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Thromboembolism
- 1. Thromboembolism Dr.Nafeeya Department of ForensicMedicine &Toxicology
- 2. Overview • Haemostasis • Briefabout Thrombus & Embolus • Various types • Pathogenesis • Gross & Histopathology findings
- 3. Normal haemostasis • Processof maintaining blood in a fluid ,clot free state in a normal vasculature & rapidly forming haemostatic plugs at the site of vascular injury . • The pathology opposite of haemostasis is thrombosis, emboli formation
- 4. Thrombosis - Pathogenesis 1.Prothrombotic effect 2. Antithrombotic effect 3. Fibrolytic effect
- 5. Role of endotheliumin hemostasis • Prothrombotic effects • Vwf – secreted by endothelium • TF (Tissue factor ) - activates extrinsic pathway • Pl.A – plasminogen activator
- 6. Fibrinolytic effect • Plasminogenactivators convert plasminogen to plasmin • Plasmin lyses Fibrin (& Fibrinogen) to degradation products which are soluble and are removed. Anti thrombotic effects PGI2 & Nitric oxide Heparin like molecule Thrombomodulin TFPI –tissue factor pathway inhibitor
- 7. Thrombosis - Definition •Thrombosis refers to the formation of thrombus within a vascular lumen, defined as an aggregate of coagulated blood containing platelets, fibrin, and entrapped cellular elements..
- 8. Thrombosis - arterial •Arterial thrombosis eg , myocardial infarction (1- cause of death). • stroke (2- cause of death), • or peripheral infarcts.
- 9. Thrombosis - Highrisk patients • Tissue damage (surgery, burns) • Prolonged immobilization • Myocardial infarction • Neoplasms ,Prosthetic heart valves • DIC (also increased risk of hemorrhage) Smokers Pregnancy/postpartum Oral contraceptives Hyperlipidemia Sickle cell disease Atrial fibrillation
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- 15. Mural Thrombus, Leftventricle
- 16. • Complications ofcardiac thrombosis – The major complication of thrombi in any location in the heart is the – detachment of fragments and their transport to distant sites (embolization), – where they lodge and occlude arterial vessels.
- 17. Thrombosis - venous Deepveins of the leg - most common site for thrombosis • Primarily due to sluggish blood flow • Prolonged immobilization. • This condition may cause swelling of the leg, or may be completely asymptomatic. • Complication - Pulmonary thromboembolism
- 18. Thrombosis, Femoral Vein,in situ
- 19. Thrombus, Femoral Vein,Recanalization
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- 21. Thrombosis - fateof thrombi • Propagation • Embolization • Dissolution (lysis by the thrombolytic system) • Organization and re-canalization
- 22. Embolism - Definition •Embolism is the passage through the venous or arterial circulations of any material capable of lodging in a blood vessel and thereby obstructing the lumen
- 23. Embolism-Types • Thromboembolism (mostcommon) • Fat embolism • Amniotic fluid embolism • Gas embolism • Cholesterol embolism • Septic embolism • Foreign body embolism • Bone marrow embolism
- 24. Embolism - Pulmonary •Source -deep leg veins - phlebothrombosis • Fate of pulmonary thrombo-emboli 1. Massive pulmonary embolism (saddle embolus), with ventricular fibrillation 2. Pulmonary infarction 3. Embolism without infarction 4. Paradoxical embolus- Intracardiac defect
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- 26. Fat Embolism • Seenafter fracture of long bones,soft tissue injury or burns • Fat embolism syndrome-symptomatic cases • Pulmonary insufficiency,neurological symptoms,anemia and thrombocytopenia • Diffuse petechial rash
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- 28. Sudan III staining •Frozen tissue sections • Small blood vessels & Capillaries Multiple fat emboli Lung tissue, kidney, brain, liver and pancreas Fat droplets stained orange
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- 34. Fat Embolism, Lung,Oil Red O
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- 36. Amniotic fluid embolism •Post partum complication-Condition in which amniotic fluid, fetal cells, hair or other debris enters the maternal circulation due to tear in amnion via placental bed. • C/f-sudden severe dyspnoea,cyanosis and shock,neurologic impairment • Cause-infusion of amniotic fluid into maternal circulation
- 37. Causes • Criminal abortion •1st and 2nd trimester abortions • Abdominal trauma • Amniocentesis • Immediate post partum • Normal labour & delivery •5-10% of maternal mortality •Cardiac arrest •Rapid respiratory failure.
- 38. Stains used • Alcianblue – detects mucin • H & E – routine staining • Attwood’s stain – stains keratin red and mucus turquoise blue • Lendrum stain ( contains Phloxine & Tartrazine ) – stains squames red • Sudan black or oil red – detects vernix caseosa
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- 43. References • K SN Reddy 34th edition - Essentials of Forensic Medicine and Toxicology • Anil aggrawal - Text book of Forensic Medicine and Toxicology Knights forensic pathology • Robbins & cotran basis of disease pathology. • Atlas of histology –Lippincotts williams &wikins Amniotic fluid embolism: Manjusha Viswanathan, International Journal of Reproduction, Contraception, Obstetrics and Gynaecology Viswanathan M et al. Int J Reprod Contracept Obstet Gynecol Forensic aspects of post-mortem histological detection of amniotic fluid embolism ,I. Sinicina , Springer- Verlag 2009 • Fat embolism, fat embolism syndrome and the autopsy, academic forensic pathology, 2019 • Pathogenesis of non-traumatic fat embolism, Geoffrey Hulman, the lancet, 1988 • Autopsy diagnosis of fat embolism syndrome, am J forensic med pathol & volume 32, number 3, september 2011