Post-traumatic aneurysmal rupture involving the circle of Willis affected by fibromuscular dysplasia. A case report and systematic review. (November 2020)

• Record Type: Journal Article
• Authors: Boscolo-Berto, Rafael; Macchi, Veronica; Porzionato, Andrea; Parenti, Anna; Petrelli, Lucia; Raimondo, Alberto; De Caro, Raffaele
• Is Part Of: Legal medicine. Volume 47(2020)
• Publication Date: 2020-11
• Subjects: Fibromuscular dysplasia -- Anterior communicating artery -- Anterior cerebral artery -- Aneurysm -- Anatomical variation -- Road traffic accident; Medical jurisprudence -- Periodicals; Forensic Medicine -- Periodicals; Médecine légale -- Périodiques; Medical jurisprudence; Periodicals; 614.1
• DOI: 10.1016/j.legalmed.2020.101742
• Languages: English
• ISSNs: 1344-6223

Abstract

Highlights: SAH of basal cisterns/ventricles after TBI needs intracranial vessels to be explored. Rupture of a subarachnoid artery may be coexistent to fibromuscular dysplasia. Un uncommon case of FMD with ruptured intracranial aneurysm in TBI is presented. Abstract: The fatal rupture of a saccular aneurysm at the junction between the left anterior cerebral artery and anterior communicating artery affected by fibromuscular dysplasia (FMD) is a rare condition. Here is reported the case of a subject involved in a road traffic accident a few minutes before the death, which opened the debate on the real cause of death in a forensic setting. By autopsy, the examination of the brain revealed subarachnoid haemorrhage with flooding of the ventricles due to the breached saccular aneurysm of the junction between the left anterior cerebral artery and anterior communicating artery, in FMD mainly affecting the circle of Willis arteries. A spontaneous aneurysmal rupture was excluded on the basis of probabilistic analysis, in the presence of alternative hypotheses that could explain the facts. The passenger's delayed loss of consciousness may be explained as much by a hypertension-linked rupture of the aneurysm triggered by the emotional stress experienced, as by the traumatic shaking/impact of the aneurysm against the bony skull structures, in a subject predisposed to aneurysm frailty due to FMD. Overall, the concausal role of both the road traffic accident, typified by high kinetic energy, and the presence of a pre-existing aneurysmatic weakness due to FMD is fully recognized. The identification of anatomical variants, jointly with uncommon diseases at the examination of the brain base arteries in any case of isolated basal subarachnoid haemorrhage, may avoid wrong legal consequences even when the cause of death seems to be obviously of simple traumatic origin.