Brainstem Injuries in Fatal Road Traffic Accidents: A Medico-Legal Autopsy Analysis of Pontine and Medullary Lesions from Southern India

Abstract

Background: Brainstem injuries are among the most devastating consequences of road traffic accidents (RTAs) because they involve vital respiratory, cardiovascular, and neurological centers. Traumatic lesions involving the pons and medulla are frequently associated with instantaneous death or rapid clinical deterioration. Despite their considerable medico-legal significance, these injuries are often overlooked during routine autopsy unless meticulous brainstem examination is performed. Materials and Methods: A cross-sectional autopsy-based study was conducted on 155 fatal road traffic accident victims examined in the Department of Forensic Medicine and Toxicology, Shimoga Institute of Medical Sciences, Karnataka, India, between January and December 2013. During medico-legal autopsy, the brain was removed along with the intact brainstem and upper cervical spinal cord. Serial gross sections of the pons and medulla were examined for traumatic lesions including hemorrhage, contusion, laceration, and transection. Demographic characteristics, road-user category, and brainstem injury patterns were analyzed using descriptive statistics. Results: Among 155 fatal RTA victims, pontine injuries were identified in 17 (10.96%) cases and medullary injuries in 5 (3.2%) cases. Pontine hemorrhage was the commonest lesion (7.1%), followed by transection (3.2%) and laceration (0.6%). Medullary injuries comprised transection (1.9%), contusion (0.6%), and laceration (0.6%). Riders and pedestrians constituted the majority of victims with brainstem injuries. Most victims sustaining medullary or pontine transection died at the scene of the accident. Conclusion: Brainstem injuries represent an important cause of mortality in fatal road traffic accidents. Pontine hemorrhage is the predominant brainstem lesion, whereas medullary transection is strongly associated with instantaneous death. Routine systematic examination of the brainstem during medico-legal autopsy is essential for accurate determination of the mechanism and cause of death.