J Forensic Sci, January 2015, Vol. 60, No. 1 doi: 10.1111/1556-4029.12571 Available online at: onlinelibrary.wiley.com
CASE REPORT PATHOLOGY/BIOLOGY
Marie Barbesier,1 M.D.; Catherine Boval,2 M.D.; Jacques Desfeux,2 M.D.; Catherine Lebreton,2 M.D.; Georges Léonetti,2 M.D., Ph.D.; and Marie-Dominique Piercecchi-Marti,2,3 M.D., Ph.D.
Acute Fatal Coronary Artery Dissection Following Exercise-related Blunt Chest Trauma
ABSTRACT: Coronary artery injury such as acute coronary dissection is an uncommon and potentially life-threatening complication after
blunt chest trauma. The authors report an unusual autopsy case of a 43-year-old healthy man who suddenly collapsed after receiving a punch to the chest during the practice of kung fu. The occurrence of the punch was supported by the presence of one recent contusion on the left lateral chest area at the external examination and by areas of hemorrhage next to the left lateral intercostal spaces at the internal examination. The histological examination revealed the presence of an acute dissection of the proximal segment of the left anterior descending coronary artery. Only few cases of coronary artery dissection have been reported due to trauma during sports activities such as rugby and soccer games, but never during the practice of martial arts, sports usually considered as safe and responsible for only minor trauma.
KEYWORDS: forensic science, forensic pathology, coronary artery, acute dissection, sports, martial arts
Coronary artery dissection is recognized as an unusual complication of blunt chest trauma (1–4). Nonpenetrating chest trauma is most commonly caused by motor vehicle accidents (5). However, a few cases of coronary artery dissection following chest trauma related to exercise have been reported in the literature (3,6–11). Similarly, spontaneous dissection cases have been described during intense physical exercise but without any chest trauma identified (12). We report the autopsy case of a 43-yearold healthy man who suddenly collapsed due to an acute coronary artery dissection, after being punched in the chest during the practice of kung fu, a martial art. We will also discuss the evidence which led to establishing the traumatic nature of the dissection. Case Report A healthy 43-year-old man was practicing a kung fu exercise aimed to counter an opponent attack, in tandem with another student. During this exercise, he mistakenly received a punch to the chest. A few seconds after the punch, he reported to his coach that he felt breathless. He then sat down on a bench on the advice of
1 Medical Examiner Office of Lyon, 12, Avenue Rockefeller, Lyon 69008, France. 2 Medical Examiner Office of Marseille, 264, Rue Saint Pierre, Marseille 13385, France. 3 UMR 6578 – Anthropologie, 27 bd jean moulin, Marseille 13005, France. Correction added on September 9, 2014 after first online publication: Dr. Marie-Dominique Piercecchi-Marti was corrected. Received 10 Feb. 2013; and in revised form 1 Oct. 2013; accepted 26 Oct. 2013.
© 2014 American Academy of Forensic Sciences
his coach and suddenly collapsed. Despite resuscitation efforts by paramedics, he never regained a cardiac rhythm and expired. Review of the decedent’s hospital records revealed that he had no specific past medical history. A forensic autopsy was performed 48 h after this sudden death to determine the manner and the cause of death. The decedent was a well-developed white male. At the external examination, we observed recent contusions on the upper limbs, and we focused on one recent contusion on the left lateral chest area, measuring 4.5 94 cm, of reddish coloration and irregular shape. At the internal examination, an area of hemorrhage was found next to the left lateral fourth, fifth, and sixth intercostal spaces and anterior to the left second rib, without rib fractures. There was no hemothorax or hemopericardium. The heart weighed 410 g, which was within the normal reference range, and it had unremarkable myocardium and cardiac valves. The coronary arteries were present in a normal distribution with a right dominant pattern. An area of hemorrhage next to the proximal segment of the left anterior descending coronary artery was found (Fig. 1). This area of hemorrhage observed on one centimeter of the coronary artery was suspected to be a possible dissection and therefore the cause of death. The other coronary arteries were without abnormalities. There were no pulmonary contusions. Other organs showed only signs of resuscitation efforts such as pulmonary edema, cerebral edema and congestion. Histological examination of the left anterior descending coronary artery confirmed an acute dissection between the inner four-fifths and outer one-fifth of the media with coagulated blood in the false channel confirming the acute character of the dissection. There was no inflammation in the adventitia, no evidence of medial degeneration, and no vasculitis. The arterial wall not involved by the dissection was otherwise unremarkable, 233
234
JOURNAL OF FORENSIC SCIENCES
(a)
FIG. 1––The outer wall of the coronary artery dissection of the proximal segment of the left anterior descending artery and the false channel filled of blood.
(b)
without increased fibrosis or pools of proteoglycan (Fig. 2a–c). An elastic stain showed essentially normal elastic fibers. In addition, the postmortem toxicological screening was negative. The manner of death was determined to be accidental. Discussion The heart’s position between the sternum and vertebral column makes it vulnerable to injury from blunt chest trauma (6). Cardiac injuries after blunt chest trauma are varied, including myocardial contusion or hemorrhage, arrhythmia (commotio cordis), cardiac rupture, valvular injury, and acute myocardial infarction (13). Coronary artery dissection occurring after nonpenetrating chest trauma is rare and is even less common in the setting of a contact sports such as kung fu. Cases of coronary artery dissection have been described after practicing rugby (3,6), soccer (11), basketball (7), and water-skiing (14). To our knowledge, this is the first report of an acute coronary artery dissection during the practice of martial arts, which are usually considered to be relatively safe compared with many other sports. The most common types of martial arts injury are sprains, strains, and contusions and the less common injuries include fractures, dislocations, and dental injuries (15,16). However, three cases of death from anterior chest trauma have been reported in the literature during the practice of martial arts, but in those cases, no abnormality of the coronary arteries was found at the autopsy (17). Coronary artery dissection has also been reported to occur spontaneously during intense physical exercise without chest trauma, such as running, weight lifting, aerobic baseball playing, or even after prolonged sneezing (18). As no specific differences have been described in the literature between spontaneous and traumatic coronary artery dissection during gross and histological examination, the traumatic etiology should be considered in a context of traumatic injury and in the presence of chest contusion at the external examination. In addition, true spontaneous dissection is confirmed only when causes such as atherosclerosis, chest trauma, and catheter-related injury during coronary angiography are excluded (15). In the current case, the history of blunt chest trauma occurring during the practice of martial arts was supported by the presence of a contusion on the left lateral chest area at the external examination and also areas of hemorrhage next to the left lateral inter-
(c)
FIG. 2––(a–c) Section of the left anterior descending coronary artery showing an acute dissection between the inner four-fifths and outer one-fifth of the media.
costal spaces opposite to the apex of the heart at the internal examination. The left lateral location on the chest area of this contusion and areas of hemorrhage excluded the possibility that these were a consequence of resuscitation efforts, which are usually in the mid-thoracic location. Moreover, the absence of inflammation in the adventitia at the histological examination
BARBESIER ET AL.
was also in favor of a traumatic context of the coronary artery dissection. Coronary artery dissection following blunt chest trauma typically involves the left anterior descending artery such as in the present case; the probable explanation is due to its vulnerable anatomic position on the anterior part of the heart. The second most commonly affected artery is the right coronary artery, although uncommon, left circumflex coronary artery involvement has also been reported (2,6,10,13). The main hypothesis mentioned in the literature is the existence of shearing forces during the traumatic episode which probably cause intimal tears of the most vulnerable part of the left anterior descending artery and subsequently initiate the process of thrombus formation (13). Other factors may include coexisting atherosclerosis with fracture of a preexisting plaque, spasm, thrombosis, and emboli (6). In the current case, no predisposing factor was found histologically on the arterial wall. This first report of acute coronary artery dissection leading to sudden death following the practice of martial arts is of interest for the clinician who should be aware of the possibility of coronary artery dissection leading to sudden cardiac death in a context of minor blunt chest trauma. References 1. Ginzburg E, Dygert J, Parra-Davila E, Lynn M, Almeida J, Mayor M. Coronary artery stenting for occlusive dissection after blunt chest trauma. J Trauma 1998;45(1):157–61. 2. Chun JH, Lee SC, Gwon HC, Lee SH, Hong KP, Seo JD, et al. Left main coronary artery dissection after blunt chest trauma presented as acute anterior myocardial infarction: assessment by intravascular ultrasound: a case report. J Korean Med Sci 1998;13(3):325–7. 3. Marik PE. Coronary artery dissection after a rugby injury. S Afr Med J 1990;77(11):586–7. 4. Imamura M, Tsuchiya Y, Tahara H, Nii T, Nakashima Y, Arakawa K, et al. Acute myocardial infarction in a patient with primary coronary dissection and severe coronary vasospasm. Angiology 1995;46(10):951–5. 5. Kawahito K, Hasegawa T, Misawa Y, Fuse K. Right coronary artery dissection and acute infarction due to blunt trauma: report of a case. Surg Today 1998;28(9):971–3.
.
SPORTS-RELATED CORONARY ARTERY DISSECTION
235
6. Vasudan AR, Kabinoff GS, Keltz TN, Gilter B. Blunt chest trauma producing acute myocardial infarction in a rugby player. Lancet 2003;362 (9381):370. 7. Hobelmann A, Pham JC, Hsu EB. Case of the month: right coronary artery dissection following sports-related blunt trauma. Emerg Med J 2006;23(7):580–1. 8. Heymann TD, Culling W. It’s not cricket! Myocardial infarction following non-penetrating blunt chest trauma. Br J Clin Pract 1994;48(6):338–9. 9. Hazeleger R, van der Wieken R, Slagboom T, Landsaat P. Coronary dissection and occlusion due to sports injury. Circulation 2001;103 (8):1174–5. 10. Christensen MD, Nielsen PE, Sleight P. Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review. Int J Cardiol 2006;108(1):1–5. 11. Atalar E, Acßil T, Aytemir K, Ozer N, Ov€uncß K, Aks€oyek S, et al. Acute anterior myocardial infarction following a mild nonpenetrating chest trauma – a case report. Angiology 2001;52(4):279–82. 12. Tweet MS, Hayes SN, Pitta SR, Simari RD, Lerman A, Lennon RJ, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation 2012;126(5):579–88. 13. Sato Y, Matsumoto N, Komatsu S, Matsuo S, Kunimasa T, Yoda S, et al. Coronary artery dissection after blunt chest trauma: depiction at multidetector-row computed tomography. Int J Cardiol 2007;118(1):108–10. 14. Greenberg J, Salinger M, Weschler F, Edelman B, Williams R. Circumflex coronary artery dissection following waterskiing. Chest 1998;113 (4):1138–40. 15. Woodward TW. A review of the effects of martial arts practice on health. WMJ 2009;108(1):40–3. 16. Buschbacher RM, Shay T. Martial arts. Phys Med Rehabil Clin N Am 1999;10(1):35–47. 17. Wilkerson LA. Martial arts injuries. J Am Osteopath Assoc 1997;97 (4):221–6. 18. Maeder M, Ammann P, Angehrn W, Rickli H. Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment. Int J Cardiol 2005;101(3):363–9. Additional information and reprint requests: Marie Barbesier, M.D. Medical Examiner Office of Lyon 12, Avenue Rockefeller Lyon 69008 France E-mail: [email protected]
CASE REPORT PATHOLOGY/BIOLOGY
Marie Barbesier,1 M.D.; Catherine Boval,2 M.D.; Jacques Desfeux,2 M.D.; Catherine Lebreton,2 M.D.; Georges Léonetti,2 M.D., Ph.D.; and Marie-Dominique Piercecchi-Marti,2,3 M.D., Ph.D.
Acute Fatal Coronary Artery Dissection Following Exercise-related Blunt Chest Trauma
ABSTRACT: Coronary artery injury such as acute coronary dissection is an uncommon and potentially life-threatening complication after
blunt chest trauma. The authors report an unusual autopsy case of a 43-year-old healthy man who suddenly collapsed after receiving a punch to the chest during the practice of kung fu. The occurrence of the punch was supported by the presence of one recent contusion on the left lateral chest area at the external examination and by areas of hemorrhage next to the left lateral intercostal spaces at the internal examination. The histological examination revealed the presence of an acute dissection of the proximal segment of the left anterior descending coronary artery. Only few cases of coronary artery dissection have been reported due to trauma during sports activities such as rugby and soccer games, but never during the practice of martial arts, sports usually considered as safe and responsible for only minor trauma.
KEYWORDS: forensic science, forensic pathology, coronary artery, acute dissection, sports, martial arts
Coronary artery dissection is recognized as an unusual complication of blunt chest trauma (1–4). Nonpenetrating chest trauma is most commonly caused by motor vehicle accidents (5). However, a few cases of coronary artery dissection following chest trauma related to exercise have been reported in the literature (3,6–11). Similarly, spontaneous dissection cases have been described during intense physical exercise but without any chest trauma identified (12). We report the autopsy case of a 43-yearold healthy man who suddenly collapsed due to an acute coronary artery dissection, after being punched in the chest during the practice of kung fu, a martial art. We will also discuss the evidence which led to establishing the traumatic nature of the dissection. Case Report A healthy 43-year-old man was practicing a kung fu exercise aimed to counter an opponent attack, in tandem with another student. During this exercise, he mistakenly received a punch to the chest. A few seconds after the punch, he reported to his coach that he felt breathless. He then sat down on a bench on the advice of
1 Medical Examiner Office of Lyon, 12, Avenue Rockefeller, Lyon 69008, France. 2 Medical Examiner Office of Marseille, 264, Rue Saint Pierre, Marseille 13385, France. 3 UMR 6578 – Anthropologie, 27 bd jean moulin, Marseille 13005, France. Correction added on September 9, 2014 after first online publication: Dr. Marie-Dominique Piercecchi-Marti was corrected. Received 10 Feb. 2013; and in revised form 1 Oct. 2013; accepted 26 Oct. 2013.
© 2014 American Academy of Forensic Sciences
his coach and suddenly collapsed. Despite resuscitation efforts by paramedics, he never regained a cardiac rhythm and expired. Review of the decedent’s hospital records revealed that he had no specific past medical history. A forensic autopsy was performed 48 h after this sudden death to determine the manner and the cause of death. The decedent was a well-developed white male. At the external examination, we observed recent contusions on the upper limbs, and we focused on one recent contusion on the left lateral chest area, measuring 4.5 94 cm, of reddish coloration and irregular shape. At the internal examination, an area of hemorrhage was found next to the left lateral fourth, fifth, and sixth intercostal spaces and anterior to the left second rib, without rib fractures. There was no hemothorax or hemopericardium. The heart weighed 410 g, which was within the normal reference range, and it had unremarkable myocardium and cardiac valves. The coronary arteries were present in a normal distribution with a right dominant pattern. An area of hemorrhage next to the proximal segment of the left anterior descending coronary artery was found (Fig. 1). This area of hemorrhage observed on one centimeter of the coronary artery was suspected to be a possible dissection and therefore the cause of death. The other coronary arteries were without abnormalities. There were no pulmonary contusions. Other organs showed only signs of resuscitation efforts such as pulmonary edema, cerebral edema and congestion. Histological examination of the left anterior descending coronary artery confirmed an acute dissection between the inner four-fifths and outer one-fifth of the media with coagulated blood in the false channel confirming the acute character of the dissection. There was no inflammation in the adventitia, no evidence of medial degeneration, and no vasculitis. The arterial wall not involved by the dissection was otherwise unremarkable, 233
234
JOURNAL OF FORENSIC SCIENCES
(a)
FIG. 1––The outer wall of the coronary artery dissection of the proximal segment of the left anterior descending artery and the false channel filled of blood.
(b)
without increased fibrosis or pools of proteoglycan (Fig. 2a–c). An elastic stain showed essentially normal elastic fibers. In addition, the postmortem toxicological screening was negative. The manner of death was determined to be accidental. Discussion The heart’s position between the sternum and vertebral column makes it vulnerable to injury from blunt chest trauma (6). Cardiac injuries after blunt chest trauma are varied, including myocardial contusion or hemorrhage, arrhythmia (commotio cordis), cardiac rupture, valvular injury, and acute myocardial infarction (13). Coronary artery dissection occurring after nonpenetrating chest trauma is rare and is even less common in the setting of a contact sports such as kung fu. Cases of coronary artery dissection have been described after practicing rugby (3,6), soccer (11), basketball (7), and water-skiing (14). To our knowledge, this is the first report of an acute coronary artery dissection during the practice of martial arts, which are usually considered to be relatively safe compared with many other sports. The most common types of martial arts injury are sprains, strains, and contusions and the less common injuries include fractures, dislocations, and dental injuries (15,16). However, three cases of death from anterior chest trauma have been reported in the literature during the practice of martial arts, but in those cases, no abnormality of the coronary arteries was found at the autopsy (17). Coronary artery dissection has also been reported to occur spontaneously during intense physical exercise without chest trauma, such as running, weight lifting, aerobic baseball playing, or even after prolonged sneezing (18). As no specific differences have been described in the literature between spontaneous and traumatic coronary artery dissection during gross and histological examination, the traumatic etiology should be considered in a context of traumatic injury and in the presence of chest contusion at the external examination. In addition, true spontaneous dissection is confirmed only when causes such as atherosclerosis, chest trauma, and catheter-related injury during coronary angiography are excluded (15). In the current case, the history of blunt chest trauma occurring during the practice of martial arts was supported by the presence of a contusion on the left lateral chest area at the external examination and also areas of hemorrhage next to the left lateral inter-
(c)
FIG. 2––(a–c) Section of the left anterior descending coronary artery showing an acute dissection between the inner four-fifths and outer one-fifth of the media.
costal spaces opposite to the apex of the heart at the internal examination. The left lateral location on the chest area of this contusion and areas of hemorrhage excluded the possibility that these were a consequence of resuscitation efforts, which are usually in the mid-thoracic location. Moreover, the absence of inflammation in the adventitia at the histological examination
BARBESIER ET AL.
was also in favor of a traumatic context of the coronary artery dissection. Coronary artery dissection following blunt chest trauma typically involves the left anterior descending artery such as in the present case; the probable explanation is due to its vulnerable anatomic position on the anterior part of the heart. The second most commonly affected artery is the right coronary artery, although uncommon, left circumflex coronary artery involvement has also been reported (2,6,10,13). The main hypothesis mentioned in the literature is the existence of shearing forces during the traumatic episode which probably cause intimal tears of the most vulnerable part of the left anterior descending artery and subsequently initiate the process of thrombus formation (13). Other factors may include coexisting atherosclerosis with fracture of a preexisting plaque, spasm, thrombosis, and emboli (6). In the current case, no predisposing factor was found histologically on the arterial wall. This first report of acute coronary artery dissection leading to sudden death following the practice of martial arts is of interest for the clinician who should be aware of the possibility of coronary artery dissection leading to sudden cardiac death in a context of minor blunt chest trauma. References 1. Ginzburg E, Dygert J, Parra-Davila E, Lynn M, Almeida J, Mayor M. Coronary artery stenting for occlusive dissection after blunt chest trauma. J Trauma 1998;45(1):157–61. 2. Chun JH, Lee SC, Gwon HC, Lee SH, Hong KP, Seo JD, et al. Left main coronary artery dissection after blunt chest trauma presented as acute anterior myocardial infarction: assessment by intravascular ultrasound: a case report. J Korean Med Sci 1998;13(3):325–7. 3. Marik PE. Coronary artery dissection after a rugby injury. S Afr Med J 1990;77(11):586–7. 4. Imamura M, Tsuchiya Y, Tahara H, Nii T, Nakashima Y, Arakawa K, et al. Acute myocardial infarction in a patient with primary coronary dissection and severe coronary vasospasm. Angiology 1995;46(10):951–5. 5. Kawahito K, Hasegawa T, Misawa Y, Fuse K. Right coronary artery dissection and acute infarction due to blunt trauma: report of a case. Surg Today 1998;28(9):971–3.
.
SPORTS-RELATED CORONARY ARTERY DISSECTION
235
6. Vasudan AR, Kabinoff GS, Keltz TN, Gilter B. Blunt chest trauma producing acute myocardial infarction in a rugby player. Lancet 2003;362 (9381):370. 7. Hobelmann A, Pham JC, Hsu EB. Case of the month: right coronary artery dissection following sports-related blunt trauma. Emerg Med J 2006;23(7):580–1. 8. Heymann TD, Culling W. It’s not cricket! Myocardial infarction following non-penetrating blunt chest trauma. Br J Clin Pract 1994;48(6):338–9. 9. Hazeleger R, van der Wieken R, Slagboom T, Landsaat P. Coronary dissection and occlusion due to sports injury. Circulation 2001;103 (8):1174–5. 10. Christensen MD, Nielsen PE, Sleight P. Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review. Int J Cardiol 2006;108(1):1–5. 11. Atalar E, Acßil T, Aytemir K, Ozer N, Ov€uncß K, Aks€oyek S, et al. Acute anterior myocardial infarction following a mild nonpenetrating chest trauma – a case report. Angiology 2001;52(4):279–82. 12. Tweet MS, Hayes SN, Pitta SR, Simari RD, Lerman A, Lennon RJ, et al. Clinical features, management, and prognosis of spontaneous coronary artery dissection. Circulation 2012;126(5):579–88. 13. Sato Y, Matsumoto N, Komatsu S, Matsuo S, Kunimasa T, Yoda S, et al. Coronary artery dissection after blunt chest trauma: depiction at multidetector-row computed tomography. Int J Cardiol 2007;118(1):108–10. 14. Greenberg J, Salinger M, Weschler F, Edelman B, Williams R. Circumflex coronary artery dissection following waterskiing. Chest 1998;113 (4):1138–40. 15. Woodward TW. A review of the effects of martial arts practice on health. WMJ 2009;108(1):40–3. 16. Buschbacher RM, Shay T. Martial arts. Phys Med Rehabil Clin N Am 1999;10(1):35–47. 17. Wilkerson LA. Martial arts injuries. J Am Osteopath Assoc 1997;97 (4):221–6. 18. Maeder M, Ammann P, Angehrn W, Rickli H. Idiopathic spontaneous coronary artery dissection: incidence, diagnosis and treatment. Int J Cardiol 2005;101(3):363–9. Additional information and reprint requests: Marie Barbesier, M.D. Medical Examiner Office of Lyon 12, Avenue Rockefeller Lyon 69008 France E-mail: [email protected]
