Chapter 11 - Vascular diseases of the central nervous system

Abstract

With the very high prevalence of strokes and other cerebro-vascular diseases (CVD) in the US population, it is inevitable that a significant percentage of cases referred for forensic investigation have CVD as the primary or contributory cause of death. However, cerebro-vascular disease is still by far the most common neurologically disabling and lethal disorder in the United States, with atherosclerosis and hypertension as the major predisposing causes of stroke. Strokes are the fourth leading cause of death in the United States. Nevertheless, depending on circumstances, only a relatively small fraction of strokes become the subject of forensic investigation. Hypertensive cerebral hemorrhages have their favored anatomic sites. Common sites are putamen and thalamus, lobar white matter, cerebellum, and pons. Clearly, the volume of hemorrhage is an important, but not the only, determinant of outcome, and those cases referred to the medical examiner usually have large hemorrhages. In this chapter, the emphasis is on the presence of severe bilateral thalamic lesions in some cases. Three major topographic patterns of cerebral injury, or some combination thereof, may result in a persistent vegetative state such as widespread and bilateral cerebral cortical damage; extensive bilateral involvement of intra- and subcortical connections of the cerebral hemispheric white matter and bilateral severe thalamic involvement.