of neglected and untreated disease. This case demonstrates that such scenarios are still possible today, despite the increased importance of prevention campaigns. In this context, the observed anatomopathological findings are crucial as they enrich the knowledge of uterine carcinosarcoma, and their images may help forensic pathologists who have not previously encountered this rare disease

The importance of the postmortem interval for the diagnosis of Waterhouse-Friderichsen syndrome by Neisseria meningitidis in a series of forensic cases

The effective value of microbiological post-mortem examinations stands as fundamental in forensic cases involving microbiology. We ran these analyses on five victims, who suddenly died after showing persistent fever. The examinations were conducted between 48 hours and 10 days after death, and adrenal gland apoplexy was detected in all the cases. Microbiological examinations identified Neisseria meningitidis, which was accountable for Waterhouse-Friderichsen syndrome. Diplococci were isolated from three cadavers that underwent forensic dissection between 2 and 3 days after death. The remaining two cadavers showed polymicrobial contamination, and a polymerase chain reaction technique was necessary to identify the pathogen. We assumed that the microbial overlap could lead to diagnostic mistakes and conceal the identification of the lethal pathogen. Therefore, we suggest using molecular techniques for a postmortem interval (PMI) longer than 72 hours. Classical microbiological examination should be performed for PMI within 72 hours

The importance of the postmortem interval for the diagnosis of Waterhouse–Friderichsen syndrome by Neisseria meningitidis in a series of forensic cases

The effective value of microbiological post-mortem examinations stands as fundamental in forensic cases involving microbiology. We ran these analyses on five victims, who suddenly died after showing persistent fever. The examinations were conducted between 48 hours and 10 days after death, and adrenal gland apoplexy was detected in all the cases. Microbiological examinations identified Neisseria meningitidis, which was accountable for Waterhouse–Friderichsen syndrome. Diplococci were isolated from three cadavers that underwent forensic dissection between 2 and 3 days after death. The remaining two cadavers showed polymicrobial contamination, and a polymerase chain reaction technique was necessary to identify the pathogen. We assumed that the microbial overlap could lead to diagnostic mistakes and conceal the identification of the lethal pathogen. Therefore, we suggest using molecular techniques for a postmortem interval (PMI) longer than 72 hours. Classical microbiological examination should be performed for PMI within 72 hours

Fatal pulmonary thromboembolism associated with uterine carcinosarcoma

Uterine carcinosarcoma (USC), also known as malignant mixed Müllerian tumor, is a rare and high-grade endometrial cancer composed of epithelial and mesenchymal elements.1 UCS accounts for 4.3% of all uterine corpus cancer, with a worldwide annual incidence of 0.5-3.3 cases per 100.000 women.1 Common risk factors include obesity, nulliparity, chronic endogenous or exogenous hyperestrogenism exposure, older age (with a median age of 70 years), African-American ethnicity, genetic predisposition, tamoxifen therapy, and prior pelvic irradiation.2 Typical UCS-related symptoms, unfortunately, associated with an already advanced stage of the disease, are large masses occupying the abdominal cavity, postmenopausal metrorrhagia, and abdominal pain. One of the most important complications of endometrial tumors, especially in UCS, is venous thromboembolism (VTE), with an incidence of 8.1%.3-4 It may also involve pulmonary arteries and is usually associated with aggressive tumor characteristics and poor patient health.3-4 While Trans-Vaginal Sonography (TVS) is the first-line method for the assessment of UCS, as it can detect neoformations of the myometrium, diagnosis can usually be made by the histopathological examination of targeted endometrial biopsies, possibly associated with hysteroscopy.5-6 Magnetic resonance imaging (MRI) is the best imaging modality for staging. Furthermore, it shows a typical high enhancement with a “spotty” distribution, which may suggest bleeding and is a distinct hallmark of carcinosarcoma.6-7 Depending on the histopathologic assessment of the tumor (depth of invasion and presence or absence of metastases) and clinical presentation,8 the management of UCS requires a multimodality treatment comprised of surgery, systemic therapy, and radiotherapy. The estimated 5-year survival rate ranges from 33 to 39%, but the recurrence rate remains high.2,8 Figure 1 refers to a 61-year-old woman found dead in her flat, dressed in a sanitary napkin and a nightgown. Because the woman lived alone and had no family members, no health information could be achieved. An autopsy was performed to determine the cause of death. The body was in a good state of preservation; it weighed 85 kg and was 158 cm long (BMI = 34 Kg/m2 - Class I obesity). The sanitary napkin was smeared with a yellow-green-blackish creamy material upon external examination,. At dissection, both branches of the pulmonary artery trunk were occupied by red-brownish clots with multiple whitish streaks extending along the intraparenchymal course of the dividing branches of the pulmonary arteries (Figure 1A). They appeared to adhere tenaciously to the intimal surface, replicating the shape of the vascular lumen as a mold. All these characteristics were confirmed upon slicing, and a friable consistency was noted. On the abdominal incision, abundant yellow-green-blackish material of pasty consistency and purulent appearance was noted near the pelvic notch and between some intestinal loops. The uterus (longitudinal diameter = 18 cm, transversal = 11 cm, anteroposterior = 5 cm) appeared to be increased in volume, and the wall had a wall thickness of 1.5 cm. Inside the uterine cavity, a vegetative neoformation was detected (longitudinal diameter = 6 cm, transversal = 5 cm, anteroposterior = 4 cm), almost occluding the lumen. It was associated with abundant material resembling in color and consistency that was found in the abdomen. This neoformation adhered to the lateral walls and fundus of the uterus, extending almost to the cervix (Figure 1B). The ovaries were unscathed. Figure 1 A - Macroscopic view of lungs showing red-brownish clots in the pulmonary artery trunk extending along the intraparenchymal branches (scale bar= 8 cm); B - Macroscopic view of the uterus after dissection with a vegetative neoformation almost occluding its lumen, in association with abundant yellow-green-blackish material of pasty consistency (scale bar= 7 cm); C - Photomicrograph of the endometrial tumor with remnants of neoplastic glandular epithelial component and of residual glandular pseudo-lumen with multi-layered epithelium and cellular atypia (H&E, 200x); D - Photomicrograph of the endometrial tumor with sarcomatous component partly with fused cellularity, partly in the form of compact bundles with marked nuclear atypia and partly with a myxoid-like structure with foci arranged in bundles associated with a scattered cell neoplastic component (H&E; 100x).: Histopathologic examination of the mass revealed features of carcinosarcoma consisting almost entirely of a sarcomatous component and small foci of endometrioid- type adenocarcinoma, with neoplastic embolization of the intraparietal venous vessels. An inflammatory infiltrate associated with marked tumor necrosis was also noted (Figures 1C and 1D). With this background, the abdominal findings were interpreted as purulent discharge and necrosis following the adjoining uterine cancer. At the end of all investigations, the cause of death was identified as massive pulmonary arterial thrombosis in a subject with uterine carcinosarcoma. For completeness, we also considered peritonitis and sepsis as possible co-participation in the cause of death. However, we considered this hypothesis unlikely based on the macroscopic and microscopic findings. Specifically, the peritoneum, abdominal viscera, and serosa were shiny, without fibrinous deposits, and of normal consistency. The purulent-looking material appeared free and not adherent to the abdominal wall and intestinal loops, as would be the case with recent extravasation, and was not organized. The histologic findings confirmed these considerations, which revealed no evidence of septic embolism. Overall, there were no postmortem findings suggestive of peritonitis and sepsis. Had the massive and acutely fatal pulmonary arterial thrombosis not occurred, local or systemic septic complications most likely could have developed. The case was considered of interest because of the rare neoplasm, its size, and the very advanced stage of the disease. Another peculiarity was that one of the most lethal direct complications of this neoplasm, pulmonary arterial thrombosis, was observed. Unfortunately, the absence of family members and health information does not allow further clinical considerations, but the severity of the disease found is glaringly the result of neglected and untreated disease. This case demonstrates that such scenarios are still possible today, despite the increased importance of prevention campaigns. In this context, the observed anatomopathological findings are crucial as they enrich the knowledge of uterine carcinosarcoma, and their images may help forensic pathologists who have not previously encountered this rare disease

Minorenni vittime di omicidio a Milano (Italia): 1993-2017

This study aims to examine the phenomenon of homicide with victims under 18 years-old in a wide and multiethnic metropolitanarea in the north of Italy. We’re dealing with a type of crime that generates a widespread alarm and a common concern.The data analysis, approached with a multidisciplinary strategy, presented in this paper is based on forensic reports of the Instituteof Legal Medicine of the University of Milan, to provide a detailed framework of the homicides of minors that took place inthe territorial jurisdiction of Milan and Monza Prosecutor’s Office between 1993 and 2017. Quantitative and qualitative analysiswere conducted regarding victims’ socio-demographic characteristics (gender, age, nationality), weapons used, places and modalityof body discovery, murderers, motives of the killing and type of relationship between offenders and victims. Purpose of thispaper is to compare the present set of data with the ones provided by the international literature, as well as make some criminologicalobservations on this matter with a view to preventing the phenomenon. To this end, some representative case studieshave been added, their characteristics and also the relationships between offender and victim have been discussed.Questo studio esamina il fenomeno dell'omicidio con vittime di età inferiore ai 18 anni in una vasta e multietnica area metropolitanadel nord Italia, un tipo di crimine che genera allarme e preoccupazione. L'analisi dei dati, affrontata con una metodologia multidisciplinare,è basata sui verbali autoptici dell'Istituto di Medicina Legale dell'Università di Milano, al fine di fornire un quadro dettagliatodegli omicidi con vittima minorenne che si sono verificati nella giurisdizione territoriale della Procura di Milano e Monzatra il 1993 e il 2017. Sono state condotte analisi quantitative e qualitative sulle vittime, quali le caratteristiche socio-demografiche(genere, età, nazionalità), le armi utilizzate, i luoghi e le modalità di rinvenimento del corpo, le caratteristiche dell’omicida, i motividell'uccisione e il tipo di relazione tra criminale e vittima. Scopo di questo studio è confrontare l'attuale insieme di dati con quelliforniti dalla letteratura internazionale, nonché porre alcune considerazioni di carattere preventivo. A tal fine, sono stati presentatianche alcuni casi studio rappresentativi, discutendone le caratteristiche peculiari e le relazioni tra l'autore del reato e la vittima

Porencephalic cyst in adult

We presented this case of death finding it of interest both for the rarity of the cerebral anomaly detected and for the survival of the man until adulthood in the absence of severe symptoms despite being a carrier of porencephalic cyst. In fact, the first diagnosis occurred only post mortem and the histopathological analysis confirmed the porencephalic nature of the large cerebral cavitated defect

Fatal hemorrhage from peripheral varicose vein rupture

Varix of the lower extremities is a common entity that eventually presents fatal outcome. Fatal massive bleeding due to rupture of a peripheral varicose vein is rare. The estimated incidence of these cases is 1/1000 autopsies. The case we present is unique among 26,054 autopsies performed in Milan from 1993 to 2020. It describes the investigations carried out in the suspicion of a non-natural event in an elderly woman. She was found dead at home with a large volume of blood near her feet that drained from the right leg. Pathological examination disclosed that the hemorrhage occurred by the rupture of a venous varix of the lower limb. Cases of fatal hemorrhage from peripheral variceal rupture are insidious and require proper characterization. The bloodstain pattern analysis, careful autopsy dissection by layers to demonstrate the rupture, and histologic examination of the lesion are the essential elements to find out the actual cause of deat