Skip to main content
SpringerLink
Log in

Postmortem magnetic resonance imaging revealed bilateral globi pallidi lesions in a death associated with prolonged carbon monoxide poisoning: a case report

  • Case Report
  • Published:
International Journal of Legal Medicine Aims and scope Submit manuscript

Abstract

A man and a woman were found dead in the same car with a burned coal briquette. The cause of death of the woman was assigned to acute carbon monoxide (CO) poisoning without difficulty based on typical findings associated with this condition, including elevation of carboxyhaemoglobin (COHb). However, the man had an unremarkable elevation of COHb and a higher rectal temperature compared to that of the woman. Postmortem computed tomography (PMCT) revealed ambiguous low-density areas in the bilateral globi pallidi. Further analysis by postmortem magnetic resonance (PMMR) imaging showed these lesions more clearly; the lesions appeared as marked high signal intensity areas on both the T2-weighted images and the fluid-attenuated inversion recovery sequences. A subsequent autopsy revealed signs of pneumonia, dehydration, starvation, and hypothermia, suggesting that the man died from prolonged CO poisoning. Both globi pallidi contained grossly ambiguous lesions, and a detailed neuropathologic investigation revealed these lesions to be coagulative necrotic areas; this finding was compatible with a diagnosis of prolonged CO poisoning. This case report shows that postmortem imaging, especially PMMR, is useful for detecting necrotic lesions associated with prolonged CO poisoning. This report further exemplifies the utility of PMMR for detecting brain lesions, which may be difficult to detect by macroscopic analysis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

Not applicable.

References

  1. Weaver LK (2009) Clinical practice. Carbon monoxide poisoning. N Engl J Med 360:1217–1225. https://doi.org/10.1056/NEJMcp0808891

    Article  CAS  PubMed  Google Scholar 

  2. Lapresle J, Fardeau M (1967) The central nervous system and carbon monoxide poisoning. II. Anatomical study of brain lesions following intoxication with carbon monoxide (22 cases). Prog Brain Res 24:31–74. https://doi.org/10.1016/s0079-6123(08)60181-8

    Article  CAS  PubMed  Google Scholar 

  3. Beppu T (2014) The role of MR imaging in assessment of brain damage from carbon monoxide poisoning: a review of the literature. AJNR Am J Neuroradiol 35:625–631. https://doi.org/10.3174/ajnr.A3489

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Jeon SB, Sohn CH, Seo DW, Oh BJ, Lim KS, Kang DW, Kim WY (2018) Acute brain lesions on magnetic resonance imaging and delayed neurological sequelae in carbon monoxide poisoning. JAMA Neurol 75:436–443. https://doi.org/10.1001/jamaneurol.2017.4618

    Article  PubMed  PubMed Central  Google Scholar 

  5. Moon JM, Chun BJ, Baek BH, Hong YJ (2018) Initial diffusion-weighted MRI and long-term neurologic outcomes in charcoal-burning carbon monoxide poisoning. Clin Toxicol (Phila) 56:161–169. https://doi.org/10.1080/15563650.2017.1352098

    Article  CAS  Google Scholar 

  6. Choi IS, Kim SK, Choi YC, Lee SS, Lee MS (1993) Evaluation of outcome after acute carbon monoxide poisoning by brain CT. J Korean Med Sci 8:78–83. https://doi.org/10.3346/jkms.1993.8.1.78

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Lo CP, Chen SY, Lee KW, Chen WL, Chen CY, Hsueh CJ, Huang GS (2007) Brain injury after acute carbon monoxide poisoning: early and late complications. Am J Roentgenol 189:W205–W211. https://doi.org/10.2214/AJR.07.2425

    Article  Google Scholar 

  8. Blokker BM, Wagensveld IM, Weustink AC, Oosterhuis JW, Hunink MG (2016) Non-invasive or minimally invasive autopsy compared to conventional autopsy of suspected natural deaths in adults: a systematic review. Eur Radiol 26:1159–1179. https://doi.org/10.1007/s00330-015-3908-8

    Article  PubMed  Google Scholar 

  9. Ruder TD, Thali MJ, Hatch GM (2014) Essentials of forensic post-mortem MR imaging in adults. Br J Radiol 87:20130567. https://doi.org/10.1259/bjr.20130567

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Eriksson A, Gustafsson T, Höistad M, Hultcrantz M, Jacobson S, Mejare I, Persson A (2017) Diagnostic accuracy of postmortem imaging vs autopsy-a systematic review. Eur J Radiol 89:249–269. https://doi.org/10.1016/j.ejrad.2016.08.003

    Article  PubMed  Google Scholar 

  11. Roberts IS, Benamore RE, Benbow EW, Lee SH, Harris JN, Jackson A, Mallett S, Patankar T, Peebles C, Roobottom C, Traill ZC (2012) Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study. Lancet 379:136–142. https://doi.org/10.1016/S0140-6736(11)61483-9

    Article  PubMed  PubMed Central  Google Scholar 

  12. Leth PM (2009) Computerized tomography used as a routine procedure at postmortem investigations. Am J Forensic Med Pathol 30:219–222. https://doi.org/10.1097/PAF.0b013e318187e0af

    Article  PubMed  Google Scholar 

  13. Bolliger SA, Thali MJ, Ross S, Buck U, Naether S, Vock P (2008) Virtual autopsy using imaging: bridging radiologic and forensic sciences. A review of the Virtopsy and similar projects. Eur Radiol 18:273–282. https://doi.org/10.1007/s00330-007-0737-4

    Article  PubMed  Google Scholar 

  14. Yen K, Lövblad KO, Scheurer E, Ozdoba C, Thali MJ, Aghayev E, Jackowski C, Anon J, Frickey N, Zwygart K, Weis J, Dirnhofer R (2007) Post-mortem forensic neuroimaging: correlation of MSCT and MRI findings with autopsy results. Forensic Sci Int 173:21–35. https://doi.org/10.1016/j.forsciint.2007.01.027

    Article  CAS  PubMed  Google Scholar 

  15. Añon J, Remonda L, Spreng A, Scheurer E, Schroth G, Boesch C, Thali M, Dirnhofer R, Yen K (2008) Traumatic extra-axial hemorrhage: correlation of postmortem MSCT, MRI, and forensic-pathological findings. J Magn Reson Imaging 28:823–836. https://doi.org/10.1002/jmri.21495

    Article  PubMed  Google Scholar 

  16. Aghayev E, Yen K, Sonnenschein M, Ozdoba C, Thali M, Jackowski C, Dirnhofer R (2004) Virtopsy post-mortem multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) demonstrating descending tonsillar herniation: comparison to clinical studies. Neuroradiology 46:559–564

    Article  Google Scholar 

  17. Franckenberg S, Schulze C, Bolliger SA, Gascho D, Thali MJ, Flach PM (2015) Postmortem angiography in computed tomography and magnetic resonance imaging in a case of fatal hemorrhage due to an arterio-venous malformation in the brain. Leg Med (Tokyo) 17:180–183. https://doi.org/10.1016/j.legalmed.2014.11.006

    Article  Google Scholar 

  18. Weustink AC, Hunink MG, van Dijke CF, Renken NS, Krestin GP, Oosterhuis JW (2009) Minimally invasive autopsy: an alternative to conventional autopsy? Radiology 250:897–904. https://doi.org/10.1148/radiol.2503080421

    Article  PubMed  Google Scholar 

  19. Oliver J, Lyons TJ, Harle R (1999) The role of computed tomography in the diagnosis of arterial gas embolism in fatal diving accidents in Tasmania. Australas Radiol 43:37–40. https://doi.org/10.1046/j.1440-1673.1999.00615.x

    Article  CAS  PubMed  Google Scholar 

  20. Iwama T, Andoh H, Murase S, Miwa Y, Ohkuma A (1994) Diffuse cerebral air embolism following trauma: striking postmortem CT findings. Neuroradiology 36:33–34. https://doi.org/10.1007/BF00599191

    Article  CAS  PubMed  Google Scholar 

  21. Abe K, Kobayashi T, Shiotani S, Saito H, Kaga K, Tashiro K, Someya S, Hayakawa H, Homma K (2015) Optimization of inversion time for postmortem fluid-attenuated inversion recovery (FLAIR) MR imaging at 1.5T: temperature-based suppression of cerebrospinal fluid. Magn Reson Med Sci 14:251–255. https://doi.org/10.2463/mrms.2014-0086

    Article  PubMed  Google Scholar 

  22. Wagensveld IM, Blokker BM, Wielopolski PA, Renken NS, Krestin GP, Hunink MG, Oosterhuis JW, Weustink AC (2017) Total-body CT and MR features of postmortem change in in-hospital deaths. PLoS One 12:e0185115. https://doi.org/10.1371/journal.pone.0185115

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Wischnewsky S (1895) Ein neues Kennzeichen des Todes durch Erfrieren. Bote Gerichtl Med 3:12–20

    Google Scholar 

  24. Prockop LD, Chichkova RI (2007) Carbon monoxide intoxication: an updated review. J Neurol Sci 262:122–130. https://doi.org/10.1016/j.jns.2007.06.037

    Article  CAS  PubMed  Google Scholar 

  25. Bleecker ML (2015) Carbon monoxide intoxication. Handb Clin Neurol 131:191–203. https://doi.org/10.1016/B978-0-444-62627-1.00024-X

    Article  PubMed  Google Scholar 

  26. Ernst A, Zibrak JD (1998) Carbon monoxide poisoning. N Engl J Med 339:1603–1608. https://doi.org/10.1056/NEJM199811263392206

    Article  CAS  PubMed  Google Scholar 

  27. Rodkey FL, O'Neal JD, Collison HA (1969) Oxygen and carbon monoxide equilibria of human adult hemoglobin at atmospheric and elevated pressure. Blood 33:57–65

    Article  CAS  Google Scholar 

  28. Wittenberg BA, Wittenberg JB (1987) Myoglobin-mediated oxygen delivery to mitochondria of isolated cardiac myocytes. Proc Natl Acad Sci U S A 84:7503–7507. https://doi.org/10.1073/pnas.84.21.7503

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Okeda R, Funata N, Takano T, Miyazaki Y, Higashino F, Yokoyama K, Manabe M (1981) The pathogenesis of carbon monoxide encephalopathy in the acute phase--physiological and morphological correlation. Acta Neuropathol 54:1–10. https://doi.org/10.1007/BF00691327

    Article  CAS  PubMed  Google Scholar 

  30. Kawanami T, Kato T, Kurita K, Sasaki H (1998) The pallidoreticular pattern of brain damage on MRI in a patient with carbon monoxide poisoning. J Neurol Neurosurg Psychiatry 64:282. https://doi.org/10.1136/jnnp.64.2.282

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Alonso JR, Cardellach F, López S, Casademont J, Miró O (2003) Carbon monoxide specifically inhibits cytochrome c oxidase of human mitochondrial respiratory chain. Pharmacol Toxicol 93:142–146. https://doi.org/10.1034/j.1600-0773.2003.930306.x

    Article  CAS  PubMed  Google Scholar 

  32. Thom SR, Bhopale VM, Han ST, Clark JM, Hardy KR (2006) Intravascular neutrophil activation due to carbon monoxide poisoning. Am J Respir Crit Care Med 174:1239–1248. https://doi.org/10.1164/rccm.200604-557OC

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Yarid NA, Harruff RC (2015) Globus pallidus necrosis unrelated to carbon monoxide poisoning: retrospective analysis of 27 cases of basal ganglia necrosis. J Forensic Sci 60:1484–1487. https://doi.org/10.1111/1556-4029.12838

    Article  CAS  PubMed  Google Scholar 

  34. Murray RR, Kapila A, Blanco E, Kagan-Hallet KS (1984) Cerebral computed tomography in drowning victims. AJNR Am J Neuroradiol 5:177–179

    CAS  PubMed  Google Scholar 

  35. Bianco F, Floris R (1987) Computed tomography abnormalities in hanging. Neuroradiology 29:297–298. https://doi.org/10.1007/BF00451772

    Article  CAS  PubMed  Google Scholar 

  36. Mohan A, Lee T, Sachdev P (2014) Surviving acute cyanide poisoning: a longitudinal neuropsychological investigation with interval MRI. BMJ Case Rep 19:2014. https://doi.org/10.1136/bcr-2013-203025

    Article  Google Scholar 

  37. Karayel F, Turan AA, Sav A, Pakis I, Akyildiz EU, Ersoy G (2010) Methanol intoxication: pathological changes of central nervous system (17 cases). Am J Forensic Med Pathol 31:34–36. https://doi.org/10.1097/PAF.0b013e3181c160d9

    Article  PubMed  Google Scholar 

  38. Renard D, Brunel H, Gaillard N (2009) Bilateral haemorrhagic infarction of the globus pallidus after cocaine and alcohol intoxication. Acta Neurol Belg 109:159–161

    PubMed  Google Scholar 

  39. Daras MD, Orrego JJ, Akfirat GL, Samkoff LM, Koppel BS (2001) Bilateral symmetrical basal ganglia infarction after intravenous use of cocaine and heroin. Clin Imaging 25:12–14. https://doi.org/10.1016/s0899-7071(00)00232-1

    Article  CAS  PubMed  Google Scholar 

  40. De Smet K, De Maeseneer M, Talebian YA, Stadnik T, De Mey J (2011) Bilateral globus pallidus infarcts in ecstasy use. JBR-BTR 94:93. https://doi.org/10.5334/jbr-btr.512

    Article  PubMed  Google Scholar 

  41. De Roock S, Hantson P, Laterre PF, Duprez T (2007) Extensive pallidal and white matter injury following cocaine overdose. Intensive Care Med 33:2030–2031. https://doi.org/10.1007/s00134-007-0773-1

    Article  PubMed  Google Scholar 

  42. Miller JM, Vorel SR, Tranguch AJ, Kenny ET, Mazzoni P, van Gorp WG, Kleber HD (2006) Anhedonia after a selective bilateral lesion of the globus pallidus. Am J Psychiatry 163:786–788. https://doi.org/10.1176/ajp.2006.163.5.786

    Article  PubMed  Google Scholar 

  43. Kim DW, Im HJ, Oh J (2013) Selective injury of the globus pallidus and hippocampus in methamphetamine-induced encephalopathy. Clin Neuroradiol 23:51–53. https://doi.org/10.1007/s00062-011-0115-0

    Article  CAS  PubMed  Google Scholar 

  44. Lin YH, Huang E, Chien YL (2012) Bilateral pallidal necrosis and cardiac toxicity in a patient with venlafaxine and bupropion overdose. Am J Psychiatry 169:993–994. https://doi.org/10.1176/appi.ajp.2012.11111708

    Article  PubMed  Google Scholar 

  45. Szolics M, Chaudhry M, Ljubisavljevic M, Corr P, Samir HA, van Gorkom KN (2012) Neuroimaging findings in a case of fluoxetine overdose. J Neuroradiol 39:254–257. https://doi.org/10.1016/j.neurad.2011.10.006

    Article  PubMed  Google Scholar 

  46. Jeong JH, Kwon JC, Chin J, Yoon SJ, Na DL (2002) Globus pallidus lesions associated with high mountain climbing. J Korean Med Sci 17:861–863. https://doi.org/10.3346/jkms.2002.17.6.861

    Article  PubMed  PubMed Central  Google Scholar 

  47. Rabitsch W, Brugger SA, Pirker W, Baumgartner C, Reiter E, Keil F, Prayer D, Hoecker P, Lechner K, Kalhs P, Greinix HT (1997) Symmetrical necrosis of globus pallidus with severe gait disturbance in a patient with myelodysplastic syndrome given allogeneic marrow transplantation. Ann Hematol 75:235–237. https://doi.org/10.1007/s002770050349

    Article  CAS  PubMed  Google Scholar 

  48. Lou M, Jing CH, Selim MH, Caplan LR, Ding MP (2009) Delayed substantia nigra damage and leukoencephalopathy after hypoxic-ischemic injury. J Neurol Sci 277:147–149. https://doi.org/10.1016/j.jns.2008.09.032

    Article  PubMed  Google Scholar 

  49. Abou Hassan OK, Karnib M, El-Khoury R, Nemer G, Ahdab-Barmada M, BouKhalil P (2016) Linezolid toxicity and mitochondrial susceptibility: a novel neurological complication in a Lebanese patient. Front Pharmacol 7:325. https://doi.org/10.3389/fphar.2016.00325

    Article  PubMed  PubMed Central  Google Scholar 

  50. Finelli PF (1984) Bilateral hemorrhagic infarction of the pallidum. J Comput Assist Tomogr 8:125–127. https://doi.org/10.1097/00004728-198402000-00025

    Article  CAS  PubMed  Google Scholar 

  51. Michel SJ, Given CA 2nd, Robertson WC Jr (2004) Imaging of the brain, including diffusion-weighted imaging in methylmalonic acidemia. Pediatr Radiol 34:580–582. https://doi.org/10.1007/s00247-004-1155-2

    Article  PubMed  Google Scholar 

  52. Schmidt TM, Fischer R, Acar S, Lorenzen M, Heinemann A, Wedegärtner U, Adam G, Yamamura J (2012) DWI of the brain: postmortal DWI of the brain in comparison with in vivo data. Forensic Sci Int 220:180–183. https://doi.org/10.1016/j.forsciint.2012.02.022

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors would like to thank Hiroko Abe, Yoshikazu Yamagishi, Katsura Otsuka, Kazuhiro Kobayashi, Yuriko Odo, and Miyuki Miura for their technical support. The authors also would like to thank Editage (www.editage.com) for English language editing.

Funding

This work was supported by JSPS KAKENHI Grant Numbers JP16H06242 and JP26870102.

Author information

Authors and Affiliations

  1. Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan

    Shigeki Tsuneya, Yohsuke Makino, Fumiko Chiba & Hirotaro Iwase

  2. Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan

    Shigeki Tsuneya, Yohsuke Makino, Fumiko Chiba, Masatoshi Kojima, Maiko Yoshida & Hirotaro Iwase

  3. Department of Molecular Pathology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan

    Takashi Kishimoto

  4. Department of Radiology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan

    Hiroki Mukai & Shinya Hattori

Authors
  1. Shigeki Tsuneya
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yohsuke Makino
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Fumiko Chiba
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Masatoshi Kojima
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Maiko Yoshida
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Takashi Kishimoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hiroki Mukai
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shinya Hattori
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Hirotaro Iwase
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the conception of this case report. Data collection and analysis were performed by Shigeki Tsuneya, Yohsuke Makino, Masatoshi Kojima, Maiko Yoshida, Takashi Kishimoto, Hiroki Mukai, and Shinya Hattori. The first draft of the manuscript was written by Shigeki Tsuneya, and all authors commented on previous versions of the manuscript. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Yohsuke Makino.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval/consent to participate/consent for publication

The ethics committee of the University of Tokyo approved this study and permitted waiver of consent from next of kin.

Code availability

Not applicable.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tsuneya, S., Makino, Y., Chiba, F. et al. Postmortem magnetic resonance imaging revealed bilateral globi pallidi lesions in a death associated with prolonged carbon monoxide poisoning: a case report. Int J Legal Med 135, 921–928 (2021). https://doi.org/10.1007/s00414-021-02506-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00414-021-02506-1

Keywords

Search

Navigation