Legal Medicine 9 (2007) 326–329
www.elsevier.com/locate/legalmed

Case Report

A case of iatrogenic cerebral infarction demonstrated
by postmortem cerebral angiography
Yutaka Tajima a, Rie Takagi a, Yoshihiko Kominato a,*, Naoya Kuwayama b
a

Department of Legal Medicine and Molecular Genetics, Gunma University, Graduate School of Medicine, Maebashi 371-8511, Japan
b
Department of Neurosurgery, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
Received 7 March 2007; received in revised form 9 May 2007; accepted 9 May 2007
Available online 5 July 2007

Abstract
A 37-year-old man with a meningioma compressing the right frontal lobe underwent preoperative embolization of the feeding vessels
from the right meningeal artery. Although the first challenge was apparently successful, an excess amount of embolization agent was
accidentally injected during the next procedure. X-ray monitoring demonstrated flow of contrast medium into the right internal carotid,
anterior and middle cerebral arteries, and then the patient suddenly developed left hemiparesis, nausea, and deep coma. He died 48 days
after the embolization treatment without improvement of the coma. A medicolegal autopsy was performed to determine whether malpractice had occurred during the embolization procedure. An internal examination demonstrated massive necrosis of the cerebral hemispheres and lobar pneumonia with abscess in the lungs. Due to the extensive brain necrosis, it was impossible to carry out ordinary
macroscopic examination to identify the precise site of the craniocerebral vessel occlusion. Postmortem angiography was therefore performed, and this successfully revealed occlusion of the right internal carotid artery. In this case, postmortem angiography played a key
role in identification of the intracranial vascular lesion that was responsible for the iatrogenic cerebral infarction.
Ó 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Postmortem angiography; Embolization; Cerebral infarction

1. Introduction
According to Boulay and O’Connell [1], cerebral angiography was first developed by Egas Moriz in 1927.
Since then, a huge volume of literature on angiography
has accumulated. Angiography can also be performed
for postmortem examination by pathologists. Postmortem angiography has been used mainly to identify the
arterial supply of any vascularized organ or tissue as well
as the location of an arterial rupture. Karhunen et al.
reported that postmortem craniocerebral angiography
was useful for clarifying head trauma and for differential
diagnosis between arteriovenous malformation and arterial aneurysm in cases of unusual intracranial hemorrhage [2,3]. Smith et al. showed that postmortem
*

Corresponding author. Tel.: +81 27 220 8030; fax: +81 27 220 8035.
E-mail address: kominato@med.gunma-u.ac.jp (Y. Kominato).

coronary angiography was a valuable tool for both gross
and microscopic anatomical studies, because it allowed
successful visualization of coronary arterial distribution
within the myocardium [4]. Furthermore, Karhunen
and Penttila reported the validity and usefulness of postmortem angiography for diagnosis of unusual gastrointestinal hemorrhage [5]. Previously, we demonstrated
that postmortem angiography could be used to reveal
associations between cerebral vessels and ruptures when
evaluating complicated cerebral injuries [6,7]. In addition,
it was also useful for identifying a bleeding point in the
left uterine artery in a fatal case of postoperative hemorrhage after hysterectomy [8]. As noted here and elsewhere, postmortem angiography is very useful for
forensic pathologists when investigating vascular lesions.
Here we report a case of iatrogenic cerebral infarction
in which the intracranial vascular lesion was demonstrated by postmortem cerebral angiography.

1344-6223/$ - see front matter Ó 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.legalmed.2007.05.006

Y. Tajima et al. / Legal Medicine 9 (2007) 326–329

327

1.1. Case report
A 37-year-old man complaining of headache and nausea was diagnosed as having an intracranial meningioma
6 cm in diameter, which compressed the right frontal
lobe. Preoperative embolization of two feeding vessels
from the right meningeal artery was attempted to reduce
the vascularity of the tumor and thus bleeding during the
planned total resection. After selective catheterization
into a feeding artery via a femoral approach, followed
by a lidocaine provocation test that resulted in no neurological complications, embolization was performed using
a mixture of n-butyl-2-cyanoacrylate tissue adhesive and
iodine-containing ethylesters of fatty acids as the embolizing material and radiopaque contrast medium, respectively. The first embolization of one of the feeding
arteries appeared to be successful. However, during the
next procedure, an excess amount of the embolization
agent was accidentally injected. X-ray monitoring showed
that contrast medium flowed into the right internal carotid, anterior and middle cerebral arteries, and then the
patient suddenly developed left hemiparesis, nausea,
and deep coma. X-ray computed tomography of the
head demonstrated right cerebral infarction as well as
the presence of residual contrast medium in the right
internal carotid, anterior and middle cerebral arteries.
To reduce the increased intracranial pressure, osmo-therapy with glycerol was carried out. Surgery was performed on the day after the embolization for resection
of the meningioma and cerebral decompression. Subsequently, the patient was treated conservatively with respiratory support and transfusion for nutrition and
circulating volume supplementation. However, he died
47 days after the operation without improvement of
the coma. A medicolegal autopsy was performed to clarify whether malpractice had occurred during the embolization procedure.
At autopsy, which was performed on the day after
death, the body measured 165 cm and weighed 65.4 kg.
External examination revealed only a few traces of the
treatment, including injection and respiratory support.
Internal examination demonstrated massive brain necrosis and severe lobar pneumonia with abscesses in both
lungs. Before opening the cranium, postmortem angiography was performed by injection of radiopaque contrast
medium consisting of 5% gelatin–barium emulsion into
both common carotid arteries. The injection pressure
ranged from 100 to 150 mmHg, corresponding to normal
human blood pressure. It took approximately 15 min to
complete selective intubation into the vascular system
and injection of around 600 ml of the radiopaque contrast medium. After the contrast medium had been
injected, it was found to fully fill the capillaries of the
left, but not the right, conjunctiva. When the cranium
was opened, the left cerebral hemisphere was found to
be rather necrotic, and filling of the contrast medium
with extravascular leakage was observed in the vessels

Fig. 1. Appearance of both cerebral hemispheres. Radiopaque contrast
medium (5% gelatin–barium emulsion) was injected into both the right
and left common carotid arteries before opening the cranium. Both
hemispheres were widely necrotic, and the dura mater was adhered to the
surface of the right hemisphere.

of the left hemisphere (Fig. 1). The right hemisphere
was highly necrotic and fragile, and the white medium
was observed not to fill the vessels. Because of the
mechanical fragility of the brain tissue due to massive
necrosis and adhesion of the dura mater to the surface
of the right hemisphere, it was difficult to identify any
vascular lesion by ordinary macroscopic inspection and
microscopic examination. Therefore, the brain was harvested and fixed in 10% phosphate-buffered formalin
solution for one month to allow examination by X-ray
exposure. X-ray computed tomography showed that the
arteries of the left cerebral hemisphere were almost fully
filled with the radiopaque medium, whereas only a small
proportion were filled in the right hemisphere (Fig. 2).
This suggested that almost complete occlusion of the
right internal carotid artery had occurred. Filling of contrast medium in some of the arteries of the right hemisphere could have been due to bypass through the
arterial circle on the inferior surface of the brain. Communications are present between the middle meningeal
artery and the intracranial internal carotid artery
through the inferolateral trunk, the meningohypophyseal
trunk, and the ophthalmic artery, which are the branches
of the internal carotid artery [9]. Therefore, the embolization agent injected into the feeding artery originating
from the right middle meningeal artery would have been
able to pass along a collateral conduit of the right intracranial internal carotid artery, and embolize the right
internal carotid artery and its branches, causing infarction of the right cerebral hemisphere, followed by edema,
impaired perfusion, and necrosis of the brain.

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Y. Tajima et al. / Legal Medicine 9 (2007) 326–329

Fig. 2. Craniocerebral angiography of the fixed brain. Radiopaque
contrast medium was injected into both the right and left common
carotid arteries before opening the cranium. Craniocerebral angiography
was performed using X-ray computed tomography. This 3-D image was
reconstructed by computer-aided calculation of radiodensity in every part
of the tomographic image. The position of this figure has been adjusted to
that of Fig. 1 to aid understanding.

2. Discussion
Using postmortem angiography, we examined a 37year-old man who had undergone preoperative embolization therapy complicated by iatrogenic cerebral infarction.
In the present case, postmortem angiography played a key
role in identifying the intracranial vascular lesion that had
caused the cerebral infarction, even though the brain tissue
was necrotic and too fragile for ordinary macroscopic
examination.
Previously, we reported an individual who died three
days after sustaining a jaw injury and becoming unconscious [6]. In this case, subdural hematoma and herniation
had caused brain death. Postmortem angiography demonstrated thrombus-like strings in the internal carotid arteries, partial filling of the main cerebral arteries, and total
loss of the peripheral arterial shadow. Therefore, postmortem angiography has only limited application to cases of
brain death. In the present case, internal examination demonstrated massive necrosis of both hemispheres. However,
postmortem cerebral angiography showed that the arteries
of the left cerebral hemisphere were almost fully filled with
the radiopaque medium, whereas only a small proportion
were filled in the right hemisphere. These results seem to
be consistent with the clinical diagnosis based on observations obtained by X-ray monitoring during the embolization procedure and computed tomography after the
procedure. Thus, postmortem cerebral angiography would
have been valid for the present case.
Currently, the angioembolization technique is widely
used in endovascular therapy for some diseases of the cen-

tral nervous system such as tumors and aneurysms. However, there have been many complications associated with
embolization therapy, mainly cerebral hemorrhage and
ischemia [10,11]. It is known that brain hemorrhage is the
most frequent and serious complication of endovascular
treatment of a brain arteriovascular malformation. A less
well recognized side effect is pulmonary embolism [12].
As reported here, postmortem examination in cases of
brain necrosis is difficult, and postmortem angiography
can be of value to forensic pathologists for identification
of occlusion in blood vessels.
Postmortem investigation is increasingly supported by
computed tomography and magnetic resonance imaging
to reveal injury or disease, and to determine the cause of
death [13–15]. Although postmortem angiography is an
invasive technique, it can be used to demonstrate the arterial supply of any vascularized organ or tissue as well as the
location of an arterial rupture [6–8]. There are several
approaches for visualizing various types of pathology in
the vascular system. Recently, postmortem 3-D coronary
angiography using electron-beam computed tomography
has been developed by Rah et al. [16]. The convincing
results obtained by these new methodologies have led to
the implementation of noninvasive or minimally invasive
autopsy techniques as alternatives for forensic autopsy in
some special cases. Postmortem angiography is now being
developed as a new and effective adjunct for investigating
vascular lesions in the field of forensic pathology.
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