title: Sudden aortic death-proposal for a comprehensive diagnostic approach in forensic and in clinical pathology practice.
abstract: BACKGROUND
  Aortic rupture or dissection as immediate cause of sudden death is encountered in forensic and clinical autopsy practice. Despite a common denominator of 'sudden aortic death' (SAD), we expect that in both settings the diagnostic workup, being either primarily legal or primarily disease related, differs substantially, which may affect the eventual diagnoses.
  
  
  METHODS
  We retrospectively reviewed case records of deceased persons who fitted a diagnosis of SAD in the continuous autopsy cohorts in a forensic (Suisse) and a clinical setting (The Netherlands). Clinical characteristics, data from post-mortem imaging, tissue blocks for histological analysis and results of ancillary studies were reviewed for its presence and outcome.
  
  
  RESULTS
  SAD was found in 7.7% in the forensic versus 2.2% in the clinical autopsies. In the forensic setting, autopsy was always combined with post-mortem imaging, showing variable outcome on detection of aortic disruption and/or pericardial bleeding. Histology of aorta was performed in 12/35 cases, mostly in the natural deaths. In the clinical setting, histology of the aorta was available in all cases, but post-mortem imaging in none. In both settings, underlying aortic disease was mostly cystic medial degeneration, atherosclerosis or a combination of both, with occasional rare unexpected diagnosis. Also in both, a genetic cause of aortic dissection was revealed in a minority (three cases).
  
  
  CONCLUSIONS
  Sudden aortic death (SAD) is more commonly encountered in a forensic than in a clinical setting. Major differences in the approach of SAD between these settings coincide with similarities in causes of death and underlying diseases. To ensure a correct diagnosis, we recommend that the investigation of SAD includes a study of the medical history, a full autopsy with histology of major organs including aorta, and storage of material for toxicological and genetic testing. Post-mortem radiological examination, useful for documentation and screening purposes, is feasible as non-invasive alternative when autopsy is not possible, but cannot substitute a full autopsy.
authors.affiliation: Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
authors.forename: Hans H
authors.initials: HH
authors.lastname: de Boer
authors.affiliation: University Hospital of Lausanne, University Center of Legal Medicine, Lausanne-Geneva, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland.
authors.forename: Fabrice
authors.initials: F
authors.lastname: Dedouit
authors.affiliation: University Hospital of Lausanne, University Center of Legal Medicine, Lausanne-Geneva, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland.
authors.forename: Nina
authors.initials: N
authors.lastname: Chappex
authors.affiliation: Department of Pathology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
authors.forename: Allard C
authors.initials: AC
authors.lastname: van der Wal
authors.affiliation: University Hospital of Lausanne, University Center of Legal Medicine, Lausanne-Geneva, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland. katarzyna.michaud@chuv.ch.
authors.forename: Katarzyna
authors.identifier: http://orcid.org/0000-0003-2681-2544
authors.initials: K
authors.lastname: Michaud
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000209:etiology / Q000473:pathology; D001011:Aorta / Q000000981:diagnostic imaging* / Q000473:pathology*; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000209:etiology / Q000473:pathology; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000209:etiology / Q000473:pathology; D002648:Child; D002675:Child, Preschool; D003645:Death, Sudden / Q000209:etiology* / Q000473:pathology; D005260:Female; D049429:Forensic Pathology; D005820:Genetic Testing / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D055947:Loeys-Dietz Syndrome / Q000175:diagnosis; D008297:Male; D008382:Marfan Syndrome / Q000175:diagnosis; D008875:Middle Aged; D010338:Pathology, Clinical; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D055815:Young Adult
keywords: Aorta; Dissection; Forensic autopsy; Rupture; Sudden death