Template:Autopsy - entire topic

Author: Mikael Häggström, M.D.

The extremely minimal autopsy checklist:

• Check the autopsy referral
• Cut open and inspect the usually clearly visible organs, as well as the thyroid, pancreas and adrenals.
• Weigh relevant organs
• Sample tissues for microscopy and/or microbiology when needed
• Report at least relevant findings

Checklist for non-forensic autopsy

There are many variants, with the following being a suggestion:

Preparations

• Confirm that there is a consent from the next of kin to perform the autopsy, and whether it includes any restrictions (such as only examining the thorax).
• Read the autopsy referral (if separate from the consent form)( and talk with the referring person and/or family why they want the autopsy and what they want to be investigated in particular, if not already evident from the referral. Surprisingly often, the main reason for performing an autopsy is not the cause of death in itself, but for some other question by the clinician or relative, such as a cause of a dementia. This information helps you focus on the most pertinent locations and possible findings to answer the question.)
• Confirm with any supervisor what you may do independently, and at what stages the supervisor will want to inspect the body and/or organs (for example before evisceration and/or after all pertinent organs have been opened).
• (Go through the patient's medical records, at least if necessary aspects are not included in the referral. The most important aspects are:

• Time of death
• Surgical history
• Current diseases
• Latest hospital and/or primary care notes
• Presence of any pacemaker or implantable cardioverter-defibrillator (ICD). If present, make sure it is deactivated before cutting open the chest. Generally remove it during autopsy as they may explode if the body is cremated.)
• ((History of smoking
• Medications, especially anticoagulant ones.
• Family history))

In the autopsy room, before starting examination:

• Charge and bring a camera to document relevant findings.
• Use protective wear, generally according to local practice. Tie any knots before putting on gloves for better dexterity.
• Confirm the identity of the body, generally from attached identity tag.

External inspection

• Measure the size of <<clinically significant / ( all)>> scars, marks, bruises or wounds. Estimate the depth of wounds, either by number or presumed anatomic layer.
• Note any therapeutic tubes or lines
• Inspect the lower legs for swelling (and compare their circumferences taken 10 cm above the ankle. If swelling is suspected, later press the legs while observing the femoral veins emptying into the pelvic cavity to discern if there is free flow.
• Discern the race, gender, nutritional status, and apparent versus stated age
• Inspect the external ears, eyes, nostrils and mouth.)

In situ inspection

• Note any atypical organ arrangement
• Estimate (or measure) excessive amount of fluid in body cavities.
• (Measure the thickness of subcutaneous fat at the thorax and abdomen.)

Evisceration

Y-incision

• The standard Y-incision is from each acromion process to the xyphoid process. For larger breasted patients, the incision is done under the breast, making it easier to manage later.
• From here the incision extends down the central abdomen, to the patient’s left of the umbilicus, ending at the pubis. Care is taken not to cut too deeply into the abdomen, to avoid puncturing the peritoneal cavity and/or bowel.
• The skin is reflected back over the face and along the sides. Always cut perpendicular to bone.
• Take measurement of the chest and abdominal pannus at this time.

Chest plate

• Using rib cutters or Stryker saw, cut laterally along the ribs, ending at the sterno-clavicular junction.
• Remove chest plate by detaching it from the diaphragm and pulling upward toward the head.
• Inspect the ribs for fractures
• Also, squeeze out bone marrow on a piece of wrapping tissue and submit.
• Perform in situ examination as per checklist.

Peritoneal loose bodies may be found in the peritoneal cavity, and are generally caused by torsion and autoamputation of an epiploic appendage, which eventually becomes embedded in a fibrous capsule.

Bowel removal

• Pull up stomach and find the ligament of Treitz (pictured).
• At the ligament of Treitz, place two hemostats & cut through the bowel between the clamps.
• Cut the mesenteric adipose close to the bowel, without perforating it.
• When you reach the rectum, place two hemostats and cut through the bowel between the clamps as before.

Supra-pelvic organ blocks

• Cut the diaphragm free from the body wall on both sides extending down to the spinal column.
• From here pull all the organs to the left and make an incision along the right side of the spinal column to free the organs
• Do the same along the left side.
• Tease the soft tissue of the neck to expose the carotid arteries.
• Tie off both sides leaving long stumps, which are marked with strings for embalming purposes.
• Dissect the tissue of the neck to expose the thyroid cartilage.
• Transect immediately above the thyroid cartilage, freeing the trachea and esophagus.
• Start to dissect away the tissue around and behind the thyroid cartilage & esophagus.
• Continue this dissection down, following the spinal column to the bifurcation of the abdominal aorta.
• At this point, remove the organ block from the body.

Pelvic organs

• Bluntly dissect the urinary bladder away from the wall of the true pelvis
• Continue this blunt dissection down into the pelvis to include the vagina (if female) & rectum
• Pull directly anterior to free these structures
• You will hear a loud suction noise when done correctly
• At this point, cut straight down to remove the pelvic organs
• If male, insert the scissors into the pelvis toward the feet as far as possible & then down to include the prostate
• To remove the testis, bluntly dissect along the inguinal canal, exposing the spermatic cord
• Pull up on the cord until the testis pulls through the canal & out of the scrotum
• Transect the spermatic cord.

 

Skull cap

• Separate the hair of the scalp, cut from ear to ear (just behind each ear) over the posterior crown of the head.
• Reflect the skin forward over the face & back to the neck, exposing the skull cap (use a towel for better grip).
• Using a scalpel, outline the cut on the anterior & posterior skull cap cutting away the temporalis muscles. The outline should make ~45 degree angle located at the level of the ear.
• Use the Stryker saw to cut along the outline. Be sure to cut through the skull bone but not into the brain tissue.
• Make a V-shaped notch in the anterior midline to help the skull cap stay in place following autopsy
• Pull skull cap off

Brain

• Do an in situ examination before removing.
• Gently insert fingers over frontal lobes and pull backwards.
• Using scalpel/scissors, cut away the exposed cranial nerves.
• Cut away the tentorium, keeping the scalpel close to the bone.
• Free the cerebellum.
• Insert scalpel/scissors as deep as possible to cut the brain stem.
• Pull brain out gently.
• Place a wedge at level of sella turcica and hit it with a hammer to expose pituitary gland.
• Remove the gland gently.
• Weigh the brain.

Organ packages

Organs are generally initially separated into the following packages:

• Thorax
• Gastrointestinal, including liver, spleen and pancreas.
• Pelvic, including urinary bladder and uterus/prostate.

The kidneys and adrenals may be included in either the gastrointestinal or pelvic package.

To separate the thoracic from the abdominal package:

• Turn the packages with the dorsal side up.
• Optionally: Cut the aorta just distally to the exit of the left subclavian vein, and separate the descending thoracic aorta from the rest of the thorax.
• Optionally: Cut the esophagus at its superior attachment to the trachea, and separate it from the thorax.
• Free the basilar aspects of the lungs from the diaphragm.
• Identify the inferior vena cava (IVC) and transect it as close to the diaphragm as possible.
• Detach the pericardium from the diaphragm as close to the line of attachment as possible.

Heart

• Remove the parietal pericardium
• Separate the heart from the from lungs by cutting through the major vessels. The pulmonary artery should be cut first and the lumen inspected for any pulmonary embolism.
• Weigh the heart.
• Dissect the coronary vessels.   Further information: Arteries
• On the right side of the heart, dissect in the direction of blood flow: Superior vena cava > right atrium > tricuspid valve > right ventricle. Look for thromboses or patent foramen ovale.
• Dissect the atrial appendages, to exclude thromboses.
• Dissect the left ventricle, such as into circumferential slices from the apex to the base. Inspect (and measure) the left ventricular wall thickness.

Valve circumferences are measured at the basal ring (bottom in image).

• (Measure the circumferences of the four valves. Cutoffs for valve dilatation:

• Mitral valve: circumference greater than 9.9 cm in males and 9.1 cm in females
• Aortic valve: circumference greater than 8.5 cm in males and 7.9 cm in females
• Tricuspid valve: circumference greater than 11.8 cm in males and 11.1 cm in females
• Pulmonic valve: circumference greater than 7.5 cm in males and 7.4 cm in females)

Look for signs of myocardial infarction. Further information: Heart autopsy and Autopsy of myocardial infarction

Other thorax

• Dissect the aorta, with an anterior dissection of the aortic arch and major branches, and posterior dissection of the descending thoracic aorta. Check for thrombosis and degree of atherosclerosis. Then separate the descending thoracic aorta from the esophagus.

Relations of the aorta, trachea, esophagus and other heart structures

• Dissect the pulmonary arterial system, from the pulmonary trunk and including at least segmental arteries. To avoid cutting through the left main bronchus (passing anteriorly to the left main pulmonary artery), the initial dissection of the left main pulmonary artery may begin from an anterior perspective but keeping the cuts along the posterior wall, until the dissection can be seen and be continued from a posterior approach. Check the pulmonary arteries for blood clots.

Blood clots

	Pre-mortem	Post-mortem
Texture	Dull	Shiny
Wall adherence	Yes	No
Color	Grey. Possibly zebraic appearance by lines of Zahn, with mixed red and grey/yellow	Dark-red ("currant jelly") to tan-pink ("chicken-fat")
Pressurized	Yes, can eject from lumen	No, needs to be pulled-out
Consistency	Firm and brittle	Elastic, jellylike

• Esophagus: Separate it from the trachea and dissect it.
• Dissect the trachea and the bronchial tree, at least to segmental bronchi. Check for obstructions.
• Make some additional sections through the lung parenchyma. Squeeze at each side to detect any pus and edema. Further information: Lung autopsy
• Cut each thyroid lobe in horizontal slices and inspect the parenchyma. Further information: Thyroid
• ((Look for parathyroid glands, and if found, inspect for nodules or hypertrophy. Further information: Parathyroid glands ))
• Look for enlarged lymph nodes in the hilar and paratracheal area.

Retroperitoneal

For orientation, the coeliac trunk and mesenteric arteries exit the aorta from the anterior side.

• Dissect the descending abdominal aorta. Cut external iliac artery from a dorsal approach, or after freeing ureters.
• Inspect the renal arteries for patency. ((Dissect them until entry into kidneys.))
• Make a couple of cuts through the adrenal glands, such as transversal ones, and look mainly for tumors. Further information: Adrenals
• Cut the kidneys in the coronal planes. Further information: Kidney autopsy
• Dissect the ureters to the bladder. Look for any increased caliber or abnormal contents.
• Dissect the prostate in males, and the urinary bladder, by an anterior approach. Dissect the ureteropelvic junctions. Inspect the bladder content and the urothelial surface.
• Dissect the rectum.
• In females, bivalve the uterus by cutting along right and left lateral aspects. Measure the ovaries.

Peritoneal

• Remove the diaphragm and excess omentum

Wischnewski spots of the stomach are associated with hypothermia.

• Dissect the stomach along the greater curvature, as well as the duodenum and the esophageal entry into the stomach.
• Dissect the extrahepatic biliary tract and gallbladder.Further information: Gallbladder
• Make consecutive liver slices, such as in the sagittal or coronal plane. Further information: Liver

"Long" and "short" axis.

Note its shape, color and consistency.

• Inspect the pancreas regarding color and consistency. ((Separate it and measure its dimensions.)) Cut it in consecutive short axis slices. Note the appearance of the parenchyma (and the size of the duct). Further information: Pancreas
• Separate the spleen and make consecutive short axis slices through it. Note its shape, color, texture and consistency.
• Separate the intestines until the rectum, and dissect them by a longitudinal section, looking for focal and diffuse lesions. Note the presence or absence of the appendix.

For the liver, pancreas and spleen, sectioning preferably goes almost but not fully through each organ, so as to keep the slices together.

Brain

• Weight the brain. Overall normal range (95% prediction interval) is 1100 to 1700 g, +60g for males and -60g for females.
• Inspect: Grooves indicating herniation? Hemorrhages?
• Dissect the basilar artery and circle of Willis, either before or after separation from the brain. [[If there is likely a need to demonstrate the case to an additional person later, the arteries of the skull base are preferably dissected after first separating them from the brain.]] Look mainly for thromboses.
• Separate the brainstem, cerebellum and cerebrum, which may be done by first separating the former two together from the cerebrum.

Normal brain versus in Alzheimer's disease.

• Slice each part, looking for hemorrhages and/or infarcts.

• For the cerebrum, cut it into slices about 1 cm thick. It can be done from frontal to occipital, or by starting coronally into two halves at the level of the mammillary bodies and continuing in each direction from there.

• At least in people aged over 65-75 years of age {{or with suggestive history}}, look for signs of Alzhemier's disease (see picture).

Further information: Brain autopsy

Demonstration

Consider summoning involved clinicians for a demonstration of any findings.

Weighing

Separate and weigh these organs, either before or after cutting into them, but before tissue sampling.

• Heart. Further information: Heart autopsy
• Each lung, separately
• Liver
• Spleen
• Kidneys, (separately)

• ((Adrenal glands))
• ((Pancreas)) Further information: Pancreas
• ((One or both testicles))
• ((Thyroid))
• ((Hypophysis))
• ((Thymus, if found))
• Volume quantification of significant amounts of ascites and/or pleural fluid.

Tissue sampling

Sample tissues for microscopy from wherever histopathology may aid in establishing the cause of death. Following are routine samples:

• Heart:

• Left ventricle
• Mitral valve with papillary muscle (including inner lining of both the left atrium and left ventricle
• Right ventricle)
• ((Interventricular septum}}
• Left atrium)

• ((Each lobe of)) each lung, including pleura (and bronchi).
• Liver, away from the capsule.
• Each kidney, including cortex, medulla(, papilla and calyx)
• Adrenal glands. If grossly unremarkable, a slice of the right adrenal gland may be submitted together with a slice of the right kidney, and the same for the left side.
• (Bone marrow (such as from squeezing at the edge of a rib)
• Each breast in females
• Pituitary
• Thyroid)

• (Parathyroids
• Gastroesophageal junction
• Pancreas, from the head
• Spleen, including the capsule
• Urinary bladder
• Prostate in males
• Thymus in young patients
• Uterus

• Endomyometrium with serosa
• Cervix ((both at 6 and 12 o'clock))

• Central nervous system:

• Cerebral cortex
• Basal ganglia
• Hippocampus
• Substantia nigra
• Medulla oblongata
• Cerebellum)

• ((Ileocecal valve
• Testicle in males
• Skeletal muscle))

In addition, generally sample all gross lesions, except uterine fibroids, diverticula and multiple intestinal polyps. One sample is sufficient in case of multiple metastases. Lesion samples should include adjacent normal tissue.

Furthermore, generally save a piece of tissue in formalin from at least all sampled locations, in case the sample gets lost or gets processed incorrectly. Further information: Gross processing

Microbiology

Indications

Cultures for microbiology are indicated in the following cases, if less than 24 hours have passed since the time of death:

• Fever of unknown origin
• At request of the requesting physician
• (Drug addicts
• Patients from nursing homes)

Sites

• Blood cultures from the right ventricle/atrium
• Any exudates or pus collections
• (Any organ suspected to have inflammation)
• {{Cerebrospinal fluid if meningitis is suspected}}
• {{Body fluids, by individual indication}}

Toxicology

• {{Toxicology is taken if highly suspected from the history. Up to 2.5 ml can be obtained from each eye, using a red top tube.}}

Reporting of non-forensic autopsy

The order of the sections may vary.

((Where findings are made, still negate additional findings in the region, such as: "There is a 18.0 cm curvilinear well-healed thin scar in the left thorax. Otherwise, there are no puncture marks or healed surgical scars on the torso."))

Data

• Autopsy No.: ________
• (Hospital No.:000046)

• Patient name: Bloggs, Joe
• (Patient No.:)
• (Ward :_______)
• Age [[or birthdate]]: _____
• (Sex: ______)
• (Race: ______)
• (Permission: From [[usually close relative of the deceased.]])

((The medical records of the <<patient/deceased>> [[Either denomination works]] were reviewed prior to the commencement of the autopsy.))

• Date (and time) of death: ______
• Date (and time) of autopsy: ______
• (Date of report: _________)
• Attending physician: _______
• (Prosector:__________)
• {{Limitation of the autopsy}} [[such as restriction to thorax only]].

Final autopsy diagnosis / Preliminary diagnoses

[[May be preliminary if histopathology samples are taken.]]

• [[First, generally the final cause of death, such as:]]

• {{Acute circulatory failure with pulmonary edema and congestion of abdominal organs.}}

• [[Other diagnoses that may have caused the death is listed in causative order:]]

• {{Acute myocardial infarction.}}
• {{Severe arteriosclerosis.}}

• [[Other autopsy diagnoses, including presumably incidental ones:]]

• {{Hepatic steatosis.}}

• [[Clinically known diagnoses may be marked as such:]]

• {{Type 2 diabetes (clinical diagnosis).}}

(Clinical history

_________)

(Laboratory data

_________)

External inspection

((The autopsy is performed approximately __ hours after death.)) The body is a ((well developed,)) << ((well nourished)) / {{underweight / overweight}}>> (__ year old) [[if not already given in data]]) << woman / man >>. ((The body appears as stated age.)) (Lengths is __ cm and weight is __ kg..)

Usual signs of death.

(Rigor mortis is << well marked / broken >>. Lividity is seen on the << front / back and/or side >>.)

(On the torso there are no puncture marks or healed surgical scars.)

((The skin is <<pale / icteric / cyanotic>>. The body hair shows a normal <<male / female>> distribution. There is no peripheral edema. The head is not deformed. It is covered by <<scanty / moderate / abundant>> amount of [[color:]] ____ hair. The irides are [[color:]] ___. The pupils are round, regular and equal, measuring _cm in diameter. The corneae and lenses are transparent. The sclerae are clear. The conjunctivae are <<pink / pale>>. The nose and external ears are unremarkable and their passages are clear. The lips and gums show no lesions. {{The lips are pale/cyanotic.}} The mouth is not remarkable {{/edentulous /contains a frothy fluid}}. The neck structures are symmetrical, and there are no unusual masses. {{There is jugular venous distention}}. The thorax has normal contour and symmetry. [[In females:]] breasts and nipples are unremarkable. (The back has lividity.) The abdomen is flat {{/protuberant}}. External abdominal palpation detects no abnormal masses or fluid waves. The extremities show no scars or deformities. The nails are normal {{/cyanotic/clubbed}}. No palpable inguinal masses.))

Internal examination

((Standard thoracic incisions are employed.))
{{Overall severe autolysis, making pathologic assessment difficult.}}
((The subcutaneous fat measures ___ in thickness over the thorax and _cm over the abdomen. The skeletal muscles are red-brown, normally firm and of normal bulk. There is no subcutaneous emphysema. The abdominal organs are in their usual anatomic positions. The diaphragmatic domes reach the <<sixth / seventh>> intercostal space, bilaterally.))

Serous cavities

No increased amount of fluid in the pericardial, pleural or abdominal cavities. Serous surfaces are smooth and lustrous.(No signs of inflammation. No adhesions.)

[[These are preferably located by the corresponding system of each cavity:]] ((The pleural surfaces are smooth and the cavities are dry. {{The <<right / left>> pleural cavity contains _cc/ml of <<clear / bloody / straw-colored>> fluid and show <<soft / hard>> adhesions.}} The pericardial cavity contains _cc/ml of straw-colored fluid and shows no adhesions. The peritoneal cavity contains _cc/ml of straw-colored fluid. ))

Circulatory system

The heart << has normal weight / is enlarged [[ > 399 g in women and> 449 g in men]] >>, weighing ___ g. ((The epicardium is transparent. There is a moderate amount of subepicardial fat.

Normal configuration

(No atrial or ventricular dilation. No ventricular wall thickening) / {{The left ventricle has {{concentric}} hypertrophy, with a wall thickness of ___ mm.}}

((No atrial or ventricular dilation. The right and left auricular appendage is unremarkable. The left ventricular wall thickness is __ cm and the right is ___. The trabeculae carneae are normal ({[Finding-begin}}/ prominent /flattened}}.)) [[A comprehensive report may describe each atrium, valve and ventricle etc. in order of blood flow.]]

(Foramen ovale is closed.) ((The ductus arteriosus is obliterated))
The coronary arteries ((arise in normal position. The coronary ostia are << patent {{partially occluded by arteriosclerotic calcification}}>>. They)) have << no / mild / moderate / severe >> {{and partially calcified}} arteriosclerosis. They are traced, ((throughout their length by transverse sections)) {{after fixation and decalcification}} <<without significant constrictions.{{ / The lumina of the left anterior descending, right coronary, and left circumflex coronary arteries are _%, _%, and _% narrowed, respectively.}} [[If the degree of stenosis on microscopy sections of coronary arteries only differ slightly from the gross description, preferably write "mild/moderate/severe atherosclerosis consistent with the gross inspection."]] (Gross measurement of coronary artery stenosis is generally more accurate than microscopic measurement, so the former generally has precedence.)

No thrombi in the cardiac atria (including auricles), chambers or coronary arteries.

Chordae tendineae, the endocardium and heart valves are unremarkable.

(The endocardium is smooth and shiny. Chordae tendineae are unremarkable. The valves are normal in number, and are thin and fine at the openings.)

((The endocardium is smooth, transparent and free of mural thrombi. The valve leaflets and chordae tendinae are overall delicate, pliable and free of lesion or calcification. <<Its leaflets are thin and pliable / No signs of inflammation>>. The tricuspid valve <is / is not> dilated, measuring _cm in circumference. The pulmonic valve <is / is not> dilated, measuring _cm in circumference. It is composed of <<two / three>> cusps which are discrete and pliable. The mitral valve <is / is not> dilated, measuring _cm in circumference. Its leaflets are thin and pliable {{/ redundant / adherent to each other}}. The aortic valve <is / is not> dilated, measuring _ cm in circumference. It is composed of <<two / three>> cusps which are thin and pliable. {{The cusps are calcified at the bases / adherent to each other.}} {{The valve displays mild / moderate / severe myxomatous degeneration.}} The epicardium and subepicardium are unremarkable. The papillary muscles are normal {{ / hypertrophied}}))

The myocardium has ((a homogeneous reddish brown color, and)) no signs of <<fresh lesion / ((areas of necrosis or hemorrhage))>> (or scar){{/ streaks of white scar tissue}}. In the aorta (and its major branches) there is {{widespread}} << no / mild / moderate / severe >> arteriosclerosis. No aneurysm. (Renal arteries ((are patent and)) have no significant stenosis.) No thrombus in (vena cava, ) the pulmonary arteries ((or the pulmonary veins)){{The <<right / left>> <<proximal and/or distal pulmonary arteries contain coiled, red-purple thromboemboli with(out) attachment to the intima.}} ((The portal system appears unremarkable. The vena cavae are also unremarkable. There is a free flow of blood from the veins of the lower extremities.))

Respiratory system

The larynx, trachea and bronchi are normally configured, with non-irritated lining.

((Larynx has normal configuration. The vocal cords are smooth and symmetrical. The trachea and the larger bronchi have non-irritated lining. No ulceration. Lumina are patent.)) {{The bronchial lumina contain small amounts of frothy mucoid material.}}

No foreign content((, dilatation or mucosal change)). ((Normal lobar structure. No tumor. No visible signs of inflammation.))
The lungs ((have the usual shape and lobar divisions, are expanded and)) have << normal / increased >> weight, of __ g on the right and ___ g on the left. (The consistency is normal) {{/ abnormally firm. There is <<minimal / moderate / extensive subpleural anthracotic pigment present.}}Cut Surfaces are unremarkably dark red, with no definable tumors( or bleeding).
{{There are firm with patchy areas of tan-grey consolidation of location. Watery and frothy liquid is pressed from the parenchyma, indicating pulmonary edema.}}
(The rib cage is intact) / {{Multiple rib fractures, consistent with CPR.}} ((There are no masses in the mediastinum.))

Digestive system

((The tongue has no bleeding.))

The esophagus, stomach and intestines are ordinarily configured, without tumors or blood in the lumen.

((The esophagus is lined by a smooth, tan-white non-irritated epithelium, and the mucosa has normal thickness. No diverticula, varices, mucosal tears or ulcerations. The ventricle is of normal size, with normal wall-thickness. There is unremarkable <<partially digested food / fluid in the lumen>>, with no suspicion of blood content. The mucosa has well-formed rugae and shows <<no signs of lesions / {{mild / moderate erosions, but no ulceration}}. The gastric serosal surface is smooth.)) ((The duodenum, jejunum and ileum and colon are ordinarily configured with non-irritated lining. Content is normal. The mucosa is intact throughout. No visible tumor. The ileocecal valve is competent.))

(The appendix is non-irritated and of normal size.) {{There are scattered <<colonic / sigmoid>> diverticula without inflammation or perforation.}}

Minimal	More comprehensive	Normal ranges
The liver weighs ___g.	The liver is << of normal size / {{enlarged}}, at ___g.	[[Men: 970-1860 g. Women 600-1770g..]]

The liver surface is <<smooth ((and glistening)) {{/deformed by small and large nodules}}((, and is <<light tan / dark brown>> in color)). << Normal/ {{/ firm}} consistency. Cut surface is normal / << (shows normal homogeneous brown parenchyma) / {{Yellowish color, indicating steatosis}} / {{dark nutmeg similar paths, indicating congestion}}. (No focal changes.)((The liver edge is _cm below the right costal margin.)) The gallbladder has (regular size,) thin walls ((lined by a velvety green mucosa)). It contains {{__ number of gallstones measuring up to __ mm. Otherwise}} normal bile ((of about ___ ml [[or cc]]. No tumor or gallstones.)) {{Mild / Moderate / Severe cholesterolosis.}} ((The gallbladder serosa is smooth.)) Further information: Gallbladder The (extrahepatic) bile ducts are open(, ordinary and without gallstones in the lumen).
The pancreas has normal size (and shape, measuring __ )[[dimensions or weight]]. Cut surfaces are normal((ly tan and lobulated, without bleeding or definable focal changes. The main pancreatic duct is patent.)).

Lymphoid and endocrine organs

The spleen is of << normal size {{ / Enlarged [[> 230g]]}}>>, at ___ g. Normal consistency / {{ Firm consistency indicating of chronic venous stasis}}. Cut surfaces have normal appearance / ( normal bluish-red color, with no definable focal changes). ((The splenic artery and vein are normal.))

The thyroid and adrenal glands are normal bilaterally / (are ordinarily configured and with no definable focal changes on cut surfaces).

[[These are preferably located by the corresponding system of each cavity:]](( The thyroid weighs _ grams [[Up to 30 g versus over 30 g grams is an accepted cutoff between normal and increased weight of the thyroid gland]] and is symmetrical. Its consistency is soft {{/firm}}. Its external surface is brown and smooth {{/nodular / wrinkled}}. On sectioning it presents a homogeneous dark red appearance {{/contains several small nodules / contains a cyst}}. <<One/Two/Three/Four>> parathyroids are identified and appear normal. Further information: Parathyroid glands The adrenals are normal in size, shape and consistency. The cortices are orange with <<normal / increased / decreased>> thickness. The medullas are grey (autolyzed). ))

No abnormal lymph nodes.

( Lymph nodes in para-tracheal, para-aortic and abdominal regions are of normal size, texture and color.) ((No definable focal changes on cut surfaces.))

Urogenital

The kidneys are equally sized / (of normal size, with a total weight of ___ g)((a weight of ___ g on the right side and ___ g on the right)).

Sex	Weight, reference range
	Right kidney	Left kidney	Total
Men	80–160 g (2.8–5.6 oz)	80–175 g (2.8–6.2 oz)	160-335g (5.6-12.8 oz)
Women	40–175 g (1.4–6.2 oz)	35–190 g (1.2–6.7 oz)	75-365g (2.6-12.9 oz)

(No abnormal adhesions between the kidneys and surrounding fibrous capsules.)
The kidneys have smooth surfaces/ {{<<Finely / Coarsely>> granular brown surface, possibly indicating benign nephrosclerosis. There are a few cysts on the surface containing clear fluid}}. Cut surfaces have well-defined medulla, cortex, and papillae. {{The cortices and/or medullas are narrowed and congested. The papillary portions are intact.}}
The renal pelvis and ureters are unremarkable /( Renal pelvis and ureters have normal calibers, with non-irritated mucosal surfaces and open lumens).
The urinary bladder ((lies below the symphysis pubis and)) is unremarkable / ( is of normal size, with normal mucosa, and no tumor.)(( The urinary bladder contains __cc/ml of <<clear {{/ turbid}} urine. The wall is not thickened. The ureteral orifices are patent. The serosal surfaces are smooth and glistening {{and show <<soft / hard>> fibrous adhesions}})).
[[Either:]]

• [[Male]]: The prostate is of <<normal size (( measures _x _ x _ cm>> and has normal color. The consistency is <<normal elastic)){{/ firm / nodular}}. (No definable focal changes on cut surfaces). The testes are ((descended {{, atrophic}} and)) without abnormal masses.(( The penis and scrotum are unremarkable.))
• [[Female]]:

Uterus and adnexa are unremarkable.

((The uterus is normal. It measures __ x __ x __cm and weighs __ grams. Its serosal surface is <<smooth {{/ deformed by multiple nodules ranging between __ and _ cm}}>>. The cervix is unremarkable. The endometrial cavity is lined by a smooth atrophic velvety, tan membrane. The ovaries and fallopian tubes are normal.))

Central nervous system

The meninges and venous sinuses are unremarkable.

((The skull is unremarkable. The calvarium is opened in the usual manner. The scalp and overlying fascia are not remarkable. The skull is <<normal in thickness {{/ somewhat thickened in the frontal areas}}. The cerebrospinal fluid is clear. The dura and venous sinuses are unremarkable. The leptomeninges are thin, shiny and non-irritated, with no visible bleeding or exudates. The superficial blood vessels are not congested. The sulci and gyri are <<normal {{/ flattened}}.

(No visible thrombi. No epidural, subdural or subarachnoid hematoma.)

The brain is symmetrical and weighs ___g.	( The cerebral and cerebellar hemispheres are of equal size, and have a normal weight of ___g. [[Men: 1.180 to 1.620 g. Women: 1.030 to 1.400 g]]
No signs of herniation	(No grooves on the bases of the cerebrum or cerebellum.)

((The cerebral ventricles are of normal size, with normal linings.)) Cut surfaces ((after fixation)) of the cerebrum, cerebellum and brainstem show (normal gray and white parenchyma, and) no ((encephalomalacia, ))(hemorrhages, tumors or other) focal abnormalities. ((The gyral pattern is preserved.))
The basal cerebral arteries << are ordinary / {{have mild / moderate / severe atherosclerosis}}>> without aneurysms or occlusions.

Skeleton

Scalp and base of skull are ordinary / (without visible lesions or injuries).
((The vertebral column is unremarkable. The musculature is fairly well developed. There are no deformities of the musculoskeletal system. The bone marrow appears red and cellular.))

{{Other organs

if evaluated.}}

Histopathology

No samples taken / {{Tissue samples have been taken from the << heart, lungs, liver and/or kidneys >> for supplementary microscopic and/or bacteriological examination.}}

((Clinicopathologic correlation))

[[Discussion of how findings relate to the probable clinical course.]]

Microscopy report

{{Overall <<moderate / severe>> post-mortem autolysis((, making interpretations on cellular level <<difficult / unfeasible>>)).}} [[The degree of autolysis may be specified for each site individually.]]

(After the location identifier, each list item can generally begin as "This section/These sections << shows / reveals >>...)

• Breast: ((Section(s) show(s))) no focal changes. {{Non-proliferative fibrocystic changes and microcalcifications.}}
• Bone marrow from <<rib / __ [[other location]] >>: Section shows trilineage hematopoiesis. There is no evidence of malignancy. Further information: Bone marrow
• Lymph nodes at __ [[ location]]: ((Section(s) show(s)))__ [[number of]] benign{{, reactive lymph node(s) with anthracotic pigment deposition}}.
• Heart: Sections of ___ [[location]] show no evidence of infarction. Further information: Heart autopsy
• Coronary arteries: Sections of the three main coronary arteries reveal << mild / moderate / severe>> atherosclerosis, with approximately __%, __% and __% stenosis of the left anterior descending, left circumflex coronary artery and right coronary artery, respectively. Further information: Arteries

Thyroid parenchyma with autolytic changes, with thyroid follicular cells sloughing off into the follicles. It does not need mentioning in the report (unless severe enough that further evaluation impossible).

• Thyroid gland: ((Section(s) show(s))) normal follicles with no focal changes.
• Parathyroid: <<1, 2, 3, 4>> parathyroid gland(s) examined; ((Section(s) show(s))) no focal changes or signs of hyperplasia. Further information: Parathyroid
• Pituitary gland: ((Section(s) show(s))) adenohypophysis and neurohypophysis with no focal changes. Further information: Pituitary
• Liver: ((Section(s) show(s))) {{congested}} hepatic parenchyma with no focal changes. Further information: Liver
• Adrenal glands: ((Section(s) show(s))) right and left adrenal glands with no focal changes. (The cortices and medullae are unremarkable.)
• Spleen: ((Section(s) show(s))) normal distribution and architecture of the red and white pulp.
• Kidneys: ((Section(s) show(s))) both kidneys with {{<<mild / moderate / severe >> <<generalized / focal / nodular>> glomerular sclerosis, and <<mild / moderate / severe >> arteriosclerosis.}} There are no focal changes. Further information: Kidney autopsy

Gastroesophageal junction with autolytically denuded gastric mucosa (no further comment needed as metaplasia or dysplasia cannot be negated).

• Gastroesophageal junction: ((Section(s) show(s))) squamo-epithelial junction with no metaplasia or dysplasia. Further information: Gastroesophageal junction
• Pancreas: ((Section(s) show(s))) {{autolytic}} (pancreatic parenchyma with) no focal changes. Further information: Pancreas
• Lungs: {{Sections of all lobes of the lung}} show vascular congestion. (There is no evidence of edema, acute bronchopneumonia, malignancy or thromboemboli.) Further information: Lung autopsy
• Urinary bladder: ((Section(s) show(s))) <<normal {{/ autolytically denuded}}>> urothelium.
• Brain: ((Standard sections of the cerebral cortex, basal ganglia, hippocampus, thalamus/substantia nigra, medulla oblongata and cerebellum show)) intact cytoarchitecture. There is no evidence of hemorrhage, tumor, metastatic disease or vasculitis. Further information: Brain autopsy

Males:

• Testis: ((Section(s) show(s))) no focal changes. (There <<are no / are few / is a normal amount of>> visible mature spermatozoa.)
• Prostate: ((Section(s) show(s))) no focal changes {{/nodular prostatic hyperplasia. There is no evidence of malignancy}}.

Females:

• Uterus: ((Section(s) show(s))) no focal changes.
• Ovary: ((Section(s) show(s))) no focal changes bilaterally.

• 

  Postmortem bacterial growth is often seen in autopsy, generally as basophilic and equally sized tiny granules. The absence of inflammation indicates that it is a postmortem change (such as leukocytes being commensurate with red blood cells as in this image of bacteria within the fibrin of a postmortem blood clot).

• 

  A true bacterial infection, on the other hand, is expected to have a presence of leukocytes, or as in this case, a monocytic and histiocytic granuloma surrounding the bacteria.

  See also: General notes on reporting

External applications

• MD Hero reference range generator for autopsy measurements by age and height etc.

The standard reference range reference is duplicated because of technical reasons by being included in Patholines:Templates.

Heart autopsy

Autopsy cutting checklist

• Remove the parietal pericardium
• Separate the heart from the from lungs by cutting through the major vessels. The pulmonary artery should be cut first and the lumen inspected for any pulmonary embolism.
• Weigh the heart.
• Dissect the coronary vessels. More details in section below. Further information: Arteries
• On the right side of the heart, dissect in the direction of blood flow: Superior vena cava > right atrium > tricuspid valve > right ventricle. Look for thromboses or patent foramen ovale.
• Dissect the atrial appendages, to exclude thromboses.
• Dissect the left ventricle, such as into circumferential slices from the apex to the base. Inspect (and measure) the left ventricular wall thickness.

Valve circumferences are measured at the basal ring (bottom in image).

• (Measure the circumferences of the four valves. Cutoffs for valve dilatation:

• Mitral valve: circumference greater than 9.9 cm in males and 9.1 cm in females
• Aortic valve: circumference greater than 8.5 cm in males and 7.9 cm in females
• Tricuspid valve: circumference greater than 11.8 cm in males and 11.1 cm in females
• Pulmonic valve: circumference greater than 7.5 cm in males and 7.4 cm in females)

In case of suspected infarction, see autopsy of myocardial infarction.

For left and right wall thickness, uppr limits of 1.5 cm and 0.5 cm, respectively, are generally used to distinguish wall thickening on autopsy.

• 

  Circumferential slice of left ventricle, showing a fresh papillary muscle infarction.

• 

  Concentric left ventricular hypertrophy. Left ventricle is at right in image, serially sectioned from apex to near base.

Gross examination of coronary arteries

To find the right and left coronary arteries, look distally to each corresponding aortic valve cusp.

Make longitudinal ((or transverse cuts at 3 mm intervals) through:

• The right coronary artery.
• ((The right marginal artery))
• The left coronary and circumflex artery.
• The left anterior descending artery.
• ((The left marginal artery))
• ((The left diagonal branch))
• {{Any vessel grafts to the heart}}

Examine for atherosclerosis, stenosis and thrombi

(If the coronary arteries are calcified, sharply dissect them from the heart, without cutting too deeply into the muscle. Fix them in formalin, decalcify them and then cut them at 3 mm intervals.)

Estimate the percentage of any significant stenosis or occlusion. Further information: Arteries

• 

  Plaque at different percentages of atherosclerotic stenosis.

The presence of a totally occlusive thrombotic mass confers a diagnosis of likely sudden cardiac death death even in the absence of microscopically visible necrosis.

Weight

Cardiomegaly can be defined as a weight exceeding the 95th percentile of normal individuals, preferably adjusted for weight, size, age and gender.

Weight of heart versus body.

Microscopic examination

Myocardium

Look for:

• Signs of myocardial infarction

If one or more is present, see Autopsy of myocardial infarction

• (Optionally, also look for:)

• 

  Ruptured intercalated discs. Further information: Ruptured intercalated discs

• 

  Myxomatous degeneration of valves.

• (Optionally, also perform a General microscopic screening.)

Reporting

This is en example report:
The heart << has normal weight / is enlarged [[ > 399 g in women and> 449 g in men]] >>, weighing ___ g. ((The epicardium is transparent. There is a moderate amount of subepicardial fat.

Normal configuration

(No atrial or ventricular dilation. No ventricular wall thickening) / {{The left ventricle has {{concentric}} hypertrophy, with a wall thickness of ___ mm.}}

((No atrial or ventricular dilation. The right and left auricular appendage is unremarkable. The left ventricular wall thickness is __ cm and the right is ___. The trabeculae carneae are normal ({[Finding-begin}}/ prominent /flattened}}.)) [[A comprehensive report may describe each atrium, valve and ventricle etc. in order of blood flow.]]

(Foramen ovale is closed.) ((The ductus arteriosus is obliterated))
The coronary arteries ((arise in normal position. The coronary ostia are << patent {{partially occluded by arteriosclerotic calcification}}>>. They)) have << no / mild / moderate / severe >> {{and partially calcified}} arteriosclerosis. They are traced, ((throughout their length by transverse sections)) {{after fixation and decalcification}} <<without significant constrictions.{{ / The lumina of the left anterior descending, right coronary, and left circumflex coronary arteries are _%, _%, and _% narrowed, respectively.}} [[If the degree of stenosis on microscopy sections of coronary arteries only differ slightly from the gross description, preferably write "mild/moderate/severe atherosclerosis consistent with the gross inspection."]] (Gross measurement of coronary artery stenosis is generally more accurate than microscopic measurement, so the former generally has precedence.)

No thrombi in the cardiac atria (including auricles), chambers or coronary arteries.

Chordae tendineae, the endocardium and heart valves are unremarkable.

(The endocardium is smooth and shiny. Chordae tendineae are unremarkable. The valves are normal in number, and are thin and fine at the openings.)

((The endocardium is smooth, transparent and free of mural thrombi. The valve leaflets and chordae tendinae are overall delicate, pliable and free of lesion or calcification. <<Its leaflets are thin and pliable / No signs of inflammation>>. The tricuspid valve <is / is not> dilated, measuring _cm in circumference. The pulmonic valve <is / is not> dilated, measuring _cm in circumference. It is composed of <<two / three>> cusps which are discrete and pliable. The mitral valve <is / is not> dilated, measuring _cm in circumference. Its leaflets are thin and pliable {{/ redundant / adherent to each other}}. The aortic valve <is / is not> dilated, measuring _ cm in circumference. It is composed of <<two / three>> cusps which are thin and pliable. {{The cusps are calcified at the bases / adherent to each other.}} {{The valve displays mild / moderate / severe myxomatous degeneration.}} The epicardium and subepicardium are unremarkable. The papillary muscles are normal {{ / hypertrophied}}))

The myocardium has ((a homogeneous reddish brown color, and)) no signs of <<fresh lesion / ((areas of necrosis or hemorrhage))>> (or scar){{/ streaks of white scar tissue}}.

  See also: General notes on reporting

Main page

• Main page of Patholines

Autopsy of myocardial infarction

Autopsy cutting checklist

• Remove the parietal pericardium
• Separate the heart from the from lungs by cutting through the major vessels. The pulmonary artery should be cut first and the lumen inspected for any pulmonary embolism.
• Weigh the heart.
• Dissect the coronary vessels. More details in section below. Further information: Arteries
• On the right side of the heart, dissect in the direction of blood flow: Superior vena cava > right atrium > tricuspid valve > right ventricle. Look for thromboses or patent foramen ovale.
• Dissect the atrial appendages, to exclude thromboses.
• Dissect the left ventricle, such as into circumferential slices from the apex to the base. Inspect (and measure) the left ventricular wall thickness.

Valve circumferences are measured at the basal ring (bottom in image).

• (Measure the circumferences of the four valves. Cutoffs for valve dilatation:

• Mitral valve: circumference greater than 9.9 cm in males and 9.1 cm in females
• Aortic valve: circumference greater than 8.5 cm in males and 7.9 cm in females
• Tricuspid valve: circumference greater than 11.8 cm in males and 11.1 cm in females
• Pulmonic valve: circumference greater than 7.5 cm in males and 7.4 cm in females)

• 

  A one week old myocardial infarction of the posterior left ventricle, with focal rupture, in fresh state (left) and after formalin fixation (right). The infarcted area is pale whereas the rupture is hemorrhagic (dark red).

• 

  Fibrosis, in this case an old myocardial infarction of the posterior wall of the left ventricle (seen as pale areas).

Look for areas of fibrosis (Further information: Myocardial fibrosis ) or hemorrhage. Sample tissue from suspected areas, at least in cases where a diagnosis cannot be made from gross examination alone.

Gross processing of coronary arteries

Make longitudinal (or transverse cuts at 3 mm intervals) through:

• The right coronary artery.
• (The right marginal artery)
• The left coronary and circumflex artery.
• The left anterior descending artery.
• (The left marginal artery)
• (The left diagonal branch)
• {{Any vessel grafts to the heart}}

Estimate the percentage of any significant stenosis or occlusion. Further information: Arteries

• 

  Plaque at different percentages of atherosclerotic stenosis.

The presence of a totally occlusive thrombotic mass confers a diagnosis of likely sudden cardiac death death even in the absence of microscopically visible necrosis.

Microscopy of the myocardium

By individual parameters

Myocardial histologic parameters (HE staining)	Earliest manifestation	Full development	Decrease/disappearance	Image
Streched/wavy fibres	0.5–4 h
Coagulative necrosis: cytoplasmic hypereosinophilia	1–3 h	1–3 days; cytoplasmic hypereosinophilia and loss of striations	> 3 days: disintegration
Interstitial edema	4–12 h
Coagulative necrosis: ‘nuclear changes’	12–24 (pyknosis, karyorrhexis)	1–3 days (loss of nuclei)	Depends on size of infarction
Neutrophil infiltration	12–24 h	1–3 days	5–7 days
Neutrophil karyorrhexis	1.5–2 days	3–5 days
Macrophages and lymphocytes	3–5 days	5–10 days (including ‘siderophages’)	10 days to 2 months
Vessel/endothelial sprouts*	5–10 days	10 days–4 weeks	4 weeks: disappearance of capillaries; some large dilated vessels persist
Fibroblast and young collagen*	5–10 days	2–4 weeks	After 4 weeks; depends on size of infarction;
Dense fibrosis Further information: Myocardial fibrosis	4 weeks	2–3 months	No

• Some authors summarize the vascular and early fibrotic changes as ‘granulation tissue’, which is maximal at 2–3 weeks

Chronological

Time	Gross examination	Histopathology (light microscopy)
0 - 0.5 hours	None	None
0.5 – 4 hours	None	Glycogen Depletion, as seen with a PAS Stain Possibly waviness of fibers at border
4 – 12 hours	Sometimes dark mottling	Initiation of coagulation necrosis Edema Hemorrhage
12 – 24 hours	Dark mottling	Ongoing coagulation necrosis Karyopyknosis Hypereosinophilia of myocytes Contraction band necrosis in margins Beginning of neutrophil infiltration
1 – 3 days	Infarct center becomes yellow-tan	Continued coagulation necrosis Loss of nuclei and striations Increased infiltration of neutrophils to interstitium
3 – 7 days	Hyperemia at border Softening yellow-tan center	Beginning of disintegration of dead muscle fibers Apoptosis of neutrophils Beginning of macrophage removal of dead cells at border
7 – 10 days	Maximally soft and yellow-tan Red-tan margins	Increased phagocytosis of dead cells at border Beginning of granulation tissue formation at margins
10 – 14 days	Red-gray and depressed borders	Mature granulation tissue with type I collagen
2 – 8 weeks	Gray-white granulation tissue	Increased collagen deposition Decreased cellularity
More than 2 months	Completed scarring	Dense collagenous scar formed
If not else specified in boxes, then reference is nr

Topography

Classify the topographic distribution of any myocardial infarction, if possible:

• 

Reporting

Example of a normal report:

• In the myocardium, there is no evidence of fresh lesion. (The myocardium has normal texture and a homogeneous reddish brown color. No inflammation or scarring.)

  See also: General notes on reporting

Main page

• Main page of Patholines

Ruptured intercalated discs

Ruptured intercalated discs, in this case regarded as a visual artifact, and was not reported.

Ruptured intercalated discs of myocytes of the heart have two main causes:

• Microtome processing, thereby being a visual artifact, not needing reporting.
• Forceful myocardial contraction, at least in case of heart autopsy. This is mainly caused by ventricular fibrillation or electric shock,

If a lab often cause it as a visual artifact, it may be ignored in the report. If not, look for signs indicating forceful myocardial contraction, and thereby the mentioning of the findings in the report. Such signs are:

• Alternating bundles of hypercontracted myocytes with hyperdistended ones.
• Square-shaped myocardiocyte nuclei.
• Hyperdistended myocardiocytes with detached sarcomeres, and in proximity of hypercontracted myocardiocytes.

• 

  Cases with ruptured intercalated discs often also display free myocardial nuclei or nuclear fragments, which should not be confused with a lymphocytic infiltrate.

Lung autopsy

Autopsy of the lungs, not including larger pulmonary vessels (instead summarized at Autopsy - Other thorax).

Basic autopsy cutting

In non-forensic Autopsy:

The lungs may be cut after removing the heart through cutting through the major vessels close to it, or by removing each lung by cuts by each lung hilum.

• Dissect the pulmonary arterial system, from the pulmonary trunk and including at least segmental arteries.
• Dissect the bronchial tree, at least to segmental bronchi. Check for obstructions.
• Weigh each lung (possibly first if having cut each lung at the hilus).
• Make some additional sections through the lung parenchyma. Squeeze at each side to detect any pus and edema.

For context, see Autopsy

Gross evaluation

Gross pathology of miliary "millet seed-like" tuberculosis.

• A spongy consistency, and watery and frothy liquid being pressed from the parenchyma, indicates simple edema.
• A spongy consistency and reddish (blood-stained) fluid being pressed from the parenchyma, indicates acute congestion.
• A brownish or dark reddish color of the fluid pressed from the parenchyma indicates chronic congestion, and may not have a spongy consistency.

Normal weight:

	Left	Right
Men	112-675g	155-720g
Women	105-515g	101-589g

Fixation

Generally 10% neutral buffered formalin.

  See also: General notes on fixation

Microscopic evaluation

Look for the most common pathologic lung findings:

• Alveolar fluid. Further information: Alveolar fluid
• Vascular congestion, which can usually be seen easiest in the alveolar walls. It indicates left sided heart failure, especially when seen together with alveolar fluid. Further information: Chronic pulmonary congestion
• Inflammatory cells, where a mild to moderate lymphocytic infiltrate is consistent with with heart failure, while neutrophils indicate pneumonia. pigmented macrophages of the lung may indicate chronic heart failure.
• Mycobacteria in regions of the world with substantial prevalence
• Carcinoma Further information: Lung tumor
• Aspiration: Other foreign contents in airways. Further information: Aspiration in autopsy
• Embolism of pulmonary arteries.

• 

  Edema

• 

  Bronchopneumonia, with neutrophils filling a bronchiole.

• 

  Carcinoma (in this case bronchioloalveolar cell adenocarcinoma) Further information: Lung tumor

• 

  hyaline membranes, suggesting diffuse alveolar damage.

• 

  A pulmonary artery with fat embolism (seen as multiple empty globular spaces on this H&E stain since its processing dissolves fat). There is a bone marrow fragment in the middle, and multiple single hematopoietic cells in the blood, being evidence of fracture as the source of the embolism.

Main diagnoses

• Left sided heart failure:

• Acute congestion manifests as alveolar capillaries being engorged with blood, as well as associated alveolar septal edema and/or focal intra-alveolar hemorrhage.
• Chronic pulmonary congestion manifests as thickened and fibrotic septa, and alveolar spaces containing numerous pigmented lung macrophages.

If respiratory epithelial shedding is seen, look for vascular leakage, mucus hypersecretion and/or widespread airway narrowing, together indicating asthma death. Otherwise, it is a frequent postmortem change.

Additional potential findings are mentioned in the general Lungs article.

Reporting

Report findings and if they are consistent with already known diagnoses.

Example:

Presence of sideophages indicating chronic heart failure. Prominent vessels, including alveolar capillaries, and a moderate lymphocytic infiltrate, consistent with chronic heart failure or acute decompensation.

Further information: Autopsy

Kidney autopsy

Autopsy cutting

A fine granular surface can be reported as nephrosclerosis, and is associated with arteriosclerosis and glomerulosclerosis.

In non-forensic autopsy, on each side:

• After evaluating the adrenal gland, dissect the renal fascia and perirenal fat laterally, and make an incision in the renal capsule. The renal capsule can then generally be loosened by hand. Note the surface texture. (Determine the color and consistency of the kidney.)
• Dissect the kidney in the coronal plane, towards the hilum. Inspect the cut surfaces.

Gross report

The kidneys are equally sized / (of normal size, with a total weight of ___ g)((a weight of ___ g on the right side and ___ g on the right)).

Sex	Weight, reference range
	Right kidney	Left kidney	Total
Men	80–160 g (2.8–5.6 oz)	80–175 g (2.8–6.2 oz)	160-335g (5.6-12.8 oz)
Women	40–175 g (1.4–6.2 oz)	35–190 g (1.2–6.7 oz)	75-365g (2.6-12.9 oz)

(No abnormal adhesions between the kidneys and surrounding fibrous capsules.)
The kidneys have smooth surfaces/ {{<<Finely / Coarsely>> granular brown surface, possibly indicating benign nephrosclerosis. There are a few cysts on the surface containing clear fluid}}. Cut surfaces have well-defined medulla, cortex, and papillae. {{The cortices and/or medullas are narrowed and congested. The papillary portions are intact.}}
The renal pelvis and ureters are unremarkable /( Renal pelvis and ureters have normal calibers, with non-irritated mucosal surfaces and open lumens).

Fixation

Generally 10% neutral buffered formalin.

  See also: General notes on fixation

Microscopic evaluation

Kidney with substantial autolysis, but otherwise being unremarkable.

The lining of a simple cyst, with inconspicuous nuclei. They usually have a single layer of cuboidal, flattened or atrophic epithelium, but this case has a somewhat thicker fibrous layer.

Findings

The main findings to look for:

Glomerular findings

• Diffuse and/or nodular mesangial deposits:

• 

  Nodular glomerulosclerosis, prompting a consideration of diabetic nephropathy, see section below.

• 

  A glomerulus with total hyalinization (also called a globally sclerotic glomerulus). People aged ≤40 should have less than 1% - 10% globally sclerotic glomeruli, and less than 30% by age 80. An increased amount indicates mainly hypertensive nephropathy, see section below.

• Mesangial hypercellularity (which has been defined as more than 3 cell nuclei per peripheral mesangial area on a 4-μm thick tissue section), prompting a consideration of diabetic nephropathy, see section below.
• Endocapillary hypercellularity, prompting a consideration of diabetic nephropathy, see section below.
• Glomerular basement membrane thickening and/or duplication, prompting a consideration of diabetic nephropathy, see section below.

• 

  Proteinaceous material in Bowman's space, see Proteinaceous material in Bowman's space

• Thrombi

• 

  Thrombi (arrows) and glomerular crescent formation (dotted enclosure, in rapidly progressive glomerulonephritis, in this case due to SLE).

Tubulointerstitial findings

• Interstitial inflammation
• Cytologic atypia in the tubular epithelial cells
• Crystals
• Atypical or pigmented casts

• 

  Distal tubular casts (in addition to interstitial inflammation and fibrosis in myeloma cast nephropathy).

Vascular findings

• Thrombi
• Mural deposition of amorphous material
• Vasculitis
• Congestion

• 

  Intimal thickening with an onion skin-like appearance, indicating mainly hypertensive nephropathy, see section below.

• 

  Histopathology of arteriolar hyalinosis, being a component of nephroarteriolosclerosis, also indicating mainly hypertensive nephropathy, see section below.

• 

  Histopathology of vasculitis (in systemic sclerosis): fibromuscular intimal proliferation and adventitial fibrosis

• 

  Glomerulus with congestion, being an unspecific postmortem finding.

Diagnoses

If indicated by findings above:

Diabetic nephropathy

Nodular acellular light purple glomerular matrix deposits, typical of diabetic nephropathy.

For alterations in glomerular matrix and/or cellularity, the most common cause is diabetic nephropathy, and typically presents as glomerular enlargement, mesangial sclerosis, basement membrane thickening and and arteriolar hyalinosis.

Hypertensive nephropathy

Hypertensive nephropathy has two types:

• Benign hypertensive nephrosclerosis: Characterized by arterial or arteriolar hyalinosis, intimal fibrosis, or medial hypertrophy.
• Malignant hypertensive nephrosclerosis: Characterized by fibrinoid necrosis (acute stage) or myointimal cell proliferation, usually with an “onion-skinning” appearance (chronic stage).

Hypertensive nephropathy, showing fibrous intimal thickening (arrow), interstitial fibrosis, tubular atrophy with thickened tubular basement membranes.

Report

• Findings and if they are consistent with already known diagnoses.

Further information: Autopsy

Brain autopsy

Gross processing

Steps

Sample from the pituitary if it protrudes above the sella turcica. Further information: pituitary Brain:

• Weight the brain. Overall normal range (95% prediction interval) is 1100 to 1700 g, +60g for males and -60g for females.
• Inspect: Grooves indicating herniation? Hemorrhages?
• Dissect the basilar artery and circle of Willis, either before or after separation from the brain. [[If there is likely a need to demonstrate the case to an additional person later, the arteries of the skull base are preferably dissected after first separating them from the brain.]] Look mainly for thromboses.
• Separate the brainstem, cerebellum and cerebrum, which may be done by first separating the former two together from the cerebrum.

Normal brain versus in Alzheimer's disease.

• Slice each part, looking for hemorrhages and/or infarcts.

• For the cerebrum, cut it into slices about 1 cm thick. It can be done from frontal to occipital, or by starting coronally into two halves at the level of the mammillary bodies and continuing in each direction from there.

• At least in people aged over 65-75 years of age {{or with suggestive history}}, look for signs of Alzhemier's disease (see picture).

Brain with bacterial meningitis: The dura is retracted to show leptomeninges with edema and multiple small hemorrhagic foci.

Report

The meninges and venous sinuses are unremarkable.

((The skull is unremarkable. The calvarium is opened in the usual manner. The scalp and overlying fascia are not remarkable. The skull is <<normal in thickness {{/ somewhat thickened in the frontal areas}}. The cerebrospinal fluid is clear. The dura and venous sinuses are unremarkable. The leptomeninges are thin, shiny and non-irritated, with no visible bleeding or exudates. The superficial blood vessels are not congested. The sulci and gyri are <<normal {{/ flattened}}.

(No visible thrombi. No epidural, subdural or subarachnoid hematoma.)

The brain is symmetrical and weighs ___g.	( The cerebral and cerebellar hemispheres are of equal size, and have a normal weight of ___g. [[Men: 1.180 to 1.620 g. Women: 1.030 to 1.400 g]]
No signs of herniation	(No grooves on the bases of the cerebrum or cerebellum.)

((The cerebral ventricles are of normal size, with normal linings.)) Cut surfaces ((after fixation)) of the cerebrum, cerebellum and brainstem show (normal gray and white parenchyma, and) no ((encephalomalacia, ))(hemorrhages, tumors or other) focal abnormalities. ((The gyral pattern is preserved.))
The basal cerebral arteries << are ordinary / {{have mild / moderate / severe atherosclerosis}}>> without aneurysms or occlusions.

  See also: General notes on reporting

Microscopy

Tissue selection

Gross pathology of a brain after sectioning, showing a normal brain with the cerebrum cut in coronal sections, and the cerebellum, pons and medulla cut in horizontal sections. Standard sections for microscopic examination are annotated.

(Take samples for microscopy from:

• Cerebrum:

• Frontal lobe
• Hippocampus
• Thalamus and substantia nigra

• Cerebellum, including dentate nucleus
• Basal ganglia
• Medulla oblongata)

Look for any hemorrhage, tumor, metastatic disease, vasculitis or infarction.

Substantia nigra

Substantia nigra in Parkinson's disease: A. Pars compacta neuron with a Lewy body, extracellular neuromelanin and pigment-laden macrophages. B. Alpha-synuclein-positive Lewy neurit.

In people over about 60 years of age, or in a history of suspected Parkinson's disease, look at the pars compacta for Lewy bodies and any alpha-synuclein-positive neurites, indicating Parkinson's disease.

Hippocampus

In people over about 60 years of age, or in a history of suspected Alzheimer's disease, look for its main signs in the hippocampus:

• 

  These signs are mainly visible in the temporal lobes and hippocampus proper, with following images taken from its CA3 area, marked in box.

• 

  Neurofibrillary tangles

• 

  Amyloid plaques

• 

  Granulovacuolar degeneration

Further information: Alzheimer's disease

Basal ganglia

A lacunar infarct in the thalamus.

Look for lacunar infarcts, which are most common in the deep nuclei of the brain.

Infarction

Attempt to estimate the age of any infarct. Also look at blood vessels for thrombus or stenosis.

• 

  On low-power, look for areas of edema, as pale areas that do not conform to anatomic borders. This case is at approximately 24 hours.

• 

  If found, or if there is clinical suspicion of infarction in the area, look at high magnification in the pale areas for signs of infarction: The neurons become hypereosinophilic and there is an infiltrate of neutrophils. There is slight edema and loss of normal architecture in the surrounding neuropil.

• 

  Gross pathology of an old stroke in the left posterior parietal lobe.

Chronology at early infarction:

• At first, injured neurons shrink and become eosinophilic, with condensed nuclei. Astrocytes swell (Alzheimer type II cells).
• After 6 to 8 hours, neutrophils have surrounded cerebral vessels and begin to infiltrate.

A more detailed chronology is as follows:

Finding	Appearance
Eosinophilic (red) neurons	6 hours -35 days
Polymorphonuclear leukocytes	1-37 days
Other acute neuronal injuries	1-60 days
Coagulative necrosis	1 day - 5 years
Spongiosis of surrounding tissue	1 day and older
Astrogliosis (gemistocytes)	2 days and older
Neo-vascularization	3 days and older
Hemosiderin pigment	3 days and older
Mononuclear inflammatory cells	3 days–50 years
Macrophages	3 days–50 years
Cavitation	12 days or older

Common normal findings

• 

  Brain sand (corpus arenaceum) in cerebral white matter, which are age related changes that generally do not need reporting.

• 

  Postmortem bacterial growth, with the absence of inflammation disproving pre-mortem presence. It has intra- and perivascular location.

Microscopy report

Example in normal findings:

((Standard sections of the cerebral cortex, basal ganglia, hippocampus, thalamus/substantia nigra, medulla oblongata and cerebellum show)) intact cytoarchitecture. There is no evidence of hemorrhage, tumor, metastatic disease or vasculitis.

Main page

• Main page of Patholines

External link

• The Human Brain Atlas, including scrollable labeled coronal planes==Notes==

Main page

• Main page of Patholines