Brain Cut: Fatal Fall?

We are privileged to have weekly tutorials from the only forensic brain pathologist in Africa. He is retiring soon – which is sad, because he is clearly a genius. He also teaches with passion, which seems rare in our field.

Anyway, we had an interesting case during brain cut today.

A 22-year-old man fell. The Professor’s first question was, “And how do 22-year-old’s fall? From ropes, and buildings, and hang gliders.”

He was a little disappointed to hear that our brain fell while being arrested by the police. Even more so when it was said to be an “alleged fall” – seems reminiscent of our country’s Apartheid era, where many inmates died after slipping on a bar of soap.

So anyway, while he was alive, it was determined that he had no skull fractures, but a sub-arachnoid haemorrhage and haemato-hydrocephalus. They then started investigating for a ruptured sacular aneurysm. None was found. The bleeding in all ventricles continued and an external drain was placed.

He started improving, and then quickly deteriorating. CT revealed first a small area of infarction in the temporal lobe. Two days later it had progressed to a large middle cerebral infarct. He died shortly afterward.

So interestingly, our Professor was tutoring us on aneurysms before we started slicing the brain. Then we got to the middle cerebral and anterior communicating arteries and, presto, nothing. No aneurysm. No sign thereof.

The brain was falling apart though. Infarcts are annoying.

More or less what the brain looked like. Image by Dr K. Mason, Iowa State University

For the first time the external appearance of the brain intrigued us. The vessels were extremely engorged. In between them were small, thin venous bleeds. Our Prof says the only time he had ever seen something similar was with viral meningitides. (Good thing the brain had been placed in formalin).

Our Prof seemed a little annoyed still. Partly, most likely, because it became clear that our understanding of neuroanatomy sucked.

Interesting case though. Even more so since we managed to cover a few diagnoses before finding the one of best fit.

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