Intracranial Hemorrhage: Traumatic Fall versus Terminal Collapse

When approaching a case in which a decedent's body is on the ground, death investigators collect circumstantial, historical, and clinical (radiographic) information to infer whether the person fell to the ground and sustained a head injury or simply experienced a terminal collapse due to a natural event. We have observed that cases presenting as presumed accidental head trauma, some of which have diagnosed subdural hematomas, are sometimes proven to be of natural causes following autopsy. Autopsies sometimes demonstrate that either 1) the intracranial hemorrhage is intracerebral rather than subdural, 2) the subdural hemorrhage is an extension from an intracerebral hemorrhage, or 3) there is no intracranial hemorrhage at all. In each of these examples, the autopsy established that the manner of death is natural rather than accidental, as originally presumed at the outset of the investigation. We performed a 5 year retrospective study on cases indicating intracranial hemorrhage in the cause of death statement in order to assess how often the cause and manner of death would have been incorrectly certified without an autopsy. We found that 6% of cases presumed at the time of initial investigation to represent falls with accidental head trauma (specifically, subdural hemorrhage) were proven by autopsy to represent intracranial hemorrhage of natural manner. Conversely, 7% of cases with intracranial hemorrhage that were presumed to be due to natural disease were proven by autopsy to represent accidental trauma. Proper certification of manner of death has important legal implications which may be of critical importance to family members.