第二十章猝死------------------------------------------------------教学纲要教学要求1．掌握：猝死的概念及其特点；猝死的法医学鉴定及注意事项；冠状动脉粥样硬化性心脏病、高血压性心脏病病理变化、猝死机制及法医学鉴定；脑血管疾病、癫痫、颅内肿瘤病理学变化、猝死机制及法医学鉴定；支气管哮喘病理变化、猝死机制及法医学鉴定；急性出血坏死性胰腺炎的病理学变化、猝死机制及法医学鉴定；青壮年猝死综合征、婴幼儿猝死综合征猝死机制及法医学鉴定；羊水栓塞症病理学变化、猝死机制及法医学鉴定。

2．熟悉：猝死常见的原因；心瓣膜病、心肌病、病毒性心肌炎、肺动脉栓塞、传导系统性疾病、主动脉瘤的病理学变化、猝死机制及法医学鉴定；流行性脑脊髓膜炎、流行性乙型脑炎的病理学变化、猝死机制及法医学鉴定；肺炎、肺气肿和气胸的病理学变化、猝死机制及法医学鉴定；急性消化道出血、急性胃扩张及胃破裂、急性弥漫性腹膜炎的病理学变化、猝死机制及法医学鉴定；糖尿病猝死机制；抑制死猝死机制及法医学鉴定。

3．了解：冠状动脉口狭窄、Marfan综合征、克山病病理学变化及鉴定要点；宫外孕、妊娠高血压综合征概念；低血糖症、嗜细胞瘤、原发性慢性肾上腺皮质功能减退症的概念和猝死机制；急性喉阻塞猝死机制及法医学鉴定。

19【教学内容】第一节概述一、猝死的特征二、猝死的诱发因素三、猝死发生的内、外条件因素四、猝死的病因五、猝死的法医学鉴定意义六、猝死的法医学鉴定注意事项第二节心血管疾病猝死一、冠状动脉粥样硬化性心脏病二、冠状动脉口狭窄三、主动脉瘤四、病毒性心肌炎五、心肌病六、克山病七、Marfan综合症八、肺动脉栓塞九、心脏传导系统疾病十、高血压性心脏病第三节中枢神经系统疾病猝死一、脑血管疾病二、颅内肿瘤三、癫痫四、病毒性脑炎五、流行性脑膜炎第四节呼吸系统疾病猝死一、急性喉阻塞二、肺气肿和气胸三、支气管哮喘四、肺炎第五节消化系统疾病猝死一、急性消化道出血二、急性腹膜炎三、急性出血性坏死性胰腺炎四、急性胃扩张及胃破裂第六节泌尿、生殖系统疾病猝死一、异位妊娠二、妊娠高血压综合征三、羊水栓塞第七节内分泌系统疾病猝死一、糖尿病二、低血糖症三、嗜铬细胞瘤四、原发性慢性肾上腺皮质功能减退症第八节免疫系统异常所致猝死一、过敏性猝死第九节其它猝死一、青壮年猝死综合征二、婴幼儿猝死综合征三、抑制死第一部分习题集一、单项选择题1、在成人猝死的统计数中，（）占首位A、心血管系统疾病B、呼吸系统C、神经系统疾病D、内分泌器官疾病2、（）目前是心血管系统疾病中对人类生命健康危害性最大的疾病，同时也是心血管系统疾病中发生猝死最常见的疾病A、高血压性心脏病B、原发性心肌病C、冠状动脉粥样硬化性心脏病D、主动脉夹层动脉瘤3、冠脉粥样硬化病变的总检出率以（）最高A、左主干B、前降支C、左旋支D、后降支4、根据冠状动脉内膜增厚并突向管腔的程度可将冠状动脉粥样硬化分为Ⅳ级，Ⅲ级管腔狭窄程度在（）A、25%B、25%－50%C、51%－75%D、75%以上5、肌梗死的病灶一般需要（）小时后肉眼方可辨认，初始梗死病灶为灰白色，与周围边界不清A、10B、6C、7D、36、正常成年人左、右冠脉开口直径分别为（）A、4－8mm；2－5.5mmB、3－6mm；3－5.5mmC、4－6mm；3－5.5mmD、4－6mm；4－6.5mm7、左冠脉开口直径小于小于（）为明显狭窄A、1mmB、2mmC、3mmD、48、冠状动脉开口直径小于（）mm时即可判定为冠状动脉开口处狭窄A、1mmB、1.5mmC、2mmD、2.5mm9、（）是主动脉瘤最常见的原因之一A、主动脉粥样硬化B、家族遗传性C、弹性蛋白减少D、外伤10、肥厚型心肌病室间隔显著增厚, 室间隔与左心室壁厚度比值由正常的0.95增加到（）以上A、1.0B、1.2C、1.5D、1.811、肺动脉栓塞95%的栓子来源于（）内大块性血栓A、下肢静脉B、心脏附壁血栓C、脑血栓D、胃肠道血栓12、脑血管疾病中最常见的是（）A、脑血管畸形B、动脉瘤C、脑栓塞D、动脉粥样硬化13、有关统计资料显示脑动脉血栓的发生率最高的为（）A、大脑中动B、颈内动脉C、大脑后动脉D、基底动脉14、（）为颅内最多见的肿瘤之一A、多形性胶质细胞瘤B、少突胶质细胞瘤C、血管瘤D、星形胶质细胞瘤15、病毒性脑炎以（）为重A、脑白质B、脑皮质C、小脑D、垂体16、异位妊娠以（）妊娠为最常见A、输卵管B、卵巢妊娠C、腹腔妊娠D、阔韧带妊娠二、多项选择题1、猝死应具有的特征为（）A、死亡的急骤性B、死亡的意外性C、疾病的潜在性D、疾病的必然性2、猝死的诱发因素包括（）A、精神、心理因素B、外伤C、热冷刺激D、过度疲劳3、心肌梗死可分为一下几种类型（）：A、薄层梗死型B、穿透梗死型C、厚层梗死型D、透壁梗死型4、心肌梗死的并发症包括（）A、心脏破裂B、乳头肌断裂C、室壁瘤D、附壁血栓形成和栓塞5、冠心病猝死的发生机制包括（）A、心率失常B、植物神经系统功能障碍C、急性心力衰竭D、室壁瘤形成 E、冠状动脉痉挛6、先天性脑血管畸形破裂出血包括（）A、动静脉畸形B、毛细血管扩张症C、海绵状血管瘤D、静脉性血管瘤三、名词解释1、猝死（sudden unexpected natural death）2、猝死综合症（sudden death syndrome）3、心肌梗死（myocardial infarction）4、冠状动脉口狭窄（stenosis of coronary ostia ）5、主动脉瘤（aortic aneurysm）6、真性动脉瘤7、假性动脉瘤8、主动脉夹层(aortic dissection)9、扩张型心肌病（dilated cardiomyopathy）10、肥厚型心肌病（hypertrophic cardiomyopathy）11、限制性心肌病（restrictive cardiomyopathy）12、脑梗死13、癫痫（epilepsy）14、肺气肿（pulmonary emphysema）15、食管贲门粘膜撕裂综合征（Mallory-Weiss综合征）16、异位妊娠（ectopic pregnancy）宫外孕（extrauterine pregnancy）17、妊娠高血压综合征（pregnancy-induced hypertension syndrome, PIH）18、羊水栓塞（amniotic fluid embolism）19、低血糖症（hypoglycemia）20、青壮年猝死综合征（sudden manhood death syndrome，SMDS）21、婴幼儿猝死综合征（sudden infant death syndrome，SIDS）22、嗜铬细胞瘤（pheochromocytoma）23、过敏性猝死（sudden death from hypersensitivity）四、问答题1、试描述心肌梗死的病理变化2、试述冠心病猝死的法医学鉴定要点3、试述冠心病猝死的法医学鉴定要点4、状动脉口狭窄猝死的鉴定要点5、动脉瘤及主动脉夹层的法医学鉴定6、病毒性心肌炎的法医学鉴定7、心脏传导系统疾病猝死的法医学鉴定8、高血压的病理学改变特点9、高血压猝死法医鉴定要点10、病毒性脑炎的病理学改变11、肺炎猝死的法医学鉴定12、重度妊高征猝死机制及法医学鉴定要点13、羊水栓塞的法医学鉴定14、过敏性休克死亡的法医学鉴定要点15、青壮年猝死综合征的法医学鉴定要点五、案例分析六、英文翻译Sudden cardiac death associated with a coronary artery anomaly considered benign1. IntroductionCoronary artery anomalies (CAAs) have an incidence variable between0.6 and 1.6% and represent 0.1–2% of all congenital cardiac conditions worldwide. In the last two decades, the most frequent use of coronary angiography has allowed to recognize a growing number of these anomalies, even if most of them occur asymptomatically and, are occasionally discovered only at the time of autopsy.Otherwise, myocardial ischemia, syncope and sudden death can be the first manifestation of these abnormalities. Clinical events are related to the type of anomaly and to the anatomical course of the artery in relation to the aorta and the pulmonary trunk.We report the case of sudden death in a young man where a separate origin of the left anterior descending (LAD) and circumflex (Cx) coronary artery from the left sinus of Valsalva was found at autopsy. The pathological findings and the pathogenetic hypothesis are discussed.2. Case reportA caucasic 24-year-old man was found collapsed at the bottom of a swimming pool during a party. Cardiopulmonary resuscitation was unsuccessful. Medico-legal autopsy and toxicological analysis were performed in our Forensic Department. The external examination of the cadaver did not reveal any sign of disease or traumatic lesions. On gross inspection, accurate heart examination revealed the presence of a separate origin of the LAD and Cx coronary artery from the left sinus of Valsalva.In particular, LAD passed between the aorta and the pulmonary trunk. Moreover, the septum and the left ventricular anterior wall appeared to have a pale color. Histological sections obtained from these areas showed a thickened endocardium with areas of fibrosis, suggesting a chronic ischemic damage. A right coronary artery arose from its normal origin with a regular course. Examination of the other organs was negative except for pulmonaryoedema and a remarkable polyvisceral stasis. Other death causes were excluded, in particular no signs of drowning were found. The toxicologic investigations were positive for a blood concentration of alcohol of 1.63 g/l.3. DiscussionCAAs are classified into 4 categories according to angiographic appearance and clinical significance: benign (class I), relevant — associated with fixed myocardial ischemia (class II); severe —related to sudden death (class III); and critical —associated with superimposed coronary artery disease (CAD) (class IV). In particular, a separate origin of the LAD and Cx coronary arteries from the left sinus of Valsalva was considered as a benign variant (class I). Indeed, sudden death attributable to this condition has not been ever reported until now. Most of CAAs are discovered as incidental findings during coronary arteriography or, as in our case, at autopsy. However, some anomalies may present with symptoms such as: angina pectoris, myocardial infarction, syncope, cardiac arrhythmias, congestive heart failure. Sudden death may be sometimes the first manifestation of these abnormalities.In the present case, the interarterial course of the LAD may be identified as the underlying cause of ischemia secondary to aortic or pulmonary artery dilatation, in particular during exercise, as this coronary artery could be susceptible to kinking and obstruction, particularly with enlargement of the aorta and pulmonary artery. More in detail, sudden death observed in our case could be related to a cardiac arrhythmia sustained by myocardial hypoxia in consequence of the strenuous efforts of the victim floating in the swimming pool. Furthermore, the high blood concentration of alcohol, proved by toxicological analysis, could have played a collateral/synergic effect as there is evidence that heavy alcohol consumption can cause sudden death due to arrhythmias and cardiomyopathies4. ConclusionsTo our knowledge this is the first report of sudden death attributable to the separate origin of LAD and Cx from the left sinus of Valsalva. Thus, this anomaly should no more be considered as a benign condition since in presence of interarterial course of LAD it could provoke chronic myocardial ischemic damage responsible of potentially fatal arrythmias. As most of the coronary artery anomalies are discovered incidentally during non-invasive imaging, these observations could have important implications in clinical evaluation for physicians dealing with these patients.第二部分参考答案一、单项选择题参考答案1、A2、C3、B4、C5、B6、C7、B8、D9、A10、B 11、A 12、D 13、A 14、D 15、A 16、A二、多项选择题参考答案1、ABC2、ABCD3、ACD4、ABCD5、ABCDE6、ABCD三、名词解释参考答案1、猝死（sudden unexpected natural death）是由于机体潜在的疾病或重要器官急性功能障碍导致的意外的突然死亡。