Individual pathologists will differ in the format and detail of their reports. However, it will be reasonably assumed that all of the following detail has been examined, if not documented in the Autopsy Report.
1.
Presumed natural adult death autopsy
Name of pathologist: Deceased’s name and age:
Time, place and date of examination:
1.1
External examination
General description. Record length and weight.
Identifying features including scars, tattoos, hair and teeth. Signs of medical intervention.
Description of all external injuries.
Post-mortem changes including lividity, rigidity, changes of decomposition.
1.2
Internal examination
Cardiovascular system
Pericardial fluid – description of fluid. Heart:
weight;
assessment of chamber size and thickness; description of myocardium; and
description of valves. Coronary arteries:
comment on configuration;
distribution and severity of stenosis; and presence/absence of old or recent occlusions. Major arteries:
aorta and carotids; and
distribution and severity of atheroma.
Respiratory system
Diaphragm – description.
Larynx-trachea – integrity of neck structures. Pleural cavities:
description of pleura, adhesions; and description of fluid, assessment of volume. Lungs:
lung weights;
description of external and cut surfaces; and
Code of Practice and Performance Standards for
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PROCEDURES
case.
Bronchi – description of mucosa. Pulmonary artery: description; and emboli. Gastrointestinal system Oesophagus – description. Stomach contents:
general assessment of volume of contents; and description of mucosa.
Small/large bowel – general description. Liver:
weight; and description.
Gallbladder/ bile ducts – description. Pancreas – description.
Peritoneal cavity – description.
Genito-urinary system
Kidneys – weight, description of external and cut surfaces. Ureters – comment.
Bladder – description, assessment of volume and contents. Reproductive organs – description.
Central nervous system
Cerebral arteries – description. Meninges – description of surface. Brain:
weight; and
Description of external surface and cut surfaces (see CNS examination below). Pituitary – description.
Reticuloendothelial system
Spleen:
weight; and
description of external/cut surfaces. Lymph nodes – description.
Endocrine system
Thyroid – description. Adrenal glands – description.
Code of Practice and Performance Standards for
Forensic Pathology in NSW
PROCEDURES Musculoskeletal system Description.1.3
Specimens
The selection of tissues for histology is purely at the discretion of the pathologist. Below is a suggested protocol. However, the pathologists must histologically examine sufficient organs thoroughly so that any case can be adequately peer reviewed or audited with confidence in respect of the cause of death.
Histology
(To include representative sections of abnormal findings.)
• Coronary artery At least one section from representative areas of most severe disease. • Heart Sections from relevant regions of left and right ventricular myocardium.
• Lungs One section from each.
• Kidney One section from kidney.
• Liver One section.
• Brain Relevant sections according to case type (see “Examination of the central nervous system” below).
• Sections of further organs and tissues as indicated by the particular case.
Toxicology
As indicated (see Appendix 4).
Microbiology
As indicated.
Radiology
As indicated.
1.4
Summary of major anatomical findings
1.5
Cause of death
1.6
Comments
Brief explanation of disease (as indicated).
Relevant medico-legal issues that have been identified at the time of completion of the autopsy report.
2.
Examination of the central nervous system
The following comments refer to the examination of the unfixed brain in the context of a routine examination for the coronial service.
If the brain is very soft or oedematous, cooling it for an hour in a refrigerator may make it easier to obtain uniform slices. Wetting the brain knife between sections eases slicing. In most conditions the cerebral hemispheres are best sectioned coronally in 1cm-thick slices, the cerebellum radially in pie slices and the brain stem sectioned transversely.
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If generalised subarachnoid haemorrhage is found, examine the arterial system first, removing blood clot from around the vessels with a blunt-edged instrument. If no ruptured berry aneurysm is found, peel back the larger arteries of the anterior cerebral and vertebro-basilar systems for closer examination (a
posteriorly-directed aneurysm may be difficult to locate with the arteries attached to the brain surface). If no extracerebral source is found, section the brain to look for an intracerebral source of haemorrhage with rupture into the ventricular system. Consider the possibility of a traumatic basal subarachnoid haemorrhage. In such cases, a detailed neuropathological examination of the fixed brain is required, and a detailed examination of the entire extracranial and intracranial course of the vertebral arteries is essential. When trauma is assessed, contusions and haemorrhages are described. Small haemorrhages (often petechial) in the corpus callosum and dorsolateral segments of the rostral pons in the unswollen brain suggest diffuse axonal injury (DAI). Brain swelling, with tentorial herniation and secondary haemorrhages in the midbrain/rostral pons, complicates the diagnosis of DAI.
Haemorrhages with DAI are not into the perivascular sheath, but into the tissues. Haemorrhages into perivascular sheaths are non-specific/agonal in type, apart from high-speed crashes associated with many perivascular haemorrhages in white matter. In this case, diffuse vascular damage (DVD) is likely to have occurred. DVD is usually a rapidly lethal condition, with death at the scene.
2.1 Histology
Tissue blocks for assessing trauma should include: one section of a contusion;
posterior corpus callosum; thalamus;
transverse section of the rostral pons; and
sections of the medulla in infants/children under the age of 4 years.
Amyloid Precursor Protein (APP) immunostaining can show axonal pathology from about 90 minutes after trauma or other types of damage.
Assessment of global hypoxia/ischaemia includes trying to decide whether the brain is affected by either cardiac arrest or by severe hypotension. Hypoxia/ischaemia should be screened for in the setting of trauma.
Sections best examined are:
parasagittal occipital cortex (“border zone” cortex); hippocampus;
thalamus;
inferolateral cerebellar (border zone) cortex.
With resuscitation after cardiac arrest, the Sommer’s sector of the hippocampus should show extensive neuronal ischaemic cell change (ICC), as well as the occipital cortex and the thalamus if CPR was
prolonged. Hypotension without cardiac arrest is suggested by sparing of the Sommer’s sector from ICC, and some involvement of the thalamus. If infarcts are also present in the occipital cortex (“accentuation”), then abrupt onset/rapid resolution of hypotension is suggested. If there is no occipital accentuation but widespread cortical ICC and severe thalamic ICC, it is likely hypotension was slow in onset or resolution.
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Chronic hypertension is associated with arterial hyaline sclerosis and loosening of perivascular tissues.
The best sections to screen for hypertension are from:
the basal ganglia (caudate nucleus and/or the lenticular nucleus); and the pons and cerebellar white matter in severe hypertension.
Spinal cord fixation Open the dura longitudinally front and back, then snip through the dura laterally
between every third spinal nerve root. The cord may then be put into a wide container in formalin and it will fix without the kinking caused by contraction of the dura.
If the spinal cord is also to be examined microscopically, remove the cord first from the posterior aspect. Imaging using CT scan or MRI prior to dissection may be useful in providing a permanent record of fractures especially in the upper cervical spine which may be difficult to access.
Code of Practice and Performance Standards for
Forensic Pathology in NSW
PROCEDURES