The Medicolegal Evaluation of Fatal Pulmonary Thromboembolism

Abstract

Deaths resulting from pulmonary emboli are common. The autopsy dissection, documentation, and ancillary studies pertaining to pulmonary emboli are important components of evaluating such fatalities. The detection of a saddle embolism at autopsy does not signify the end of the investigation because the underlying risk factors still may need to be determined. The gross, microscopical, and genetic findings can distinguish various thrombotic risk factors and etiologies. Because deaths caused by pulmonary emboli may involve medicolegal issues, a dependable protocol is needed for their investigation. In particular, the timing of a pulmonary embolism may have important medicolegal consequences. Because of the pathophysiology and propagation of a thrombus, one may see a broad histological range of thrombosis and organization. Histological examination of residual deep vein thrombus provides the best opportunity to properly age the thrombus. Understanding the pathogenesis and pitfalls of venous thromboembolism allows the pathologist to properly certify the proximate cause of death. Currently, there are DNA techniques that allow for the postmortem diagnosis of some hereditary thrombophilias. These include factor V, prothrombin, and methylenetetrahydrofolate reductase mutations. Decedents who are candidates for these tests include those who are younger than 45 years of age; those whose deaths were related to pregnancy; those with a history of recurrent or unexplained stillbirths, oral contraceptive pill use, hormone replacement, or treatment with chemotherapy; those with weak risk factors (long car ride, flights, obesity); or those with deep venous thrombosis of undetermined etiology. These tests benefit the investigator, who is attempting to discern the proximate cause, and potentially the surviving family members.