Stroke is a major cause of mortality and disability worldwide and represents an important category of sudden natural deaths encountered during medicolegal autopsy.¹⁻³ Cerebrovascular accidents encompass both ischemic infarctions and intracerebral haemorrhages resulting from interruption of cerebral blood flow or rupture of cerebral vessels.⁴⁻⁷

In forensic practice, fatal CVAs frequently pose diagnostic dilemmas. Victims often collapse suddenly, sustain falls, or present with external injuries raising suspicion of assault or accidental trauma.¹⁰⁻¹²,¹⁵⁻¹⁷ Delayed hospital deaths may be complicated by bronchopneumonia, pressure sores, and systemic infections, obscuring the primary pathology.²¹⁻²³ In decomposed bodies, recognition of cerebrovascular pathology becomes even more challenging.²⁴

Indian literature predominantly focuses on epidemiological aspects of stroke, whereas studies addressing the medicolegal implications of fatal CVAs remain scarce.¹³,¹⁴ The present study was undertaken to evaluate the spectrum of medicolegal challenges encountered during autopsy diagnosis of fatal cerebrovascular accidents.

MATERIALS AND METHODS

Study Design

Retrospective descriptive study.

Study Setting

Medicolegal autopsies performed at tertiary care centres of Eastern India.

Study Period

Cases included in the present series spanned multiple years represented in the autopsy records reviewed.

Study Population

Twenty-three medicolegal autopsies diagnosed as fatal cerebrovascular accidents.

Inclusion Criteria

• Autopsy-confirmed fatal cerebrovascular accidents.
• Ischemic cerebral infarctions.
• Intraparenchymal haemorrhages.
• Cases referred as medicolegal deaths.

Exclusion Criteria

• Purely traumatic intracranial haemorrhages without evidence of primary cerebrovascular disease.
• Incomplete autopsy records.

Variables Studied

• Age and sex.
• Circumstances preceding death.
• Survival interval.
• Type of cerebrovascular lesion.
• Brain regions involved.
• External injuries.
• Internal traumatic findings.
• Pulmonary complications.
• Cardiovascular pathology.
• Associated renal findings.
• Diagnostic challenges.

Statistical Analysis

Data were entered into Microsoft Excel and analysed using descriptive statistics. Frequencies and percentages were calculated.

RESULTS

A total of 23 medicolegal autopsies of non-traumatic fatal intracranial haemorrhage were analysed. Males constituted the majority (56.5%), with a male-to-female ratio of approximately 1.3:1. The age of the deceased ranged from 29 to 85 years, with the highest frequency observed in the 61–80-year age group (47.8%).

Table 1. Demographic Characteristics and Circumstances of Fatal Intracranial Haemorrhage Cases (n = 23)

More than half of the decedents (52.2%) developed sudden neurological deterioration or collapse, while 34.8% experienced falls following the onset of symptoms. One case involved a pregnant woman presenting with abdominal pain and subsequently found to have fatal intracranial haemorrhage.

Deep intraparenchymal haemorrhage was the predominant autopsy finding (65.2%). Extension into subdural or subarachnoid spaces was observed in 26.1% of cases, whereas two cases demonstrated liquefactive necrosis consistent with older cerebrovascular events.

Table 2. Spectrum of Intracranial Haemorrhagic Lesions Identified at Autopsy (n = 23)

External injuries were absent in nearly half of the cases (47.8%). Where present, the injuries were generally minor and compatible with secondary impact during collapse rather than primary traumatic mechanisms.

Associated systemic pathology was common. Cardiovascular abnormalities, including left ventricular hypertrophy, atherosclerosis, valvular thickening, and vascular sclerosis, were present in 78.3% of cases. Renal changes suggestive of chronic hypertensive disease were observed in 82.6%, and pulmonary pathology such as oedema, consolidation, or bronchopneumonia was identified in 65.2%.

Table 3. Medicolegal Challenges and Associated Autopsy Findings in Fatal Intracranial Haemorrhage (n = 23)

DISCUSSION

The present study highlights the unique medicolegal dimensions of fatal cerebrovascular accidents.

A notable finding was the frequent occurrence of falls preceding death. Similar observations have been reported previously, where sudden neurological compromise predisposes patients to collapse and secondary injuries.¹⁹,²⁰,²⁹ Such injuries may be misinterpreted as evidence of assault if the underlying pathology is overlooked.¹⁰⁻¹²,¹⁵⁻¹⁷

The coexistence of abrasions, bruises, black eyes, scalp contusions, and even cranial fractures underscores the importance of careful interpretation. In the present series, traumatic findings often represented consequences rather than causes of the fatal event.

Delayed hospital deaths introduced additional complexity. Bronchopneumonia, pressure sores, and pulmonary complications reflected prolonged survival following the initial cerebrovascular insult, findings that are well documented in previous studies.²¹⁻²³ Failure to recognize these secondary changes may divert attention from the primary diagnosis.

Batchelor et al. reported falls as a frequent complication among stroke survivors, a finding comparable to the present series where several individuals sustained secondary traumatic injuries following neurological collapse.²⁰ Similarly, Langhorne et al. identified respiratory infections as important contributors to post-stroke morbidity and mortality, which is consistent with the bronchopneumonia observed in our delayed deaths.²¹

Cardiovascular abnormalities, particularly left ventricular hypertrophy and coronary sclerosis, were common. These findings support the established association between hypertension, atherosclerosis, and fatal stroke described in standard pathology literature.⁸,⁹

The study also emphasizes the importance of thorough examination of decomposed bodies. Recognition of residual pathology in decomposed remains continues to be an important challenge in forensic practice.²⁴

The principal contribution of this study lies in demonstrating that fatal CVAs frequently masquerade as unnatural deaths, necessitating meticulous autopsy examination and clinicopathological correlation.¹⁵⁻¹⁷,²⁵

LIMITATIONS

• Small sample size.
• Retrospective study design.
• Single geographical region.
• Lack of histopathological examination in all cases.
• Limited clinical and radiological correlation.

CONCLUSION

Fatal cerebrovascular accidents represent an important cause of medicolegal autopsy referrals. Sudden collapse, falls, secondary traumatic injuries, delayed complications, and decomposition frequently obscure the underlying natural disease process. Awareness of these diagnostic pitfalls, combined with systematic autopsy examination, is essential to distinguish natural cerebrovascular deaths from traumatic fatalities and to formulate accurate medicolegal opinions.

ACKNOWLEDGEMENTS

The authors acknowledge the Department of Forensic Medicine and Toxicology and the medico-legal staff involved in maintaining autopsy records.

CONFLICT OF INTEREST

None declared.

FUNDING

No external funding was received.

ETHICAL CONSIDERATIONS

The study utilised medicolegal autopsy records and adhered to prevailing ethical principles governing biomedical and health research.²⁷

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