Case Report Delayed rupture of thoracic aorta aneurysm following a kick to the abdomen Antonio Oliva a , Fabio De Giorgio a, * , Sara Partemi a , Vincenzo L. Pascali a , Arnaldo Carbone b a Institute of Legal Medicine, Catholic University of the Sacred Heart (CUSH), School of Medicine, Lrgo Francesco Vito 1, Rome 00168, Italy b Department of Pathology, Center for High Technology Research and Education in Biomedical Sciences, Catholic University of the Sacred Heart (CUSH), Contrada Tappino, Campobasso, Italy article info Article history: Received 26 March 2008 Received in revised form 25 August 2008 Accepted 26 August 2008 Available online xxxx Keywords: Forensic science Forensic autopsy Aortic dissection Blunt chest trauma Manslaughter abstract Several theories have been proposed to explain the Blunt Traumatic Aortic Rupture (BTAR) because dif- ferent mechanical forces act on the aorta, at anatomically susceptible sites, including shearing, torsion and stretching, but the origin, transduction and relative importance of these forces remain uncertain. We report a case of a 74-year-old man injured by a kick to the abdomen. After 2 days he felt chest pain paroxysm and weakness in his left leg. The patient was admitted to an emergency care department where he experienced sudden and severe hemodynamic deterioration, dying rapidly. The autopsy, performed 3 days later, showed haemorragic infarction of hypogastric subcutaneous tissues and revealed an extended dissecting aneurysm of the thoracic aorta with following haemopericardium. In our case we considered that a low energy compression to the abdomen, in presence of underlying atherosclerosis, caused aortic dissection rather than rupture and then the 48 h time span after the traumatic event and the cardiac tam- ponade was enough to complete the aortic retrograde dissection. We finally emphasise the importance of the careful surveillance of any trauma close to the abdomen in view of initially unpredictable, as well as eventful injuries. The finding of early signs of neointima formation in thoracoabdominal portions of aortic dissection strongly supported our interpretation. The forensic interest of this case is correlated to the vol- untary character of the inflicted injury. The culprit was thus charged with manslaughter. Ó 2008 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Although many cases of direct aortic rupture due to blunt trau- ma have been reported [1–9], occurrence of the isolated phenom- enon of aortic dissection connected to a trauma is more uncommon [10–12] and spontaneous acute retrograde abdominal aortic dis- section is reported in the literature as an extremely rare event [13]. Wilson and Hutchins reported 204 cases of aortic dissection, but only three of these were the result of a trauma [14]. The mechanism of traumatic aortic dissection is acknowledged among clinical spe- cialists [10–12,15,16], but it has seldom been the subject of a foren- sic probe. This can of course occur when the phenomenon generates cardiac tamponade, occlusion of a coronary artery, or rupture into the chest/abdomen with following death of the victim [10]. The phenomenon of traumatic aortic dissection is now well acknowledged, as well as its diagnosis and treatment [3]. However, there remain uncertainties over the exact mechanisms involved in this rare form of injury. There also exist limit-cases in which only an isolated, mild trauma is only antecedent and the only plausible cause of extended sub-intimal, double-barrel tearing and there is of course interest in examining these cases in search of the most likely production mechanism. In this report we examine the unusual case of a 74-year-old male injured by a kick to the abdomen and who then died two days later, soon after admission to an emergency care department. In this case, obvious doubts had been initially cast over both the aftermath and its connection to the trauma that required accurate postmortem examination to deduce the most plausible succession of events: the apparently harmless trauma to the abdomen, with clinically mute sub-intimal vessel dissection, then delayed rupture of the aorta, massive bleeding into the pericardial cavity and death. We will describe the autopsy findings and finally emphasise the importance of the careful surveillance of any trauma close to the abdomen in view of initially unpredictable, as well as eventful injuries. 2. Case report A 74-year-old man was physically assaulted through a kick to the abdomen by his son who was a drug addict. Two days after the assault, he was brought by ambulance to the CUSH Emergency Department (ED) due to chest pain paroxism and weakness in his left leg. His blood pressure was 60/40 mmHg and heart rate 84/ min, though the former rose to 128/48 mmHg after the administra- tion of fluids. Computed tomography (CT) was planned. Meanwhile the patient was started on atropina with continuous ECG monitor- 1344-6223/$ - see front matter Ó 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2008.08.004 * Corresponding author. Tel.: +39 06 35507031; fax: +39 06 35507033. E-mail address: fabio.degiorgio@rm.unicatt.it (F. De Giorgio). Legal Medicine xxx (2008) xxx–xxx Contents lists available at ScienceDirect Legal Medicine journal homepage: www.elsevier.com/locate/legalmed ARTICLE IN PRESS Please cite this article in press as: Oliva A et al., Delayed rupture of thoracic aorta aneurysm following a kick to the abdomen, Leg Med (2008), doi:10.1016/j.legalmed.2008.08.004