hemopericardium is an effusion of blood into the pericardial sac and it is due to heart disease ( heart rupture as a consequence of necrosis or traumas ) or to an intrapericardial aortic rupture . in both cases ,
death may occur as a result of cardiac tamponade due to the accumulation of blood in the pericardium , which leads to an obstructive shock . as the external pressure on the heart increases , the distending or transmural pressure ( external - intracavitary pressure ) decreases and consequently the intracavitary pressure rises for compensation , leading to an impaired venous return and an elevation of the venous pressure .
if the external pressure is so high to exceed the ventricular pressure during diastole , diastolic ventricular collapse and a cardiac arrest may occur .
the obstructive shock results in a moderate / severe cyanosis of the face and neck. during the last few years , with the introduction of post - mortem computer tomography ( pmct ) , a valuable contribute has been given to forensic investigations in making , contributing and supporting the diagnosis of several violent and natural causes of death , leading to the introduction of this technique in some offices of forensic sciences as a standard procedure before the traditional autopsy and in sporadic cases even to substitute it .
in this paper , a case of death due to cardiac tamponade as a consequence of hemopericardium is reported , in which pmct was useful in order to understand the dynamic and cause of death , before the post - mortem examination .
the body was still warm and no signs of trauma or other injuries were found .
he had a medical history of hepatitis c and hypertension with a poor pharmacological response . before the autopsy a pmct examination was performed about 3 h after the discovery of the corpse .
the obtained dicom scans were rendered in 2d and 3d images using the open source software osirix on a maxosx computer . a board certified radiologist interpreted all radiological images .
the pmct report was available before the autopsy examination and showed an intrapericardial aortic dissection together with a periaortic hematoma , a sickle - shaped intramural hematoma and a false lumen .
a hemopericardium was also shown , consisting in fluid and clotted blood , which differentiated to each other because of their densities ( figure 1 ) .
even before the traditional postmortem examination , we were able to declare death due to a cardiac tamponade as a consequence of hemopericardium in a type - a aortic dissection according to stanford classification .
at the external examination of the body , no signs of trauma were observed . at the autopsy examination , the features observed by the pmct scans were totally confirmed .
on opening the pericardial sac , a cardiac tamponade was present , consisting in a large size hematoma of clotted blood ( 800 g ) and fluid blood ( 500 g ) ( figure 2a ) .
after a block dissection of the heart together with the ascendant aorta , and a careful dissection of the soft tissues of these anatomical structures , an intrapericardial aortic dissection was found ( figure 2b ) .
( a ) : a hypodense area compared with the lumen ( blue arrow in the red circle ) ; ( b ) : a false lumen together with an intramural hematoma displayed as a hyperdense area ( blue arrow in the red circle ) ; and ( c & d ) : a hemopericardium consisting in fluid blood ( blue circle ) and clotted blood ( red asterisk ) .
( a ) : the presence of the hemopericardium confirmed the pmct findings when the pericardial sac was opened ; ( b ) : site of aortic dissection ( indicated by the probe ) involving the ascending aorta in its intrapericardial tract .
aortic dissection is by far the most common and serious condition affecting the aorta . among these pathologies ,
the ascendant aortic dissection is the most severe condition that may lead to death in a large number of cases , due to the rapidity of the pathological process .
the dissection seems to be strictly related to the cystic medial necrosis , a disorder of large arteries , in particular the aorta , characterized by an accumulation of basophilic ground substance in the media with cyst - like lesions .
it usually results from chronic hypertension or from rare conditions ( such as marfan 's syndrome , aortic coarctation and bicuspid aortic valve ) .
whatever the mechanism , it is often brought about by degenerative changes in the aortic wall .
since dissection can involve any aortic segment , the disease can manifest itself through a variety of clinical presentations .
in fact , when aortic dissection occurs , aortic branches occlusion may happen . in case of dissections of the ascending aorta ,
the major aortic branches are occluded , resulting in rapidly fatal complications such as cardiac tamponade , major stroke , or massive myocardial infarction. if the fluid occurs rapidly ( as may occur after trauma or myocardial rupture ) , as little as 100 ml can cause tamponade .
however , the data reported in literature about the amount of blood able to cause death in acute cases are discordant . frequently , a quantity of 300400 ml of blood is found in bodies , even if other reports show a greater volume. aortic dissections can be classified by the location of the tear . according to the stanford classification,
there are two types of aortic dissections : ( 1 ) type a aortic dissections involve the ascending aorta and frequently needs emergency surgery .
these types of dissections are often found in subjects with a history of high blood pressure , an ascending aortic aneurysm , connective tissue disorder ( e.g. , marfan syndrome , bicuspid aortic valve , or a family history of aortic dissections ) .
( 2 ) type b aortic dissections do not involve the ascending aorta ( involvement of aortic arch without involvement of the ascending aorta is considered type b or simply called arch dissection but is not a type a dissection ) .
these types of dissections may be managed conservatively with blood pressure and heart rate control .
therefore , the case here reported can be classified as a type a aortic dissection .
the evaluation in living subjects of cardiac tamponade due to a hemopericardium , using diagnostic imaging techniques with special regard to the ct , allows a good interpretation of the anatomy and the pathology of the pericardium .
, in post - mortem investigations , few studies have used pmct imaging to investigate cardiac tamponade in the last decade, ( table 1 ) and the results obtained show the feasibility of using the pmct technique to diagnose haemopericardium and cardiac tamponade in cadavers .
it must also be considered that since in in - vivo imaging of aortic dissections the contrast - enhancement of the lumen is essential to detect critical radiological features , it is possible that these findings can be missed during a standard pmct without contrast . to overcome this problem ,
a pmct - angiography can be carried out , even if the use of this technique is currently limited . regarding this topic ,
f : female ; m : male ; pmct : post - mortem computer tomography .
bello , et al . have recently reported a case involving a 72 year - old man , in which multi - phase pmct angiography was helpful in defining the diagnosis , detecting a hemopericardium and the ruptured wall situated in the posterior part of the left ventricle .
the autopsy was then performed , totally confirming the ct angiography findings . in the present case ,
this pathology was the trigger for the development of the ascendant aortic dissection resulting in a rapid cardiac tamponade , causing the man 's death .
according to the italian jurisdiction , when a subject ( even a foreigner ) dies in italy and questions concerning the cause and the manner of death arise , the prosecutor requires the forensic pathologist to perform a full postmortem examination , consisting in external and internal examination .
the family of the deceased can not refuse the autopsy . because the deceased was jewish ,
his family objected to the autopsy in observance of their religion , however , the prosecutor ordered that the autopsy had to be carried out , notwithstanding the fact that the pmct was able to demonstrate the cause of death , because it was not considered a technique reliable and accurate enough to determine the cause of death . according to this conclusion ,
the autopsy was performed , confirming the ct findings . according to us , a pmct examination in always necessary in all cases of violent deaths , such as gunshot wounds , asphyxia , sharp force injuries , etc .
, in such cases , the pmct must be considered as a support to the traditional postmortem examination that must always to be carried out . in case of natural deaths ,
a pcmt should always be performed whenever possible , because it sometimes can give a clue regarding the cause of death , making the autopsy virtually not mandatory ( in the countries where it is allowed ) .
for example , regarding to sudden natural deaths in the absence of traumas or in deaths due to infectious diseases , the real effectiveness of a full autopsy should be evaluated taking into account the potential risks for the pathologist during the autopsies . in these cases ,
a full pmct examination , together with an accurate clinical history of the deceased , exhaustive investigative reports concerning the circumstances surrounding the death and toxicological analyses from biological samples collected at the external examination , is a valuable tool that can alone led to determine the cause of death . the forensic pathologist , on the basis of the available information , to his own experience and also to the specific justice issues concerning the case , should be able to decide when and why the pmct alone is enough to clarify the cause of death or if a full postmortem examination is required .
furthermore , ethical and religious issues should be taken into consideration in such cases , when the traditional autopsy is not really necessary .
a pmct approach in these cases can be useful to reduce the manipulation of the bodies , allowing families to observe their own religions .
however , despite the rapid growth of forensic radiology , we must underline that a multidisciplinary approach in suspicious cases is always required .
on the one hand , the pmct should become a standard in forensic practice in order to be performed whenever possible . on the other hand ,
if that happens , it must be avoided that the pmct led the pathologist to focus his attention only on the main radiological findings , giving less importance to other features , hence missing possible secondary diseases .
specifically , a pmct - guided postmortem examination must always to be carried out as fully as possible . in conclusion
, pmct should be considered as an essential support to the traditional autopsy of violent deaths ( and not its replacement ) , becoming as important as histopathological and toxicological analyses , in order to allow the forensic pathologist to have an overall view of all the features concerning the case . in natural deaths ,
conversely , when no specific issues arise , the pmct alone should be virtually considered as a valuable technique to clarify the cause of death , to reduce potential risks for the pathologist and also to overcome ethical and religious issues .
 hemopericardium is a common finding at autopsy , but it may represent a challenge for the forensic pathologist when the etiopathological relationship in causing death is requested . 
 hemopericardium and cardiac tamponade can be evaluated in living people using radiological techniques , in particular computer tomography ( ct ) . 
 only a few studies are reported in literature involving post - mortem ( pm ) cases , where pmct imaging has been used in order to investigate acute hemopericardium , and they have shown a good accuracy of this technique . here 
 we report a case involving a 70-year - old white male found dead on the beach , with a medical history of hepatitis c and chronic hypertension with a poor pharmacological response . 
 a pmct was performed about 3 h after the discovery of the body . 
 the pmct examination showed an intrapericardial aortic dissection associated to a periaortic hematoma , a sickle - shaped intramural hematoma , a false lumen , and a hemopericardium consisting in fluid and clotted blood . in this case , the pmct was able to identify the cause of death , even though a traditional autopsy was required to confirm the radiological findings . 
 pmct is a reliable technique , which in chosen cases , can be performed without the need for a traditional autopsy to be carried out . 