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Determination of post-traumatic interval remains one of the foremost important goals of any forensic investigation related to human crimes. The estimation of time since injury in cases of subdural haemorrhage has been studied only by a few investigators on the histological and radiological front. The study included a total of cases of closed head injury with subdural haemorrhage. Statistically significant results were obtained between the HU measurements of the SDH and the post-traumatic intervals and were found to be statistically significant. A rough attempt was made to determine the effect of haematoma volume on attenuation and was found out to be statistically insignificant. The density of the subdural haematoma decreases with increase in the post-traumatic interval that concurs with the limited number of studies being conducted in the past.
All the variants were correlated with the post-traumatic interval. Lysis of red blood cells was observed partly beginning at a PTI of 7 hours. It was observed that there was significant difference between all the RBC groups i.
There were no cases in which neutrophils were very scarce or absent in our study. Macrophages, Red Blood Cells containing macrophages, haemosiderin containing macrophages, fibroblast, collagenous fibers, early membrane formation, endothelial proliferation were first observed at a PTI of Correlation of histopathological features with post traumatic interval groups using Chi- square test.
Logistic regression was deduced using all the histopathological variables with respect to time since the injury. The rate of successful classification was Results of logistic regression tables using histopathological variables with respect to time since injury a-e. There is an increasing awareness among the common public as well as the medical fraternity of the prevalence of traumatic brain injury and its clinical sequelae which have led to an exponential increase in the number of lawsuits and medico-legal cases.
Microscopic study of the organization of the SDH verified against the time period can help us in the determination of its age. This determination can be especially valuable in the absence of a true history of the events along with other parameters for the determination of PTI.
The majority of the SDH cases which are encountered in routine practice have PTIs within the clinically classified acute and subacute phases [ 13 ]. In this study, all the cases were observed within the PTI period of hours.
Although Walter et al. Fibrin strands were noted within a few hours of the occurrence of the SDH though was not quantified in this study. There is acute hemorrhage with alarge number of neutrophils seen on the dural side.
I have Dating Hemorrhage On Mri got calls from woman who wanted to cheat on her husband (implying they wanted to sleep with me). Most people think that this is just too weird to be true. Let me tell you a truth, its not. I am Dating Hemorrhage On Mri an average looking guy, over weight by Kgs, so I dont have a six pack or a muscular built / Dating on retinal hemorrhage is not relevant enough. Abstract. Background. Dating the traumatic event is usually done on subdural hematoma (SDH). After infant deaths due to Abusive head trauma (AHT) without SDH available, the magistrates still ask experts to date the traumatic event. To do so, the expert only has tools based on adult series of shawchapman.com: Clemence Delteil, Martin Kolopp, Caroline Capuani, Sarah Humez, Mohamed Boucekine, Georges Leonetti. Apr 01, Though few studies suggest that dating of subdural haematoma cannot be done accurately using radiological methods , the present study, yet gives a reliable and a reproducible method for the estimation of the age of early subdural haemorrhage. Not many studies have been conducted recently on the radiological dating of shawchapman.com by: 3.
Prussian blue-reaction x f Photomicrograph showing SDH 6 days old having a cells thick layer of fibroblastsat the dural-clot interface. As observed by Walter et al. Later they spread along the dura-clot interface and into the clot. Also, neutrophils were observed in larger numbers in a few early cases. To explain the above phenomenon, one may hypothesize that the increase in the number of neutrophils may be due to the injury rather than a reaction to it.
In simple terms, few of the circulating neutrophils in hemic proportions might have spilled into the subdural space at the moment of rupture of the bridging veins. This accumulation of the neutrophils along the dura-clot interface would have resulted in greater number of neutrophils observed in the early posttraumatic periods. The neutrophils which are reactionary to the injury appeared late and were accompanied by vascular alterations such as dilatation, endothelial swelling, emargination, and emigration, etc.
Also, the biological function of leukocyte immigration is not known about traumatic brain injury and haemorrhage [ 14 ]. This study differed from the observations of Walter et al.
This may be because CD68 monoclonal antibody was used to detect the presence of the same. Though Munro and Merritt made no mention of the duration of appearance of the macrophages, the pigment-laden histiocytes appeared on the 5 th day [ 9 ].
Engel et al. Another study conducted to detect the macrophage reactivity of the dura and the SDH using immunohistochemistry revealed that the expression of major histo-compatibility complex MHC class II can be observed within the first 24 hours whereas the CD68 expression can be detected quantitatively in hours following the trauma along the inner ct of the dura [ 16 ].
Haemophagocytosis was first observed at Perls stained sections were considered reliable as it could differentiate between formalin pigments and the haemosiderin. Haemosiderin containing macrophages were detected at similar time periods as in Walter et al.
The first mesenchymal reaction was observed on the fourth day of PTI and was mainly characterized by proliferation and invasion of fibroblasts into the clot from the dural side. The fibroblasts were earliest detected at The same was observed by Munro and Merritt on the third day. This reactive scarring process is accompanied by endothelial proliferation along the dural margins of the clot. Endothelial proliferation was observed much earlier in our study as compared to Munro and Merritt.
Overall, the observations of the present study deviates from the Munro and Merritt study in the fact that lysed RBCs, neutrophils, and macrophages were detected earlier in our study [ 9 ].
When compared to Walter et al. Further the authors would like to propose a new classification of the SDH according to the histological features into forensically relevant acute, early subacute and late subacute stages. Till the engulfing of the red blood cells by the macrophages, the SDH may be called acute and from there on till the appearance of the membrane, the early subacute and once the neo-membrane has appeared it may be called late subacute, i.
The influence of hypothermia, shock, hypoxia, variations in the blood pressure, the effect of medications during emergency care, potential effects of associated injuries and failure of the internal organs were not evaluated. The variations in the hospital care and treatment, the mode of injuries high velocityhave considerably changed over the years and hence could have contributed to the observed variations in spite of proper study design.
These are also in part due to the active nature of such lesions and the diverse manner in which trauma victims respond to injury. Also due to the short PTI in our study, the role of rebleeding could not be accounted completely in influencing the histological observations about post-traumatic interval.
Though this study was limited to cases with shorter PTIs, there was an apparent correlation between the frequency of a given histomorphological phenomenon and the length of the PTI.
The simple way to meet for sex. MeetBang lets you enjoy the benefits of Dating Subdural Hemorrhage Autopsy dating without having to give up the excitement of being single. Find sexy singles and couples anywhere, anytime. MeetBang makes it fun, safe, and discrete / An intracerebral hemorrhage, or intraparenchymal cerebral hemorrhage, is a subset of an intracranial shawchapman.com can encompass a number of entities that share the acute accumulation of blood in the parenchyma of the brain. The etiology, epidemiology, treatment and prognosis vary widely depending on the type of hemorrhage, and as such these are discussed separately. A diagnosis of myocardial infarction is created by integrating the history of the presenting illness and physical examination with electrocardiogram findings and cardiac markers (blood tests for heart muscle cell damage). A coronary angiogram allows visualization of narrowings or obstructions on the heart vessels, and therapeutic measures can follow immediately.
Further in developing countries, routine staining scores over immunohistochemistry considering cost effectiveness and requirement of technical expertise. For future prospects a long-term study involving more number of cases will help in the better understanding of the overlapping histomorphological characteristics of the SDH with relation to time using routine methods. This study could be extended to cases below 18 years.
Also, additional criteria may be established using other staining methods and by the electron microscope. National Center for Biotechnology InformationU.
J Clin Diagn Res. Published online Jul 1. Find articles by Murali G Rao.
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Find articles by Suresh Kumar Sharma. Author information Article notes Copyright and License information Disclaimer. Corresponding author. E-mail: moc. This article has been cited by other articles in PMC. Abstract Introduction Microscopic study of the organization of the Subdural Haemorrhage SDH verified against the time period can help us in the determination of its age which has serious medico-legal implications. Aim This study was conducted for dating the early subdural haemorrhage by routine histopathological stains.
Materials and Methods A prospective analytical study was conducted during July to December Results Correlation between the frequency of a given histomorphological phenomenon and the length of the Post-Traumatic Interval PTI was evidential. Conclusion We concluded that routine histopathology was reliable in the dating of early subdural haemorrhages. Keywords: Medico-legal, Polymorphonuclear leuckocytes, Post-traumatic interval, Subdural haematoma. Introduction Road traffic accidents take about 1.
Materials and Methods After obtaining clearance from the ethical clearance committee of the Institute PGIMER, Chandigarhthis prospective analytical study was conducted during July to December in the Department of Forensic Medicine in collaboration with the department of Pathology and Neurosurgery. Histological Procedure Sections of the brain along with the dura mater were removed at the time of autopsy; great care was taken not to disturb the clot underlying the dura as it usually falls away from the underside of the dura.
Histopathological Evaluation Histomorphological features of the dura and the clot such as Red Blood Cells RBCsPolymorphonuclear Leukocytes PMNmacrophages, and red blood cell containing macrophages, haemosiderin containing macrophages, fibroblasts, collagen fibers, capillary proliferation and early membrane formation were examined by two independent observers blinded to survival time.
Open in a separate window. Deviation Std. Histomorphological criteria Appearance hours Total no. Step 2 Step Discussion There is an increasing awareness among the common public as well as the medical fraternity of the prevalence of traumatic brain injury and its clinical sequelae which have led to an exponential increase in the number of lawsuits and medico-legal cases.
The attenuation coefficient defines the extent to which the intensity of an energy beam is diminished as it passes through a particular material [ 5 ]. From the clinical point of view, classification of subdural haemor-rhage into different ages or post-traumatic Intervals PTI based on its density on CT scan decides the further course of management of the patients. Though discussion on the management of subdural haemorrhage is out of the scope of this paper, few points can be noted.
Hyperdense subdural haematomas are usually managed by craniotomy and at times by performing craniectomy.
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The surgical procedures like trephination and twist drill craniotomy are used in the management of hypodense subdural haemorrhage. Further with the passage of time, the variation in the MRI appearance of SDH can indicate the approximate stage of haemorrhage and even the age of the blood clot [ 12 ]. These observations have immense forensic applications where multiple traumatic events have occurred in the same case, in cases with the paucity of external injuries or in cases with repeated non-accidental trauma.
Thus the radiological dating of SDH is of immense help, both from the forensic point of view as well as for the management of the patient.
From the forensic perspective, the radiological tools have been valuable in the detection of foreign bodies, disaster victim identifications, child abuse, gunshot wounds, traffic accidents, and air embolisms [ 13 ].
However, only a few studies have described the changes occurring in SDH using CT [ 14 - 16 ] or MRI [ 12 ] with relation to the time of occurrence of the traumatic event. Few histological studies on the aging of SDH have also been conducted and till date remains as the gold standard [ 1718 ].
Interest in the application of attenuation numbers in forensic radiology has again evolved recently following many studies on its reliability and reproducibility [ 1920 ].
This study is also the first of its kind to be conducted in India. The findings of head CT done at the time of diagnosis were noted. Conservatively treated cases of SDHs with a known mode, manner and topography of the incident were included in this study.
All those cases with history of ataxia, stroke attacks, dementia, haemorrhagic tendencies liver cirrhosis, anticoagulant therapy, and haemorrhagic diathesisknown prior traumatic brain injuries and with more than one episode of epilepsy were excluded from this study.
Also, excluded were cases that were surgically treated and in whom rebleeding was noted clinically and radiological. The post-traumatic interval varied from 0. Non-contrast computed tomography of the head was done using single slice hi-speed GE machine scanner with a tube current of mA, tube voltage of kVp and a slice thickness of 10 mm Window Width HU, Window centre HU.
The clinical, as well as police records of the patients, were reviewed and the time interval between the occurrence of trauma and Non-contrast computed tomography was noted. All the measurements were performed on a picture archiving and communication system PACS workstation. The crescentic subdural haematoma having the maximum length the linear distance between the corners of the subdural haemorrhage crescent in any single slice was chosen for HU measurement.
To avoid the partial volume effect and to maintain a constant relationship between the diameter of ROI and the breadth of the haemorrhage, a circular region of interest ROI along the maximum breadth of the haematoma was chosen for HU measurement in all cases [ 1920 ]. If the haematoma was present in more than one slice, then the average HU measurement of all those slices were taken as mentioned above.
The HU measurements were measured away from the rim of the subdural haemorrhage to avoid partial volume effect.
To assess intra-reader reliability, each reader repeated HU measurements thrice in an individual case with an interval of three weeks between each measurement. Though the scanner and the protocol utilized in the present study, not being state of the art, an attempt was made to determine roughly the effect of the volume of the subdural haematoma on its attenuation.
Length was measured as the linear distance between the corners of the SDH crescent. The breadth was measured as the maximum distance of haematoma from the inner table of the skull perpendicular to the length.
The depth was determined by multiplying the number of slices on which haematoma was visible, by the slice thickness. Intra-reader reliability was assessed using the intraclass correlation coefficient ICC. A total of cases in the age group of years were studied. The post-traumatic time interval varied from 0. The volume of the SDH varied from 0. Axial view: A crescentic subdural haematoma over the left fronto-parieto-temporal region with a contralateral midline shift. Distribution of cases according to the post-traumatic interval and mean attenuation of subdural haemorrhage.
The intra-class correlation coefficient for intra-reader reliability of the first and second readers were 0.
The prediction of PTI was based on density and volume. In logistic regression, after applying forward likelihood ratio method, only density was found out to be significant and is used in the model to predict PTI. The timing of a traumatic event by post-mortem findings carries immense significance for the forensic experts. Multiple methods to determine the age of injury are available which include but not limited to the healing of abrasions, contusions, and other injuries.
The aim of the present study was to determine the post-traumatic interval of the early subdural haematomas based on computed tomography attenuation numbers.
In this study, crescent shaped haemorrhages were distinctively selected to determine the effect of blood volume on attenuation. The variation in density pattern is observed on computed tomography about extravasation of blood with time [ 14 - 16 ].
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An acute subdural haemorrhage has a computed tomographic attenuation value that is dependent largely on the proportions of red blood cells, haemoglobin and iron content, and fibrin. An acute thrombus is formed from fibrin, platelets, neutrophils, and red blood cells, and as the cells start losing its integrity, swelling often occurs [ 17 ]. Attenuation also depends on beam energy and may, therefore, differ significantly between different CT scanners.
Earlier studies have reported Scanner-dependent variability in CT numbers [ 192223 ]. However, in Strandberg et al. This contention was avoided in our study by the utilization of a single CT machine with a single standard specification for all the cases.
Few studies have been attempted long back for dating the subdural haemorrhage using computed tomography. Bergstroem et al. Scotti et al. Lee et al. All the above studies have tried to classify subdural haemorrhage into acute, subacute or chronic depending on the attenuation.
Murali G Rao et al., Dating of Acute and Subacute Subdural Haemorrhage: A Histo-Pathological Study shawchapman.com Journal of Clinical and Diagnostic Research. Jul, Vol(7): HCHC07 4 4. Feb 03, Retinal hemorrhage is bleeding from the blood vessels in the retina, inside your eye. Your retina is the thin layer that lines the back of your eye. What causes retinal hemorrhage? Medical conditions, such as diabetes, high blood pressure, anemia, or leukemia. Eye problems, such as macular degeneration, or a bulging of the blood vessels in the. Jul 01, Microscopic study of the organization of the Subdural Haemorrhage (SDH) verified against the time period can help us in the determination of its age which has serious medico-legal implications. Very few studies concerning the dating of SDH are present Cited by: 5.
The present study, unlike others, included only early cases of SDH and further differentiation of the haemorrhage according to age was attempted within this short post-traumatic interval.
It is pertinent to note that these studies also do not mention the specific radiological methods applied in estimating the age of the subdural haematoma. After about days of the clot formation, the density drops to about 30HU and becomes isodense with the adjacent cortex [ 4 ].
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Since the cases in the present study were well within or close to 10 days, all the cases had a high attenuation, which is in concordance with all the above published data.
Correlation of attenuation of the haematoma and time interval between injury and computed tomography was found to be highly negative i. The determination of the post-traumatic interval of the subdural haemorrhage is a complex problem and has been worked out by a very few investigators. Hence a very limited number of studies with which the results of the present study could be compared. These findings accord with the results of other studies examining Intra-reader reliability of attenuation measurements [ 19 ].
Currently, the dating of subdural haemorrhage by measuring the CT number alone could lead to inaccuracies as it depends on measurement technique, object composition, and beam energy. Therefore with further research on this subject, the attenuation of subdural haemorrhages can be measured with more reliability and, thereby placing them accurately into particular post-traumatic interval groups.
However, the outcome of living patients may not be entirely transferable to post-mortem radiology. The application of the current methodology to post-mortem cases will be an oversimplification. Though, the few post-mortem radiological studies conducted previously have inferred minimal difference with the autopsy findings in cases of craniocerebral trauma, not much work has been done on decomposed bodies [ 2324 ].
Further in these studies [ 2324 ], the cases had a time interval of less than 24hours between the death and postmortem radiological examination. These studies concentrated mainly on the gross features rather than going into specifics like aging and the degree of the autolytic process if any. From the radiological point of view, the dating of early SDH remains limited, in the fact that all the SDH were hyper dense, but concurs with the already published data [ 42526 ].
However, on a further classification of these HU numbers about post-traumatic intervals, information was obtained on the range of attenuation for a particular post-traumatic interval. Though few studies suggest that dating of subdural haematoma cannot be done accurately using radiological methods [ 25 - 27 ], the present study, yet gives a reliable and a reproducible method for the estimation of the age of early subdural haemorrhage.
Not many studies have been conducted recently on the radiological dating of SDH. Those studies which have dealt with the radiological dating of SDH have not specified the radiological methods and hence the comparison with different studies have been limited. The results from one of the recently conducted questionnaire based study showed that there was a considerable variation among the radiologists, regarding medico-legal opinions on the age of SDH and concluded it unsuitable to use in court because of non-uniformity [ 28 ].
The study was limited by the small sample of materials investigated. The influence of hypothermia, shock, hypoxia, variations in the blood pressure, the effect of medications during emergency care, potential effects of associated injuries and failure of the internal organs were not evaluated.
Repeat CT examinations of the same patient at various times were not done in our study. Also, a single CT scan machine was used in this study hence variations in attenuation between different CT Scanners could not be appreciated. Because of the difficulty in differentiation into antemortem and postmortem breakdown of cellular components, it is hard to predict the post-traumatic intervals in decomposing bodies. Finally, the CT Scanner and protocol that have been used in this study is not the state of the art concerning its various parameters.
Though single slice CT scanners are not used in state of the art head scans [ 29 ], the constraints on the availability of advanced scanners in a developing country like India, has compelled us to use the resources at hand. A long-term study involving more number of cases helps in the better understanding of the attenuation variations of the SDH with relation to time. Further this study could be extended to cases below 18 years of age that hold a lot of medico-legal significances.
More innovative research can be done by the application of HU measurements on different organs in determining the time since death. Considering a few recent studies being done on the postmortem use of the radiological technologies in the interpretation of the cranio-cerebral traumatic injuries [ 2324 ] one can with some confidence say that these methods hold a lot of stake for the future of radiological autopsy or may indeed replace few of the routinely conducted forensic autopsies of the present times.
The present study has adopted one of the most objective and scientific methods in determining the attenuation of the subdural haematomas in contrast to the other previous studies where none has been applied or has not been mentioned.
Though this study has been limited to the early post-traumatic intervals, it could still grasp some significant findings in the form of variations in the attenuation of the subdural haemorrhage with relation to time of the injury.