Harish Kumar Agarwal, Ankur P Patel
Department of Forensic Medicine, Maharaja Agrasen Medical College, Agroha, Hisar (Haryana)
Department of Forensic Medicine, Government Medical College, Surat (Gujarat)
Pregnancy is a thrombogenic state that puts a pregnant mother at risk of pulmonary thromboembolism (PTE), deep venous thrombosis (DVT), and stroke during the antenatal period, and more commonly during puerperium. Cerebral venous sinus thrombosis (CVST) is one such known but rare neurologic complication.1The most common form of CVST is the superior sagittal sinus (SSS) thrombosis.2In India, the incidence of SSS thrombosis is 1 per 250 pregnant women3. Here, we are report a case of fatal SSS in a female. The present case is an attempt to emphasize the role of the application of integrating medical knowledge in the aid of justice.
A 25year old woman went to a nearby hospital for normal delivery at term. Being asymptomatic, the patient was discharged on the second postpartum day. On the twelfth postpartum day, she came to the emergency department with complaints of headache with vomiting and little frothing from the mouth. On examination, the patient had a Glasgow Coma Scale (GCS) of Eye opening, Verbal Response and Motor Response (E1V2M3). The vitals were unremarkable except for a slight increase in blood pressure. Laboratory investigations showed anisocytosis, hypochromic anemia sub arachnoid hemorrhage (SAH) on bilateral frontal lobes, subdural hemorrhage (SDH) on the right frontal lobe along with multiple small hemorrhagic contusions and edema of brain parenchyma were noted in the computed tomography (CT) scan of head. (Fgure.1) There was an episode of seizure and the patient died on the same day about 6 hours after the hospitalization.
Due to the sudden death, an alleged history of assault and ﬁndings of hemorrhage on radiological imaging, the treating doctor informed the police and an autopsy was conducted.
Dried white stain was present over the mouth and nostrils. Pleural cavity contained blood mixed ﬂuid. Bilateral lungs were edematous and congested. On cut sections of the lung, white frothy ﬂuid was seen.
No scalp injury and skull fracture were present. Dura was intact, tense, with congestion of superior sagittal sinus. No epidural or subdural hemorrhage was present. SAH of dark red color with clotted blood about 80 cc was present over the convexity of both frontal lobe more on the right side. Brain parenchyma was congested and edematous. Dilatation of blood vessels of the base of the brain was present without any aneurysm.
After reviewing the clinical records, CT scan, postmortem examination, and negative chemical examination, the ﬁnal cause of death was opined as failure of function of the brain as a result of superior sagittal venous thrombosis which was further aggrieved by acute pneumonia. The possible manner of death suggested after the histopathological report was natural.
Superior sagittal sinus (SSS) thrombosis comprises nearly 70%-80% of all CVST cases. It may happen in all ages but mostly occurs in young and middle-aged women.4 CVST is an under diagnosed condition. Patients with CVST may present with various signs and symptoms, which lead to delay in the diagnosis.
The sudden death of a young married woman most of the time creates suspicion of foul play in the mind of her close relatives as well as for the law enforcement agencies. According to Government guidelines, the case must be registered for Maternal Mortality Rate (MMR) and investigated for alleged assault, both health, and law enforcement agencies needed an accurate cause as well as the manner of death. Many etiological factors are reported in the literature but in 20-25% of the cases, the exact etiology could not be identiﬁed.5 The mortality rate is 5-30%.6 The standard median time between the onset of symptoms and death was 13 days and between diagnosis and death, was 5 days.7 Factors leading to poor prognosis in SSS thrombosis are the absence of any signiﬁcant history, complaint of headache not thoroughly examined before, and delay in arrival at the hospital. In the present case, the patient presented with headache, vomiting and frothing from the mouth. On enquiry, relatives said that the deceased was complaining of headache for one week. During her transport to the hospital, she had episodes of vomiting, and froth was coming out from her mouth due to which they suspected the possibility of unnatural death (alleged head injury and giving poison to her) and made charges against her in-laws. The present case is of maternal death by sagittal sinus thrombosis due to predisposition to clotting after birth. Integration of the knowledge of clinical symptoms, radiological ﬁndings, autopsy ﬁndings, and histopathological examination was all supportive of the cause of death as pathological bleeding.
This case report emphasized the need for the integration of medical knowledge among various ﬁelds as the same has been envisaged by National Medical Commission in pursuance of competency based medical education.
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Conﬂicts of interest
There are no conﬂicts of interest.
Ethical conduct of research
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms for images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due eﬀorts will be made to conceal their identity, but anonymity cannot be guaranteed.
1. James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005;106:509-16.
2. Saposnik G, Barinagarrementeria F, Brown RD Jr, Bushnell CD, Cucchiara B, Cushman M et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:1158–92.
3. Srinivasan K. Ischemic cerebrovascular disease in the young. Two common causes in India. Strokes. 1984;15(4):733-5.
4. Iskandar BJ, Kapp JP. Nonseptic venous occlusive disease. In: Wilkins RH, Rengachary SS (eds.). Neurosurgery. 2nded. McGraw Hill, USA. 1996;217790.
5. Kimber J. Cerebral venous sinus thrombosis. QJM 2002;95:137-142.
6. Crassard I, Bousser MG. Cerebral venous thrombosis. J Neuroophthalmol 2004;24:156-63.
7. Canhao P, Barinagarrementeria F, Lindgren AG, Bousser MG, Stam J. ISCVT Investigators: causes and predictors of death in cerebral venous thrombosis 2005; 36(8):1720-5.