American Journal of Forensic Medicine & Pathology:
Cardiac Contusion and Hemopericardium in the Absence of External Thoracic Trauma: Case Report and Review of the Literature
Gonin, Julie MD; de la Grandmaison, Geoffroy Lorin MD, PhD; Durigon, Michel MD, PhD; Paraire, François MD
From the Department of Forensic Medicine and Pathology, Raymond Poincaré Hospital, AP-HP, Versailles Saint-Quentin-en-Yvelines University, Garches, France.
Manuscript received September 19, 2007; accepted March 20, 2008.
Reprints: Geoffroy Lorin de la Grandmaison, MD, PhD, Department of Forensic Medicine and Pathology, Raymond Poincaré Hospital, 104 boulevard Raymond Poincaré, 92380 Garches, France. E-mail: firstname.lastname@example.org
The case of an unusual homicidal cardiac contusion is described. A previously healthy 24-year-old woman suddenly died after being kicked on the chest by her boyfriend. A forensic autopsy was performed showing no external sign of thoracic trauma. An hemopericardium and a cardiac contusion of the basal and posterior surface of the left ventricle were found to be the cause of the death. Death could be a direct consequence of the myocardial contusion through electrical instability or/and consequence of the hemopericardium because its volume and sudden apparition were sufficient to cause tamponade. Numerous associated recent skin contusions mainly located on the face were consistent with inflicted blunt force trauma, supporting homicide as a manner of death. This case report underlines the importance of a systematic complete autopsy in all cases of sudden death occurring in a young adults, to rule out a possible homicide. The present case also shows that myocardial injury must be ruled out in every living patient presenting blunt chest trauma even in the absence of external sign.
Blunt cardiac trauma can lead to various cardiac injuries, including cardiac contusion with an incidence rates depending on series between 5% and 50%.1 This large range is probably due to the high frequency of undiagnosed cases. The most common situation leading to myocardial contusion is traffic accidents,2,3 very few cases have been reported in a context of manslaughter.4,5 The case of a cardiac contusion after a chest kick in a context of manslaughter is reported with a review of the literature.
A previously healthy 24-year-old woman received several blows in the face while quarreling with her boyfriend, until she fell into the bathtub, her head hitting the wall. Although she was lying on her back on the bathroom floor, her boyfriend stood up and kicked her on the precordial area. One or 2 minutes after the trauma, her boyfriend noticed that her breathing was abnormal and her eyes were wide opened, still. So he dragged her on the sofa to start performing a cardiopulmonary resuscitation (CPR) and then called the police department. Five minutes later, the police arrived and kept performing, for 10 minutes, an unsuccessful resuscitation.
A forensic autopsy was performed 4 days after death. The external examination of the 176-cm tall and 53 kg, slim woman showed areas of recent contusions: one, 2-cm long, on the right cheek; another, on the nape of the neck, medial, and vertical, 10-cm long and 0.8-cm deep and small ecchymotic spots on the inner side of the inferior lip and on third finger of the left hand. Two linear lacerations were also found: one, 1-cm long on the right eyebrow and one 1.4-cm long on the inferior eyelid. No other external traumatic lesion, especially on thoracic area was seen.
Internal examination showed that right lung was contused around its hilum without hemothorax. Heart examination showed a 500-mL hemopericardium, without pericardial tear and a contusion of the basal and posterior surface of the left ventricle, involving epicardial fat and the outer half of the underlying myocardium (Fig. 1). The histologic examination of this myocardial contusion showed interstitial foci of hemorrhage into epicardial fat and between myocardial fibers of the external half of the myocardium, preferentially located around veins (Fig. 2). Interstitial was also edematous. There was no infiltration of the contused area by polymorph nuclear leukocytes. In the free wall of the left ventricle away from the macroscopic heart contusion were also found numerous foci of interstitial extravasation of erythrocytes. These perivascular hemorrhages often disrupted the cardiomyocytes bundles (Fig. 3). Around hemorrhage, cardiomyocytes showed contraction band necrosis (Fig. 4). No foci of hemorrhage was found in the cardiac conduction system. Histology of the lung contusion showed subpleural alveolar hemorrhage. Other organs show no microscopic anomalies. Toxicological analysis was negative for drugs and alcohol.
Blunt cardiac injury has been mostly found in a context of traffic accidents.1–3 Such injury may also be encountered in other circumstances such as falls, sport activities, blast, gunshot wounds, and cardiac massage.1,2 Very few cases occurring in a context of homicide have been reported,4–10 as most of the cardiac injuries found in such context results from penetrating chest injury.11 The spectrum of homicidal blunt cardiac injuries range from myocardial concussion to myocardial contusion and laceration. Cases of myocardial concussion occurring in the homicide of small children were reported in the literature.8–10 Cohle et al reported 6 cases of child abuse showing fatal cardiac lacerations.6 The case reported by Nadesan corresponded to a fatal rupture of the right atrium in a front passenger victim of a true vehicular homicide.7 In most of the cases of blunt cardiac injuries in a context of homicide, other violence lesions may be found during autopsy. However, such lesions may be absent as in the case reported by Vougiouklakis et al,4 in which a healthy 29-year-old-man died of a right atrial contusion after being involved in a fight. In our case, numerous associated recent skin contusions and lacerations mainly located on the face were in favor of homicide as an manner of death. Indeed, such traumatic lesions could be secondary to blows. However, some of these traumatic lesions may also be due to the victim's fall described by her assailant.
Blunt chest trauma can induce myocardial lesions by several mechanisms, including direct transfer of kinetic energy during the impact on the chest, a sudden forceful deceleration process of the heart, and compression of heart between the sternum and the spine.1 Direct injury by a fractured sternum may damage the right ventricle. Another mechanism is an abrupt blood pressure increase in cardiac chambers after chest or abdominal compression or crushing.2,12 Impact may produce distension, shearing, or rupture of the heart according to the “water hammer effect.”2,12
In the current case report, the blunt cardiac injury resulted from a direct kick impact to the precordial area. The traumatic lesions found at autopsy included one cardiac contusion associated with a hemopericardium and a pulmonary contusion. In our case, hemopericardium could be secondary to the myocardial contusion as no pericardial tears or injury of intrapericardial portion of a major vessel were found. The practice of a long-standing resuscitation could have contributed to the abundance of the hemopericardium. Indeed, CPR is known to cause a variety of cardiovascular injury in adults.13 Fractured ribs from CPR may perforate the heart and excessive vigor in performing CPR has been blamed for a rupture of the interventricular septum and right ventricle.6 In the autopsy series of Krischer et al,13 8.4% of the cases were found to have whole blood in the pericardial sac as a complication of CPR. Other cardiac injuries included ventricular subendocardial contusion and laceration of the right atrium.13 Significant injuries to the cardiac conduction system after CPR, especially external chest compression, have been recently described in case report14 and in a large autopsy series.15
In our case, the pathologic changes found were typical for a cardiac contusion. The morphology of a cardiac contusion resembles those of acute myocardial infarction, but the amount of hemorrhage is more prominent in case of contusion. In addition, contusion presents an abrupt change between normal and abnormal myocardium, whereas the changes related to infarction are more gradual.8 In our case, there were also no coronary artery disease and no epicardial coronary artery trauma. The numerous foci of perivascular hemorrhages found away from the macroscopic heart contusion showed that severe shearing strains were applied to the heart. Indeed, they can be considered as micro tears of the myocardium with surrounding hemorrhage. The intensity of such shearing strains depends of the amount of kinetic energy delivered in the chest area after the blunt impact. There is some evidence that the absence of rib fractures-a common feature with young people-in cases of chest trauma may be associated with more severe cardiac injury.2 In our case, as the energy of forces was not dissipated by the fracturing of sternum or ribs, almost the whole amount of kinetic energy was delivered on the heart. Although the chest trauma was anterior, the macroscopic heart contusion was found in the posterior wall of the heart at autopsy. This can be the result of impact of the heart against the vertebral column.
Concerning the mechanism of death in our case, myocardial contusion may induce life-threatening complications through rhythm abnormalities (including ventricular fibrillation or asystolia), myocardial rupture, or conduction disturbance.16 According to experimental studies on rabbits, a high contusion kinetic energy was found to result in increased arrhythmia seriousness.17 In such experimental animal studies, arrhythmias occurred in up to 50% of cases.18 Arrhythmia occurs as a result of abnormal perfusion patterns, conduction anomalies by damaged myocytes or vagal-sympathetic reflexes.17 Major mechanism of death in our case was tamponade due to hemopericardium. Indeed, hemopericardium may develop acutely or be delayed after myocardium contusion19 and may reach sufficient volume to cause cardiac tamponade.2 As little as 150 mL of blood can cause death.20 Death could be a direct consequence of the myocardial contusion through electrical instability or/and a consequence of the hemopericardium because its volume and sudden apparition were sufficient to provoke tamponade.21 Cardiac contusions are very rarely lethal and in most of the lethal cases fatal outcome is usually caused by associated extracardiac injuries.17 As the lung contusion was found in a small area, it seemed to have played a minor role in the mechanism of death in our case.
One striking element in our case was the importance of serious internal traumatic lesions in contrast with the absence of external sign of chest trauma. This finding underlines the importance of a systematic complete autopsy in all cases of sudden death occurring in young adults, to rule out a possible homicide. This also shows that occult cardiac injury after blunt chest trauma is probably more common than generally suspected in living patients. Indeed, the clinical presentations of such injuries are extremely variable and are frequently unnoticed in the multitraumatized patient.22 So the diagnosis of myocardial contusion must be ruled out in every patient presenting blunt chest trauma even in the absence of external sign.
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cardiac contusion; commotio cordis; blunt cardiac injury; homicide; forensic; autopsy
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