Autopsy dissection of heart and spinal cord
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Autopsy dissection of heart and spinal cord

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Presentation on procedure of autopsy dissection of the heart and spinal cord.

Presentation on procedure of autopsy dissection of the heart and spinal cord.

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Autopsy dissection of heart and spinal cord Autopsy dissection of heart and spinal cord Presentation Transcript

  • 12-06-2066Autopsy dissection ofthe Heart and theSpinal cord Dr. Rijen Shrestha M.D. Resident Dept. of Forensic Medicine
  •  references: ludwig for heart anatomy books by foreign authors(no names included) spinal and scrotum -gresham and turner +ludwigs dissection techniques recommendations given after presentation: short pause between change of slides, more details on layers of scrotum and heading as dissection of spinal cord and not vertebral column.. heart dissection can be tried or practiced by u..but sudnt forget the names..in regular autopsy.. THign learnt: myocardium dissection sud not be done like we do in there..whole myocardium sud be subjected to rule out artifects produced by formaldehyde to middle layer of myocardium.
  • Dissection of heart Removal of heart:-chest plateHeart -thoracic bloc: pericardial adhesion, previous h/o open heart surgery, pericarditis, congenital cardiac disease, esophageal/pulmonary carcinoma, aortic dissection , injuries to heart (tamponade).Heart- removed separately acquired diseases , no adhesions or injuries to heart.
  • Color of myocardium: Gray : old infarct Pale : anemic Mottled/hemorrhagic spots: acute infarct/ruptureShape: Conical : normal Irregular/globoid : verntricular aneurysms, ventricular thromboembolism, 1 or more chamber irregular in shape(DCM)
  • Left ventricular Consistency: Firm: hypertrophy, fibrosis, amyloidosis, calcification, rigor mortis. Soft: Myocardial infarction, myocarditis, DCM, decomposition
  • Evaluation of coronaries: -Before any forms of cardiac dissection is applied, coronaries should be inspected for calcification and tortuosity. -Subjects younger than 30yrs or where cause of death is non cardiac: coronaries may be opened longitudinally -Otherwise, transverse section : 3.5-5mm . -Calcified vessels are stripped off and decalcified.
  • Grading of coronary obstruction:-Mild :grade I: > 25% narrowing (cut off point)-severe : to 70%, critical stenosis : >90% (grade IV) -Depending on number of vessel involved:vessel 1,2,3..if LAD is involved..vessel4. Ex:grade 4-critical- vessel4 = >90%, critical stenosisinvolving all 4 major coronaries.
  • Cardiac dissection methods:1. Inflow-outflow method2. Short-axis method Useful for3. Four chamber method demonstrating cardiac pathology4. Long axis method Anatomic 5.Base of heart method teaching and museum 6.Window method specimen 7.Unrolling method demonstrationsConsiderable Mutilation 8.Partition method. / preparations.of the heart
  • 1. Inflow-outflow method:Right: -Using scissors, initial cut is made from IVC to right atrial appendage sparing SVC and SA node. -Right ventricle opened with knife along 1cm parallel to the posterior ventricular septum -Outflow tract :1cm parallel to anterior ventricular septumLeft: -Left atrium-between R and L pulmonary veins -Left atrial appendage checked for mural thrombus. -Inflow tract: left ventricle opened along its inferolateral border. -Outflow tract :to avoid damage to mitral valve, 1cm parallel to anterior ventricular septal groove.
  • 2. Short Axis dissection: -Method of choice :slices expose largest surface area of myocardium. -Diaphragmatic aspect kept over paper towel to prevent slippage. - 1.0-1.5cm thick cuts parallel to atrio- ventricular groove with long knife. -One firm slice -Each slice viewed from apex to base.
  • 1-1.5ccm
  • 3. Four chamber method: -long knife, begin at apex of the heart. -cut extended through acute margin of right ventricle, obtuse margin of left ventricle and ventricular septum. -cutting extended through mitral and tricuspid valve through atria. -divides heart into 2 pieces each having all 4 chambers. -Upper half can be opened using inflow-outflow technique.
  • 4. Long axis method: -3 straight pins are used to demarcate. -First pin : apex, 2nd pin : right aortic sinus (just adjacent to right coronary sinus) 3rd pin: near mitral valve annulus (between 2 pulmonary veins openings). -Heart is cut along this plane from apex to base or vice versa using knife and scissors passing through both mitral and aortic valves.
  • 5.Base of the heart method: -Displays all the valves -Ideal for demonstrating anatomical relations of the valves and adjacent coronaries.6. Window method : -Perfusion fixed, window of various sizes removed with scalpel and sent for HP study. -Small windows, enlarged depending on the size of the lesions. -Useful for cardiac museum specimen.
  • 7.Unrolling method: -Causes considerable mutilation of the heart, only done in research studies.8. Partition method: -Coronaries and epicardial fats are stripped off -Ventricles separated from IV septum, atria removed. -All weighed separately. -Mutilation.
  • Dissection of cardiac conduction system: -procedure of no practical diagnostic value - mentioned at instances in literatures but in practice such examination is not performed.Quantitative measurements of the heart: -Weight -Wall thickness -Valve size -Amount of pericardial fluidQualitative analysis of the heart: -Cardiac valve patency - Embolism
  • Weight of the heart: “Total heart weight is most reliable single measurement at autopsy for correlation with cardiac disease states.”-Reiner .L., Gross examination of heart, Pathology of heart and great vessels, 3rdedition, IL, pp1111-1149. Other described measurements like linear external dimension, surface area and volume of entire myocardium are less useful.-great vessels are trimmed to about 2cms in length.-PM clots are removed.-weights recorded (+/- 5gms adult; =/- 0.1gms infants)-fixation alters the weight by 5-10%-heart weight proportional to body weight rather than age, gender and body size.
  • Thickness of walls of heart: -usually measured at the level of mitral valve; but since the wall is thin towards apex and thick towards base; -MOST reliable average measurement is found at level of papillary muscles. -ventricular septum and right ventricle should also be measured at the same level. -Trabeculations and papillary muscles should be excluded. -Fixation increases the size by 10%.Confusions: -physiological hypertrophy - 25% in athletes. -decomposition vs. dilatation -postmortem > 24hrs, RM passes –natural dilatation vs.
  • Cardiac valve patency/Size: ◦ Regurgitation can be accessed to some extent by filling chambers with water to check for retrograde flow through intact valve. ◦ Stenosis and valve size is best evaluated by measuring effective orifice size by a calibrated cone (but not annular size). ◦ Thickness and area of valve increase with age and is higher in females than males of same body size.
  • Air embolism :-first coronaries, to check for systemic air embolism.-all chambers to be perforated, RV-LV-RA- LA.
  • Dissection of spinal cord 1.Anterior approach 2. Posterior approach 3.Combined approach
  • Anterior Approach: -first cut is made across uppermost part of T1 or T2. -head is dropped back, wooden block under mid back. -either side of thoracic spine up to length of 15cms. -angle of blade changed and adjusted according to the type of vertebra. -muscles removed and vertebra(L1-L4) cut in similar pattern like thoracic vertebra. Sacrum and L5 is removed together. -Carotids are pushed sideways and cervical vertebrae removed till c2 similarly.
  • Advantages: -prevents leakage after embalming. -less mutilation visible. -course of peripheral nerves for any length in contiguity from spinal cord can be accessed.Disadvantages: -difficult approach to proximal cervical vertebrae -conditions like myelomeningocele, and occipital encephalocele cannot be demonstrated. -Flexion extension injuries to back of the neck or other injuries along the posterior vertebral column cannot be demonstrated.
  • Posterior approach: -Body prone, wooden blocks under both shoulders. -Head rotated forward, flexed. -Midline incision over spinous processes, muscles are resected. -Parallel saw-cuts through vertebral laminae -Cauda equina divided and lifted up by Spencer Wells forceps. -Not to twist or bend the spinal cord.
  • Advantages: -Pathological conditions like myelomeningocele, occipital encephalocele can be demonstrated.- -dissection can be limited up to the desired level and stopped.- -both anterior and posterior aspect of vertebra can be accessed.Disadvantages: -course of peripheral nerves cannot be pursued along its contiguity. -Embalming leakage -Cosmetic disadvantage.
  • Combinedapproach:- For complete removal of meningocele, myelomeningocele or other midline fusion defect-Body is turned back and incision is made around the desired area then continued anteriorly.
  • Thank you…