Table Of ContentFORENSIC
NEUROPATHOLOGY
FORENSIC
NEUROPATHOLOGY
Second Edition
Edited by
Helen Whitwell
Formerly Professor of Forensic Pathology
University of Sheffield
and
Neuropathologist
West Midlands, UK
Christopher Milroy
Forensic Pathologist and Professor
Department of Pathology and Laboratory Medicine
University of Ottawa, Canada
Daniel du Plessis
Consultant Neuropathologist
Neuropathology Unit
Department of Cellular Pathology
and
Greater Manchester Clinical Neurosciences Centre
Salford Royal Hospital NHS Foundation Trust
Liverpool, UK
Second edition published 2021
by CRC Press
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© 2021 Taylor & Francis Group, LLC
First edition published by Edward Arnold (Publishers) Ltd. 2005
CRC Press is an imprint of Taylor & Francis Group, LLC
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Library of Congress Cataloging‑in‑Publication Data
Names: Whitwell, Helen L., editor. | Milroy, Christopher (Christopher M.), editor. | Du Plessis, Daniel (Daniel G.), editor.
Title: Forensic neuropathology / edited by, Helen Whitwell, Christopher Milroy, Daniel du Plessis.
Other titles: Forensic neuropathology (Whitwell)
Description: Second edition. | Boca Raton : CRC Press, 2021. | Includes bibliographical references and index. | Summary:
“Forensic Neuropathology is written by experts for specialists and trainees alike and succeeds in addressing the concerns of
the forensic pathologist and the neuropathologist by tackling the overlapping problems that arise during the postmortem
examination and subsequent legal proceedings.
Totally updated and revised, the new edition contains many new chapters, including much more information on non-accidental
injury in pediatric cases, alcohol, sudden death, imaging, sports and transportation injury, long term effects of chronic brain
injury and anoxal death”– Provided by publisher.
Identifiers: LCCN 2020045920 (print) | LCCN 2020045921 (ebook) | ISBN 9781498706162 (hardback) | ISBN 9781003158035
(ebook)
Subjects: MESH: Forensic Pathology–methods | Craniocerebral Trauma–pathology | Central Nervous System–pathology
Classification: LCC RA1147 (print) | LCC RA1147 (ebook) | NLM W 825 | DDC 614/.1–dc23
LC record available at https://lccn.loc.gov/2020045920
LC ebook record available at https://lccn.loc.gov/2020045921
ISBN: 978-1-498-70616-2 (hbk)
ISBN: 978-0-367-74460-1 (pbk)
ISBN: 978-1-003-15803-5 (ebk)
Typeset in Utopia Std
by KnowledgeWorks Global Ltd.
Contents
Preface vii 11 Traumatic axonal injury 116
Contributors viii Daniel du Plessis
12 Brain swelling, raised intracranial pressure and
1 Anatomy of the head and neck 1 hypoxia-related brain injury 128
Peter Dangerfield Daniel du Plessis
2 Clinical aspects of head injury 17 13 Sudden unexpected death in epilepsy 139
Graham Flint Christopher Milroy and Daniel du Plessis
3 Imaging of head trauma 25 14 Contact sport and blast-related neuropathology 145
Calvin Soh Daniel du Plessis and Christopher Milroy
4 Biomechanics of primary traumatic head injury 45 15 Head injury in the child 151
Michael Jones Helen Whitwell and Christopher Milroy
5 Techniques 55 16 Spinal injuries 167
Helen Whitwell Graham Flint and Helen Whitwell
6 Scalp, facial and gunshot injuries 66 17 Difficult areas in forensic neuropathology:
Christopher Milroy Homicide, suicide or accident 178
Christopher Milroy and Helen Whitwell
7 Adult skull fractures 80
Helen Whitwell and Philip Lumb 18 Non-traumatic neurological conditions in
m edico-legal work 186
8 Intracranial haematomas – Extradural and subdural 87
Colin Smith
Helen Whitwell
19 Alcohol, drugs, toxins and post-mortem toxicology 195
9 Subarachnoid haemorrhage and cerebrovascular
Colin Smith and Christopher Milroy
traumatic pathology 94
Daniel du Plessis and Paul Johnson 20 The role of the expert witness 203
Paul Watson and Christopher Milroy
10 Contusional brain injury and intracerebral
h aemorrhage – Traumatic and non-traumatic 107
Helen Whitwell Index 208
v
Preface
This second edition builds on the previous one with the addi- Other chapters especially those on hypoxia, clinical aspects
tion of two further co-editors, Christopher Milroy, forensic of head injury, spinal injury, subarachnoid haemorrhage as
pathologist from Ottawa who contributed much to the first edi- well as infant head injury have been considerably revised. The
tion and Daniel du Plessis, neuropathologist from Manchester. latter now includes a section devoted to ocular pathology.
As before, this book is not intended to be a fully compre- New photographs and references are further additional fea-
hensive forensic pathology or neuropathology text as there are tures.
many available. The aim is to concentrate on those difficult and We hope, as with the previous edition, that readers, includ-
emerging areas of forensic neuropathology. These often impact ing forensic pathologists, neuropathologists and general
in the medico-legal setting. pathologists, will find this latest text informative and practi-
In updating, we have added a number of new chapters, cally useful. Neuroscience clinicians and others will also find
including biomechanics, neuroradiology and the important areas of interest. Members of the legal profession found the last
topics of chronic traumatic encephalopathy and sudden unex- edition of assistance – including for cross-examination pur-
pected death in epilepsy where knowledge has considerably poses – as some of us have experienced!
advanced over recent years.
vii
Contributors
Peter Dangerfield Philip Lumb
Clinical Anatomist Forensic Pathologist
University of Liverpool Manchester, UK
Liverpool, UK
Colin Smith
Graham Flint Neuropathologist
Neurosurgeon University of Edinburgh
Queen Elizabeth Hospital Scotland, UK
Birmingham, UK
Calvin Soh
Paul Johnson Neuroradiologist
Forensic Pathologist Manchester Royal Infirmary
Royal Liverpool University Hospital Manchester, UK
Liverpool, UK
HH Judge Paul Watson QC
Michael Jones Circuit Judge
Clinical, Trauma and Orthopaedic Engineer Middlesbrough, UK
Cardiff University
Wales, UK
viii
1 Anatomy of the head and neck
Peter Dangerfield
The surface anatomy and features of the head and neck are associated with hyperthyroidism can result in prominent eyes.
derived from skeletal and soft tissue structures covered by skin Facial fractures affecting the maxilla and inferior margin of the
and connective tissue that covers the underlying bony skull. In orbit can lead to a sinking of the eyeball. The shape of the lids
some areas, particularly the face, the skin is thin, allowing easy themselves can lead to a wide range of different appearances of
palpation of underlying skeletal features. It is also highly mobile the eye within the orbit.
as a result of the presence of a number of small but extensive
subcutaneous muscles of facial expression, all supplied by a The internal facial structures
single cranial nerve (facial). The scalp is, in contrast, relatively
Internally, the muscles of facial expression and their nerve and
tough and hidden from view in most individuals by hair. Within
vascular supplies contribute to the facial structures. In addi-
the skull, which acts as a protective shield, are the brain and
tion, the parotid gland is located within the lateral parts of the
brainstem, with its associated covering of tissue layers and
cheeks.
blood vessels. The anatomy is complex and this chapter can only
The facial expression muscles are supplied by the facial
provide an overview of the principal features, with craniofacial
(cranial VII) nerve. Their function is to control and support
anatomy included to link anatomically with the underlying
the structures and openings in the face, such as the eyes and
structures, including the neuroanatomy, which may be of par-
mouth. In humans, their functionality serves an important role
ticular significance in penetrating or blunt head trauma.
in non-verbal communication as well as aiding actions such as
screwing up the eyes and chewing. The mouth is surrounded
The external face by the sphincteric orbicularis oris muscle into which merge the
fibres of the buccinator, the muscle of the cheek. The buccina-
The anatomical surface features of the face are never totally
tor contracts during chewing and serves to prevent trapping of
symmetrical. As facial expressions have evolved as a commu-
food within the space between the gums and teeth; it also acts
nication method, the underlying anatomy has evolved from the
to raise the pressure of air expelled by musicians playing wind
functional need. The skin is often marked by moles and freckles
instruments or by whistling. The orbicularis oculi surrounds
and may also present with scars consequential to cuts and other
the eye and serves to function in two ways. First, fibres that
trauma.
surround the eye serve to screw the eye up because they are
The shape and size of the hairline vary with race and the eye-
attached to the bone on the medial aspect of the orbit. Second,
brows can also be highly variable.
the palpebral fibres attach to the lateral palpebral raphe and
The nose comprises underlying cartilaginous and bony
serve to close the eye when blinking. Additional fibres are
structures. In the coronal section, the nose is triangular in
attached to the lacrimal sac and serve to dilate the sac and keep
shape. The external nares (nostrils) are protected by coarse
the puncta in contact with the eyeball.
hairs (vibrissae) and serve to filter air entering the nose. The
The facial nerve enters the face by passing through the tough
anterior part of the nose is composed of flexible underlying
fibrous capsule of the parotid gland and can be damaged during
fibrocartilage.
surgical procedures to that gland.
Inferior to the nose is the mouth, surrounded by the lips.
Here, the size and shape of the mouth are very variable, both
The nose
within races and between different racial groups. The lips have
non-keratinised epithelium and thus appear pink as a result of The nose, as the upper part of the respiratory tract, is located
the underlying blood vessels. superior to the hard palate and contains the organ of smell. It
The eyes are set within the bony orbits of the skull but pro- is divided into right and left nasal cavities by the nasal septum,
tected by the rim of bone. Their individual position relative to with each nasal cavity having an olfactory and a respiratory
the nose is variable and can be close-set or wide set in normal area.
individuals. Attached within the orbits are the muscles that The external nose varies considerably in size and shape in
control eye movement while, superficially, the paired eyelids individuals and races because of differences in the nasal car-
cover and protect the eye from potential damage. The lids nor- tilage structure. The inferior aspect is composed of two open-
mally permit only a portion of white sclera to appear laterally, ings called the nares (nostrils), each separated from the other
with the transparent conjunctiva and cornea that cover the pig- by the nasal septum. The nasal bones, the frontal processes of
mented iris seen medially. The upper lid normally overlaps the the maxillae, the nasal part of the frontal bone and the bony
iris, but the sclera may be seen between the iris and the lower part of the nasal septum form the skeletal components of the
lid. The shape of the lids can vary between individuals; in par- nose, whereas five main cartilages form the cartilaginous nose.
ticular, the elevator of the upper lid can be weak or damaged, These are two lateral cartilages, two alar cartilages and a septal
leading to a drooping appearance. cartilage that articulates with the bony septum.
Ethnic differences are often prominent. Mongoloid epican- The nasal cavities open through the choanae into the naso-
thic folds and other minor folds of skin in the medial aspect of pharynx at the posterior. The nasal mucosa is bound closely
the orbit should be noted. Conditions such as exophthalmos to the periosteum and perichondrium of the nasal bones and
