Autopsy

Autopsy was once a mainstay of pathology. It is now in decline and uncommonly done. Fetal autopsy is dealt with in a separate article called fetal autopsy.

Value of autopsy

A significant number of major findings cannot be diagnosed without histology; thus, without a biopsy or an autopsy they cannot be diagnosed. Autopsies can be regarded as a form of quality control.

One large review in JAMA suggests that approximately:

• 25% of autopsies reveal a finding that would have changed clinical management.
• 5% of autopsies reveal a missed diagnosis that probably affected the outcome.

Autopsy checklist

Minimum to proceed

• Death certificate complete.
  • Cause of death as per death certificate.
• Autopsy consent properly done.
• Patient identified.

Clinical history checklist - hospital admission

• Admit date.
• Admit diagnosis.
  • History of illness prior to admission?
• Past medical history.
  • Recent hospital admissions?
  • Significant medical conditions.
• State preceding death - especially the last 24 hours.
  • Level of consciousness.
  • Vitals.
• Location at time of death and preceding 24 hours.
  • Ward.
  • Intensive care unit.
  • Other.
• Time immediately prior to death.
  • Code called.
  • Found cold.
  • Other.
• Date and time of death.
• Clinical status prior to death.
  • Expected versus unexpected.

Autopsy consent

General

• In a hospital autopsy the most important thing is: proper consent.
• Generally, corner's cases/medical examiner's cases do not require a consent for autopsy; however, the retention of tissue may require consent.

Who has authority?

• Consent should be given by the executer of the estate.

Hierarchy

If the executer of the estate is not specified the hierarchy is as follows:

1. Spouse - by marriage (same sex or opposite sex) or by common-law or by together the parents of a child or by cohabitation agreement (in law).
2. If no spouse, any children 16+ years old,
3. If no children, either parent,
4. If no parent, any brother or sister 16+ years old,
5. If no sibling, any next-of-kin 16+ years old,
6. If no next-of-kin, the person lawfully in possession of the body (not the hospital).

Notes:

• The power a person that is designated as power of attorney for health care decisions does not have the authority to consent for an autopsy; their power ends with death (unless they are also the executer of the estate).
• In clinical medicine, it is allowable to skip down the hierarchy if the "consent giver" is not reachable, e.g. if a child of the patient is present they can consent in emergency circumstances, if the spouse is not reachable. In the context of (non-corner's) autopsies, the hierarchy has to be followed strictly, as there is no such thing as an "emergency autopsy"; it is not acceptable to ask the child of the decedent 'cause they aren't distraught like the spouse of the decedent.
• In non-corner's cases, a physician cannot consent an autopsy.

Religious objections

• There are religious objections to autopsy among Jews and Muslims.
• It is not considered good practise to agree to restrictions that will impair a complete assessment, e.g. "stop as soon as one has the cause of death", especially in the medicolegal context (when the extent of the autopsy is at the pathologist's discretion). It is often said that... incomplete autopsies give incomplete answers.

Timeliness

There are turnaround time standards from the College of American Pathologists:

Deliverable	Time	Comment
Provisional report	2 working days	gross findings & history
"Most" final reports	30 days
All final reports	60 days

External exam

General

• Very important in the forensic context.
• Medical devices, tubes and lines should be left in situ to allow the determination of their precise location within the body; it is very difficult to determine what the location of a line was once it is removed.

Extremities

• Fingers should be identified by name (e.g. ring finger), as some people number the digits 1-4 and consider the thumb separately, while others number 'em 1-5.

Body should be examined for defensive-type wounds:

• Between the finger, esp. thumb and pointing finger.
• Dorsal aspect of the hand.
• Forearm.

Findings

• External exam findings are found in the forensic pathology article.

Internal exam

General

• This is usually where the money is in hospital autopsies.
• Like surgeons say... you should never cut anything until you're sure what it is.

Before the first incision

If there is suspicion of pneumothorax - one the the three following can be done:

1. Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity).
2. Open chest underwater and watch for air bubbles.
3. Needle puncture with water filled syringe - where plunger has been removed.

• If there are neck abnormalities or suspicion of pressure on the neck, it is prudent to remove the cranial contents and thoracic contents before doing the neck dissection.
  • If the above does not apply, i.e. there is no neck injury/suspected neck injury, the tongue & neck can be taken together with the thorax pluck or organ pluck.

Incisions

• Y-shaped incision (standard):
  • Superior "points" of the Y ~ at the deltoid muscle.
  • "Confuence of lines" in the Y ~ inferior to the suprasternal notch.
• Neck dissection incisions:
  • Deltoid to mastoid process.

Chest plate

• Removed by cutting the ribs - usu. at the rib ends.
• Ribs should be examined for fractures.
• Usually of no interest.

Notes:

• The sterum may have cleft or foramen - as an anatomical variant.
• If the decedent has a history of a CABG removal of the chest plate should be done with care to preserve the grafts.

Blood clots - pre- and post-mortem

Feature/time	Pre-mortem	Post-mortem
Shininess	dull	shiny
Adherent to wall	yes	no
Colour	grey; may have zebraic appearance (lines of Zahn) - red alt. with grey/yellow	dark purple or bilayered yellow/red
Pressurized	yes; "ejects itself" from lumen	no; needs to be pulled-out
Consistency -elastic modulus (E) -fracture toughness (K)	firm (high E) brittle (low K)	jello (low E) elastic (high K)
Image - gross	thrombus (pathguy.com), thrombus (thrombosisadviser.com)	coronary thrombus (luc.edu)
Image - micro.	pre- & post-mortem (elsevier.es)	thrombus (oxfordjournals.org), thrombi (ucsf.edu)

Notes:

• Post-mortem thrombi: one (superior) yellow portion (called "chicken fat") and one (dependent) red portion (RBCs); components layer due to gravity.

Retrieval of the (organ) "pluck"

One piece (standard):

• Diaphragm cut: at chest wall.
• Superior cut: through arch vessels.
• Inferior cut: through the common iliac vessels.
• Posterior:
  • Thorax: cut paravertebral.
  • Abdomen: blunt dissection for kidneys, then paravertebral.

Two pieces (thorax & abdomen):

• May be preferred in a "glued" (fibrosed/post-surgical) abdomen.
• Procedure - similar to one piece but:
  • Cut aorta distal to the left subclavian + detach from thoracic pluck.
  • Cut esophagus distal to pharynx + detach from thoracic pluck.

Neck organ pluck

1. Trim tissue posterior to horns of the thyroid.
2. Cut between thyroid horns & hyoid.
3. Cut off base of tongue.

Hyoid bone

• Important in forensic pathology.
• Fracture is seen in manual strangulation.
• May appear fractured if triticeous cartilage (or triticeal cartilage) is present; triticeous cartilage may be confused with a fragment of hyoid bone.
  • Triticeous is pronounced tri-tish´us.

Larynx injury

These are worked-up in great detail in Germany. In Canada, the examination, by comparison, is superficial. A detailed examination of the larynx may offer significant information in asphyxial deaths.

Process:

• Pre-evaluation - if a larynx injury is suspected:
  • The larynx should not be opened.
  • Soft tissue should be removed with blunt dissection.
• Evaluation (done with a stereo microscope):
  • Tension - splits/tears, bleeding.
  • Compression - surrounding tissue no splits/tears.
  • Partial fractures - give information about directionality.

Recognized patterns:

• Left horn of thyroid cartilage fracture - choking with left-handed.
• Right horn of thyroid cartilage fracture - choking with right-hand.
• Cricoid cartilage two fractures anteriolateral - choke hold from behind.

Dissection of thoraco-abdominal pluck

Process

1. Place organ pluck with anterior aspect down.
2. Open aorta (posterior aspect - from just distal to subclavian + common iliacs).
   • Probe celiac trunk, SMA, renal arteries, IMA.
   • Open renal arteries.
3. Blunt dissection to separate aorta from thorax distal to left subclavian artery.
4. Cut through aorta distal to left subclavian artery.
5. Separate aorta from pluck.
6. Open IVC to diaphragm.
   • Check renal veins.
7. Separate IVC.
8. Transect esophagus (~2 cm) distal to inferior margin of the cricoid cartilage.
9. Take down esophagus using blunt dissection (to separate from thorax).
10. Separate thorax and abdomen - by dissecting through the pericardium.

Common finding(s)

• Aorta = atherosclerosis.

Things to think about

• Renal arteries = atherosclerosis (old), fibromuscular dysplasia (young).
• Renal veins = renal cell carcinoma.

Thoracic pluck

Heart

• Dissection - see Heart article.
• Conducting system - see Heart article.

Respiratory system

1. Open trachea + bronchus (see Note).
2. Examine proximal airway.
3. Examine proximal pulmonary arteries.
   • May be done from intralobular fissures.
     • The large arteries of the right lung is found deep to oblique fissure.
4. Slice lungs - one lobe at a time (easier to cut).
5. Squeeze lungs - to test for the presence of pus and edema fluid.

Note:

• If the lungs are to be inflated the bronchi should be left long.

Common findings

Main article: Lung

• Plural adhesions.
• Plural effusions.
  • Types: serous (clear), serosaginous (cloudy), serofibrinous (clotted/webbed), purulent (yellow).
• Edema - fluid comes-out when you squeeze 'em, "heavy" (large mass).
• Emphysematous change (usu. upper lung zone predominant) +/- black pigment (anthracosis).
• Consolidation - best appreciated by running a finger over the cut surface of the lung with a small-to-moderate amount of pressure; often pneumonia.
• Atelectasis - depressed red areas.

Abdominal organ pluck

Adrenal glands

1. Place cuts at anatomical location.
2. Take section for stock.

Common findings

Main article: Adrenal gland

• Cortical adenomas - seen in ~ 2% of autopsies.

Others

• Atrophy - typically iatrogenic, may be Addison's disease.
• Hyperplasia (bilateral).
• Hemorrhage (Waterhouse-Friderichsen syndrome).
• Metastatic cancer, esp. in the context of lung cancer.
• Adrenal myelolipoma.

Stomach

• Opened along greater curvature.
  • Large carcinomas preferentially involve the lesser curvature.
• GE junction should not be opened if portal hypertension is suspected (see: esophagus).

Findings

Main article: Stomach

• Haemorrhage = usu. post-mortem.
• Small ~1 mm pellets (medicinal capsule contents).

Esophagus

• Should be everted, if portal hypertension is suspected, as varices are thus more readily demonstrated.
  1. Stomach opened (without opening GE junction).
  2. String tied to proximal esophagus.
  3. Forceps inserted from stomach to grasp tied end and invert esophagus.

Omentum

Main article: Omentum

• It is a good idea to trim this from the stomach.

Spleen

1. Separate stomach from spleen.
2. Identify the splenic vessels.
3. To separate the spleen from the pluck:
   • Cut across vessels at splenic hilum - close to the spleen.

Common findings

Main article: Spleen

• Sugar-coated spleen.
  • Properly referred to as hyaloserositis of the spleen.
  • Capsule of the spleen is white - resembles sugar-coating.
  • Importance: none - benign.
• Splenomegaly secondary to portal hypertension.

Kidney

• Renal vein & artery already examined.

1. +/-Open ureter.
2. Strip capsule.
3. Left ureter is left long - to tell apart the kidneys.
4. Kidney (nearly) bisected in coronal plane from anti-ureteric surface; a small rim of tissue is left on the hilar (or ureteric) aspect -- to keep the kidney as one piece.

Common pathologic findings

• Size of the kidney - small kidneys are seen in chronic renal failure.
  • Normal adult kidney ~11 cm from pole-to-pole.
• Nephrosclerosis:
  • Flea-bitten appearance - seen in hypertension.
• Acute tubular necrosis (ATN).
  • ATN is difficult (or impossible) to prove on autopsy material.
  • Look for:
    • Heme-granular casts in the lumen.
    • Regenerative activity (mitoses).

Liver

1. Remove diaphragm (with scissors).
2. Separated liver from abdominal pluck at porta hepatis.
3. Open Gallbladder.
4. Get mass, i.e. weigh.
5. Slice axially - as seen on CT imaging.

Notes:

• If there is a suspected biliary tract obstruction:
  1. Open the duodenum (from distal end) and identify the duodenal papilla - this is usually obvious as everything distal to the duodenal papilla is usually light brown (bile-stained).
  2. Compress the gallbladder and bile should emerge from the duodenal papilla.
  3. Disect bilary tree from duodenal papilla to the porta hepatis.

Common pathologic findings

Liver

Main article: Liver

• Firm - suggests cirrhosis.
• Micronodularity (with uniformity of the nodules) - suggestive of alcoholic cirrhosis.
• Macronodularity (with heterogeneity of the nodules) - suggestive of viral hepatitis.
• Yellow or pale liver:
  • DDx:
    1. Shock liver.
    2. Steatosis or steatohepatitis.
• Congested (blood red/yellow) "nutmeg liver".
  • Image: Nutmeg liver (pathology-india.com).

Gallbladder

Main article: Gallbladder

• Gallstones (cholelithiasis).
• Mucosa with strawberry-like appearance (cholesterolosis).

Pancreas

• Serially section along axis of pancreatic duct.
• Pieces of head & tail for stock or stock and histology.

Genitourinary-rectal or pelvic pluck

Female

1. Orient rectum down, bladder up.
2. Open bladder with scissors via urethra with cuts in sagittal plane.
3. Flip over specimen.
4. Open rectum with scissors with cuts in the sagittal plane.
5. Flip over specimen.
6. Open vagina with cuts on its lateral aspect.
7. Open cervix & uterus with cuts on its lateral aspect.
8. Bisect ovaries.

Common pathologic findings

Main article: Ovary

• Ovary:
  • Corpus luteum - bright yellow (non-pathologic).
  • Simple cyst.

Main article: Uterus

• Uterus:
  • Leiomyoma (uterine fibroid).

Main article: Urinary bladder

• Urinary bladder:
  • Focal haemorrhage secondary to urinary catheter.

Male

1. Orient rectum down, bladder up.
2. Open bladder with scissors via urethra/prostate with cuts in sagittal plane.
3. Serially section prostate in the planes defined by the axis of the urethra.
4. Flip over specimen.
5. Open rectum with scissors with cuts in the sagittal plane.

Common pathologic findings

Main article: Prostate gland

• Prostate gland:
  • Enlargement (benign prostatic hyperplasia).

Main article: Urinary bladder

• Urinary bladder:
  • Trabeculation secondary to BPH.
  • Focal haemorrhage secondary to urinary catheter.

Skull & brain

Opening the skull

1. One should saw through the skull completely, i.e. one should not "crack" the skull open with a chisel.
   • Cracking open the skull may result in artefactual fractures that are impossible to differentiate from antemortem fractures.
   • Cuts into the brain from opening the skull ("city morgue sulcus") are not difficult to distinguish from antemortem injuries.

Extraction of the brain

1. Cranial nerves should be cut.
2. Tentorium should be released.
3. Spinal cord should be completely cut as far down as possible.
4. Dura should be stripped from the skull base (to look for fractures).

Notes:

• Scalp hematoma:
  • May result from intracranial pressure.
    • Types of scalp hematomas.

Brain

Considerations for the retension of the brain (for prolonged fixation):

• Survival interval in hospital.
• Neurosurgical intervention.
• Clinical Dx of DAI.
• Hypoxic changes (make brain hard to cut).

Sectioning

Up-down anatomically oriented (right side-up):

1. Examine meninges.
2. Remove dura.
3. Examine venous sinuses.
4. Look for gyri effacement - due to edema or haematomas.

Not up-down anatomically oriented (top down):

1. Remove brain stem - with one cut ~ at level of mid-brain.
2. Cerebrum section - first cut at mammillary bodies.
   • Subsequent cuts ~ 1.0 cm in thickness.

Anatomic variants

• Metopic suture - midline in frontal bone.
• Wormian bones = "extra" bone at the sutures in the skull.

Anatomy

• Lambdoidal suture - occipital bone/parietal bones.
• Coronal suture - frontal bone/parietal bone.

Weird stuff

• Methylene blue, used for refractory shock, turns organs green.

• Leukostasis in acute myelogenous leukemia can lead to congestion of organs and fatal haemorrhages.

• Hyperviscosity syndrome - in leukemia.

Starvation

Main article: Starvation

• Serous fat atrophy.
  • Gross appearance: brown goo replaces fat.
    • May be associated with blood vessel tortuosity.

Histology

General

It's the at the pathologists discretion. In decomp cases it is reasonable to submit nothing.

Forensic context

A standard (minimum) for adult homicides is:

1. Heart (1).
2. Lung (1).
3. Liver (1).
4. Kidney (1).

Hospital autopsies

Non-neuropathology

A standard based on a Toronto teaching hospital:

• Thyroid gland (1).
• Lung - each lobe (5).
• Heart - posterior papillary muscle & LV, anterior papillary muscle & LV (2).
  • More extensive histologic sectioning is discussed in the heart article.
• Liver - left lobe, right lobe (2).
• Spleen - including hilum & capsule (1).
• Adrenal gland (1).
• Gastrointestinal tract:
  • The quality is often very poor (even in "fresh" bodies). These are often omitted.
    • Pancreas - head & tail (1).
    • Stomach (1).
    • Esophagus (1).
    • Small bowel (1).
    • Large bowel (1).
• Genitourinary tract:
  • Kidney - each side (2).
  • Gender specific:
    • Male:
      • Prostate gland (1).
      • Testis (1).
    • Female:
      • Uterus +/- cervix (1).
      • Ovary + tube (1).
• Bone marrow (1).

Neuro

• Pituitary gland (1).
• Cortex usu. frontal/parietal (1).
• Hippocampus (1).
• Cerebellum (1).
• Brain stem (1).
• Basal ganglia (1).

Stock

• Thyroid gland.
• Heart:
  • Complete (axial) slice (including RV and LV).
  • Tissue with SA node.
  • Tissue with AV node.
• Lung - all five lobes.
• Spleen.
• Urinary:
  • Kidney.
  • Urinary bladder.
• Gastrointestinal tract:
  • GE junction.
  • Stomach.
  • Small bowel.
  • Large bowel.
  • Appendix.
  • Pancreas (head & tail).
  • Liver.
• Reproductive:
  • Male:
    • Prostate gland.
    • Testis.
  • Female:
    • Breast.
    • Uterus.
    • Ovary.
• Neurologic:
  • Hippocampus + basal ganglia.
  • Cortex.
  • Brainstem.
  • Cerebellum.
• Skin.
• Nerve.
• Muscle.
• Lymph nodes.

Autopsy report

Normal size parameters

Normal organ masses (adult)

Caucasoid population of 684 adults:

	Men	Women
Heart	365 +/- 71 g	312 +/- 78 g
Right lung	663 +/- 239 g	546 +/- 207 g
Left lung	583 +/- 216 g	467 +/- 174 g
Liver	1677 +/- 396 g	1475 +/- 362 g
Spleen	156 +/- 87 g	140 +/- 78 g
Right kidney	162 +/- 39 g	135 +/- 39 g
Left kidney	160 +/- 41 g	136 +/- 37 g

Pediatrics

Main article: Growth charts

Negative autopsy

Definition:

• A negative autopsy is a post-mortem exam that has no anatomical or toxicological cause of death.
  • This does not preclude the presence of pathology (that is not sufficient to cause death).

Cause of death (in a negative autopsy):

• Unascertained.

Considerations

• Channelopathy - may be elucidated by molecular testing.
• Electrocution (unrecognized).
• Decomposition.
• Sudden Unexpected Death in Epilepsy (SUDEP) - missing history.
• Sudden infant death syndrome.

Histology checklist

Section/organ	Expected finding(s)/common finding(s)	Findings to consider
Bone marrow	trilineage hematopoiesis	infection tumour
Coronary arteries	atherosclerosis - should give percent stenosis for major arteries (LMCA, LAD, LCx, RCA)	atherosclerotic plaque rupture thrombi inflammation
Heart muscle	fibrosis - esp. post. LV (old MI) nuclear enlargement, arteriolosclerosis, periarteriolar fibrosis (hypertensive heart disease)	hemorrhage wavy fibres (early ischemic change) necrosis - coagulative/contraction band (recent MI) inflammatory infiltrate - not associated with necrosis hyaline material (cardiac amyloidosis)
Adrenal gland	tumour - primary (cortex)	tumour primary (cortex, medulla) metastatic hemorrhage fat
Kidney	vessels (atherosclerosis, arteriolar hyalinization)	tumour glomeruli (enlargement, crescents, mesangial expansion, inflammation - esp. PMNs) vessels - thrombi (thrombotic microangiopathy) interstitial (fibrosis, inflammation) tubules (regeneration, casts, inflammation)
Liver	steatosis - should give location & type (macrovesicular vs. microvesicular)	fibrosis (septa, rounded contours, cirrhosis), inflammation (cell type, location (portal, interface, lobular)) tumour - esp. metastatic bile ducts ballooning degeneration (steatohepatitis)/feathery degeneration (cholestasis) necrosis (location important)
Spleen	normal white pulp/red pulp	tumour surface abnormalities
Gastrointestinal tract	autolytic changes	tumour vessels inflammation - esp. PMNs fibrosis
Thyroid gland	tumour - papillary thyroid carcinoma, goitre	inflammation
Lung	infectious pneumonia emphysema	pulmonary hypertension (may be focal) interstitial fibrosis tumour granulomas hemorrhage hyaline membranes (diffuse alveolar damage)

Sign out

Sample clinical history

A 63 year old male with a history of alcohol abuse was admitted on December 13, 2018 for
recurrent alcohol related pancreatitis. On December 21, he was found unresponsive at 0:15. 
Approximately fifteen minutes earlier, he was on oxygen and in no apparent distress. A code 
blue was called; however, the attempted resuscitation was unsuccessful.  Death was declared 
at 1:00 on December 21, 2018.

See also

• Fetal autopsy.
• Forensic pathology.