33A

Forensic pathology The

neuropathology of head
injury
Paragraph
FORENSIC PATHOLOGY THE NEUROPATHOLOGY OF
HEAD INJURY.................................................................................
Anatomy of the brain..........................................................................
Head injury .........................................................................................
Introduction ....................................................................................
Lesions of the scalp.......................................................................
Skull fracture ..................................................................................
Contusion and laceration of the brain ...........................................
Intracranial haemorrhage...............................................................
Extradural haematoma ..............................................................
Acute subdural haematoma ......................................................
Chronic subdural haematoma ...................................................
Intracerebral haematoma ..........................................................
Subarachnoid haemorrhage ......................................................
Vertebral artery trauma ..................................................................
Carotid artery trauma.....................................................................
Traumatic pontomedullary laceration.............................................
Cranial nerve damage ...................................................................
Hypothalamic and pituitary gland damage ....................................
Diffuse axonal injury ......................................................................
Ischaemic brain damage................................................................
Brain swelling.................................................................................
Diffuse vascular injury....................................................................
Fat embolism .................................................................................
Outcome following blunt head injury .............................................
Infection .....................................................................................
Severe disability and the vegetative state ................................
Traumatic epilepsy.....................................................................
Dementia ...................................................................................
Non-accidental injury in children....................................................
Missile head injury .........................................................................

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Glossary
abrasion injury of the superficial layers of the skin only (graze or scratch).
abscess (brain abscess) localised infection within the brain substance.
air sinuses spaces within the skull bones that are continuous with the air passages.
Includes nasal sinuses.
amnesia loss of memory.
aneurysm a swelling or abnormal dilatation of the wall of a blood vessel.
aneurysm an aneurysm is a focal dilation of the lumen of a vessel or of the heart. A true
aneurysm (as compared to a pseudoaneurysm) will have thinned out or degenerated remnants
of the original parent structure layers (ie, arterial intima, media or myocardium) in the wall
of the aneurysm.
angiography visualisation of blood vessels by radiography after injection of radio-opaque
dye into blood vessel.
anterior towards the front.
aphasia defect in speech due to brain damage.
apnoea transient cessation of respiration, whether normal (as in hibernating animals) or
abnormal.
arachnoid mater or arachnoid meningeal (membrane) covering of the brain between
dura mater and pia mater.
arteries high pressure blood vessels carrying oxygenated blood from the heart to the
organs of the body.
autopsy the preferred term for the post-mortem examination of a body undertaken, inter
alia, to identify the disease processes present in the deceased.
axon the long process of a nerve cell with synapses with another nerve cell or muscle.
axonal swelling swelling occurring on an axon.
basal ganglia structure composed of nerve cells deep within the cerebral hemispheres.
basal skull fracture fracture involving base of skull.
battered baby syndrome syndrome characterised by repeated infliction of injuries to a
young child over a period of time.
berry aneurysm see saccular aneurysm.
blood vessels the flexible tubes and pipes which carry blood around the body.

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brainstem part of the brain at the base. Consists of medulla, pons and midbrain, which
connects it to the spinal cord. It contains vital centres for breathing and heart function.
bruise the presence of blood in tissues as a consequence of ruptured blood vessels.
burst lobe the occurrence of cerebral contusion, subdural haemorrhage and haemorrhage
in white matter at the same site.
cardiac referring to the heart or a part of an organ nearest the heart.
cardiac of, relating to, situated near, or acting of the heart; of, relating to, or affected
with heart disease.
cerebellar tonsillar herniation herniation of part of the cerebellum downwards through
the foramen magnum.
cerebellum part of the brain at the base involved with movement and co-ordination.
cerebral atrophy wasting of the cerebral hemispheres.
cerebral oedema swelling of the brain.
cerebrospinal fluid fluid made in the ventricles of the brain which flows over the surface
of the brain.
cerebrovascular incident usually sudden occurence of or involving a disturbance
involving the brain and the blood vessels supplying it.
cervical spinal cord spinal cord in the neck.
cervical spine spine in the neck.
chronic subdural haematoma subdural haematoma that has been present for weeks or
longer.
circle of Willis circle of arteries at the base of the brain joining arteries which supply the
brain with blood.
compound fracture bone fracture with overlying skin (including scalp) laceration.
concussion transient loss of awareness and memory or transient loss of consciousness due
to head injury.
contrecoup contusion contusion of the brain occurring at a site remote from site of
impact.
contrecoup fracture fracture occurring remote from the site of impact.
contusion see bruise.
coronial autopsy an autopsy conducted under the authority of a coroners request or
order.
corpus callosum the part of the brain joining the cerebral hemispheres.
coup contusion contusion occurring at the site of impact without fracture.
cranial nerves nerves that arise from the brainstem and base of brain.
craniotomy operation usually involving opening the skull.

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GLOSSARY

death a process involving the ceasing of vital physiological functions of the cells, tissues,
and organs of the body and the integration of these activities.
dementia syndrome characterised by progressive loss of cognitive functions.
depressed skull fracture fracture characterised by depression of bone into the skull
cavity.
depression a reduction in functional activity, amount, quality or force.
diffuse axonal injury diffuse damage to axons.
diffuse hypoxic brain damage diffuse brain damage due to hypoxia.
diffuse vascular injury diffuse damage to blood vessels.
disruption the act or process of breaking apart or rupturing.
dura mater or dura the outermost meningeal covering of the brain tightly adherent to
the skull.
dysfunction, disfunction impaired or abnormal functioning.
extradural haematoma collection of blood between skull and dura.
extradural heat haematoma haematoma occurring between the skull and dura due to
heat.
fat embolism passage of fat along blood vessel causing obstruction.
fissure fracture of skull fracture characterised by crack or split in skull.
foramen magnum hole in the base of the skull through which the cervical spinal cord
passes.
forensic generally, relating to the law; jurisprudentially, relating to the courts.
forensic autopsy see coronial autopsy.
fracture contusions contusions occurring at the site of a fracture.
frontal lobes the frontal part of the cerebral hemispheres.
Glasgow coma scale a clinical score which is commonly used to assess the severity of
any state of profound consciousness caused by disease, injury or poison. The maximal
achievable score is 15, the minimal score is 3.
gliding contusions traumatic haemorrhages occurring in the white matter at the top of the
brain.
growing fracture skull fracture occurring in infancy associated with the insertion of brain
and meninges between the edges of the fracture preventing the fracture healing.
gyrus convolution or raised elongated part of the cerebral hemisphere bounded by
grooves in the brain (sulci).
haematoma collection of blood, haemorrhage (see bruise).
haemorrhage the action of bleeding. See also bruise.
hemiparesis one sided paralysis.

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herniation protrusion of part of the brain into another compartment within the skull.
hinge fracture fracture dividing the skull base into halves (the fracture acts as a hinge in
the post mortem setting).
hippocampus part of the brain involved in controlling various functions and activities
involved in emotional states, and memory.
hydrocephalus enlargement or dilatation of the ventricles of the brain.
hyperkalemia the presence of an abnormally high concentration of potassium in the
blood. Potassium is an important electrolyte.
hypertension abnormally high arterial blood pressure. Also used to describe a systemic
condition resulting from hypertension that is either symptomless or may be accompanied by,
inter alia, dizziness or headache.
hypertensive haemorrhage haemorrhage occurring in the brain substance due to high
blood pressure.
hypokalemia the presence of an abnormally low concentration of potassium in the blood.
Potassium is an important electrolyte.
hypotension low blood pressure.
hypotension abnormally low arterial blood pressure, also called low blood pressure.
hypothalamus part of the brain which secretes hormones that act on the pituitary gland
causing it to release particular hormones.
hypoxia decreased oxygen in the blood.
infarction death of tissue due to interference with the blood supply.
infarction the process of forming an area of necrosis in a tissue or organ resulting from
ischaemia within the local circulation, such as obstruction by a thrombus or embolus, or
compression of the vessel, or any other condition which may cause ischaemia.
internal carotid arteries arteries in the neck supplying blood to the brain.
intracerebral haematoma haematoma within brain substance.
intracranial within the skull.
intracranial haemorrhage haemorrhage occurring within the skull. Includes extradural
and subdural haematoma, subarachnoid, intracerebral and intraventricular haemorrhage.
laceration a tear or split in the skin or other organ usually resulting from a blunt impact.
laceration tear or split in tissue.
lateral relating to structures further away from the midline plane of the body.
lesion general term indicating a physically discrete pathological entity.
medial relating to structures closer to the midline plane of the body.
medulla part of the brainstem.
meninges the coverings of the brain.
meningitis inflammation of the meninges, usually due to infection.

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GLOSSARY

microcephaly small head.

midbrain part of the brainstem.
multicystic encephalopathy multiple cysts within the brain.
neuroendocrine of, relating to, or being a hormonal substance that influences the activity
of nerves.
neuron nerve cell.
non-accidental injury injury occurring in children (or adults) due to assault.
osteomyelitis of the skull infection of the skull bone.
pathology the study of disease.
penetrate enter but does not pass through.
penetrating fracture fracture with dural and scalp laceration.
perforate enter and exit.
pia mater or pia innermost meningeal covering of the brain.
pituitary part of the brain that releases hormones which act on other glands of the body.
pole (as in frontal pole) the very front part of the frontal lobe.
pons part of the brainstem.
posterior towards the rear.
posterior cerebral artery one of the arteries at the base of the brain supplying the back
part of the brain.
posterior fossa compartment of the skull containing the cerebellum and brainstem.
pus liquid product of the bodys response to injury, consisting of dead tissue,
polymorphonuclear leukocytes and serum.
quadriplegia paralysis of both arms and legs.
ring fracture fracture occurring in a ring around the foramen magnum.
rupture the tearing apart of a tissue.
saccular aneurysm pathological outpouching of blood vessel wall. In relation to the brain
these most commonly occur on the arteries of the circle of Willis.
secondary brainstem haemorrhages haemorrhages in brainstem occurring secondary to
expanding lesions in cerebral hemispheres or cerebral oedema.
shaken baby syndrome syndrome in infants characterised by retinal, subdural and/or
subarachnoid haemorrhage due to severe shaking.
subarachnoid haemorrhage haemorrhage beneath the arachnoid, ie, between arachnoid
and pia arachnoid.
subdural empyema pus within the subdural space.
subdural haematoma collection of blood beneath dura.

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subfalcine herniation herniation of part of the brain beneath the falx.

sulcus groove in a cerebral hemisphere.
tear to wound by or as if by pulling apart by force.
temporal lobes part of the cerebral hemispheres related to the temporal region.
tentorial herniation herniation of part of the brain downwards past the tentorium, due to
expanding lesions within the skull or raised intracranial pressure.
tentorium that part of the dura that overlies the cerebellum.
transcalvarial herniation herniation of part of the brain through a skull defect.
tumour an abnormal mass of tissue that is not inflammatory, arises from cells of
pre-existent tissue, and serves no useful purpose. Tumours can be classified as benign or
malignant.
vegetative state clinical state characterised by unconsciousness and involuntary function.
venous sinuses spaces within the dura into which blood from the brain drains before
returning to the heart.
ventricles (cerebral) spaces within the brain through which cerebrospinal fluid flows.
vertebral arteries arteries in the soft tissues and spine of the neck supplying blood to the
brain.
wound disruption in the integrity of an organ or tissue. Jurisprudentially, a full thickness
defect of the skin.

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33A
Forensic pathology The
neuropathology of head
injury
by

Kenneth Opeskin MBBS, FRCPA

[The authors would like to thank Melbourne University Press
and Professor V D Plueckhahn for permission to use extracts
from Ethics, Legal Medicine and Forensic Pathology (2nd ed)
by V D Plueckhahn and S M Cordner (1991), and Melbourne
University Press for permission to use extracts from Forensic
Medicine and the Law by D L Ranson (1996).]

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Author information
Kenneth Opeskin is the Consultant Forensic Neuropathologist of the Victorian Institute of
Forensic Medicine, Honorary Senior Lecturer in the Department of Forensic Medicine at
Monash University, Victoria.
Kenneth Opeskin is a Fellow of the Royal College of Pathologists of Australasia and is a
member of the following societies: American Academy of Forensic Science (associate
member), Australian New Zealand Forensic Science Society, and International Academy of
Pathology.
Kenneth Opeskin has published numerous scientific papers in the fields of forensic pathology
and neuropathology.

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FORENSIC PATHOLOGY THE

NEUROPATHOLOGY OF HEAD INJURY
Anatomy of the brain
[33.1500] The brain sits within the skull and consists of two cerebral hemispheres, two
lobes of the cerebellum and the brainstem composed of medulla, pons and midbrain. Each
cerebral hemisphere is divided into a number of lobes called the frontal, temporal, parietal and
occipital lobes. The posterior fossa is one compartment within the skull and encloses the
cerebellum and brainstem. The medulla is continuous with the cervical spinal cord. The hole at
the base of the brain through which the upper cervical cord passes is called the foramen
magnum. Twelve pairs of cranial nerves involved in various bodily functions arise from the
brainstem and base of brain.
The cerebral hemispheres consist of external grey matter and internal white matter. The grey
matter consists mainly of nerve cell (neuron) bodies whereas the white matter consists mainly
of nerve cell processes (axons) and supporting cells.
The internal part of the cerebral hemispheres contain deep grey matter structures called the
basal ganglia. The brainstem contains vital centres controlling breathing and heart function.
The internal part of the brain also contains spaces called ventricles which are filled with
cerebrospinal fluid which flows through the ventricles and into the subarachnoid space over the
surface of the brain.
The brain and spinal cord are surrounded by meninges. The meninges consist of three layers,
the outermost one of which is the toughest and is attached firmly to the skull being called the
dura mater or dura. The next inner layer is the arachnoid. The innermost layer is the pia which
immediately overlies the brain.
The brain is supplied by blood from the internal carotid and vertebral arteries. These arteries
join a circle of blood vessels at the base of the brain called the circle of Willis. Once blood has
been supplied to the brain it drains from there into spaces within the dura (venous sinuses) and
thence into major veins to return to the heart. Figure 2 [33.2700], a photograph of the base of
the skull, shows the anterior, middle and posterior cranial fossae, the foramen magnum and
cervical spinal cord. Figure 3 [33.2710], a side view of the brain, shows the frontal and
temporal lobes, brainstem, cerebellum and spinal cord. Figure 4 [33.2720], a photograph of the
base of the brain, shows the base of the frontal and temporal lobes, pons, medulla, cerebellum,
cervical spinal cord, olfactory nerves and internal carotid arteries.

Head injury
INTRODUCTION
[33.1510] Head injury is characterised by the initial injury, the effects of which may be
delayed. In addition complications of the head injury may ensue, including raised intracranial
pressure, inadequate blood flow (ischaemia), infection, seizures and effects on other parts of

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the body. Often there are co-existing injuries or disease in other parts of the body which may
aggravate the injury or its complications even further. The ultimate outcome depends on
whether any or all of these factors actually occur, and if so, the interaction with each other.
Brain damage may be focal or diffuse. Diffuse brain damage includes axonal injury, hypoxic
damage, brain swelling and vascular injury to be described later: see below [33.1670],
[33.1690], [33.1700]. Diffuse axonal injury is considered to be the cause of concussion and
unconsciousness that occurs immediately from the time of head injury. It is possible for some
types of brain damage to occur in isolation. However, multiple types of damage frequently
occur within the one brain. Mechanisms of damage in head injury include direct application of
blunt force (eg, a blow to the head), acceleration/deceleration applied to the head without
impact (eg, a severe shaking of the head) or a combination of the two. Blunt head injury refers
to head injury resulting from the application of blunt force and may be due to assault, motor
vehicle accidents or falls. The head is commonly injured in assaults due to blunt trauma
directly applied with or without subsequent impact with the ground as an additional factor.
A discussion of types of focal and diffuse brain damage follows. These may be associated with
secondary effects including raised intracranial pressure. An understanding of this therefore is
critical to an understanding of the effects of these lesions within the skull. Raised pressure
within the skull (raised intracranial pressure) due to an expanding lesion or brain swelling may
result in various types of brain herniation. Herniation in this context refers to protrusion of part
of the brain into another compartment within the skull. Figure 5 shows the brain in relation to
the dura and skull and the herniations that may result from raised intracranial pressure. It can
be seen that an expanding lesion in a cerebral hemisphere may force the medial part of the
temporal lobe downwards past the dura overlying the cerebellum (tentorium) causing tentorial
herniation ((a) in Fig 5). This type of herniation is associated with brainstem compression
affecting the vital centres controlling respiratory and heart function. Commonly the brainstem
is forced downwards and there is stretching and tearing of blood vessels in the brainstem
causing haemorrhage (secondary brainstem haemorrhages). This is a common terminal
mechanism of death due to raised intracranial pressure.
Expanding lesions in the posterior cranial fossa may force the cerebellar tonsils downwards
((b) in Fig 5) through the foramen magnum again compressing the vital centres (possibly also
causing secondary brainstem haemorrhages) in the brainstem causing death.
Other types of herniation include subfalcine herniation (herniation beneath the falx) ((c) in
Fig 5) and herniation through a skull defect (transcalvarial herniation) (not shown in diagram).

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