Guidelines on autopsy practice

Traumatic brain injury

December 2023

Series authors: Dr David Bailey, Clinical Lead for Autopsy Guidelines

Dr Ben Swift, Forensic Pathology Services, Oxon

Specialist authors: Dr Rob Goldspring, Nottingham University Hospitals NHS Trust

Dr Ian Scott, The Walton Centre NHS Foundation Trust
Unique document G188
number
Document name Guidelines on autopsy practice: Traumatic brain injury
Version number 2
Produced by The specialist content of this guideline has been produced by
Dr Rob Goldspring, Consultant Neuropathologist, Nottingham
University Hospitals NHS Trust, and Dr Ian Scott, Consultant
Neuropathologist, The Walton Centre NHS Foundation Trust.
Date active December 2023 (to be implemented within 3 months)
Date for full review December 2028
Comments In accordance with the College’s pre-publications policy, this
document was on the Royal College of Pathologists’ website for
consultation from 29 March to 26 April 2023. Responses and
authors’ comments are available to view on publication of the
final document.
Dr Brian Rous
Clinical Lead for Guideline Review

The Royal College of Pathologists

6 Alie Street, London E1 8QT
Tel: 020 7451 6700
Fax: 020 7451 6701
Web: www.rcpath.org

Registered charity in England and Wales, no. 261035

© 2023, the Royal College of Pathologists

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This work is copyright. You may download, display, print and reproduce this document for your personal, non-commercial
use. Requests and inquiries concerning reproduction and rights should be addressed to The Royal College of
Pathologists at the above address. First published: 2023.

Contents
1 Introduction.................................................................................................................. 5

2 The role of the autopsy ................................................................................................ 5

3 Brain pathology encountered at post-mortem examination ......................................... 6

4 Specific health and safety aspects .............................................................................. 9

5 Clinical information relevant to the autopsy ................................................................. 9

6 The autopsy procedure ............................................................................................. 10

7 Specific organ systems to be considered .................................................................. 11

8 Organ retention ......................................................................................................... 11

9 Histological examination ............................................................................................ 13

10 Paediatric head injury13,14 .......................................................................................... 15

11 Toxicology and other relevant samples ..................................................................... 15

12 Imaging...................................................................................................................... 15

13 Clinicopathological summary ..................................................................................... 16

14 Summary of post-mortem brain examination with head injury ................................... 16

15 Examples of cause of death opinions/statements ..................................................... 17

16 Criteria for audit ......................................................................................................... 18

17 References ................................................................................................................ 19

Appendix A Recommended blocks to assess diffuse traumatic brain injury ................ 21

Appendix B Summary table – Explanation of grades of evidence ................................ 22

Appendix C AGREE II guideline monitoring sheet ....................................................... 23

NICE has accredited the process used by the Royal College of Pathologists to produce
its autopsy guidelines. Accreditation is valid for 5 years from 25 July 2017. More
information on accreditation can be viewed at www.nice.org.uk/accreditation.

For full details on our accreditation visit: www.nice.org.uk/accreditation.

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Foreword
The autopsy guidelines published by the Royal College of Pathologists (RCPath) are
guidelines that enable pathologists to deal with non-forensic consented and
Coroner’s/Procurators Fiscal’s post-mortem examinations in a consistent manner and to a
high standard.

The guidelines are systematically developed statements to assist the decisions of

practitioners and are based on the best available evidence at the time the document was
prepared. Given that much autopsy work is single observer and one-time only in reality, it
has to be recognised that there is no reviewable standard that is mandated beyond that of
the FRCPath Part 2 exam or the Certificate of Higher Autopsy Training (CHAT).
Nevertheless, much of this can be reviewed against ante-mortem imaging and other data.
This guideline has been developed to cover most common circumstances. However, we
recognise that guidelines cannot anticipate every pathological specimen type and clinical
scenario. Occasional variation from the practice recommended in this guideline may
therefore be required to report a case in a way that that maximises benefit to pathologists,
Coroners/Procurators Fiscal and the deceased's family. Pathologists should be able to
justify any departure from recommended practice.

There is a general requirement from the General Medical Council (GMC) to have
continuing professional development (CPD) in all practice areas and this will naturally
encompass autopsy practice. Those wishing to develop expertise/specialise in pathology
are encouraged to seek appropriate educational opportunities and participate in the
relevant external quality assurance (EQA) scheme.

The guidelines themselves constitute the tools for implementation and dissemination of
good practice.

The following stakeholders were consulted for this document:

• Human Tissue Authority, which includes representatives from:

– Association of Anatomical Pathology Technology

– Institute of Biomedical Science

– The Coroners’ Society of England and Wales

– Home Office Forensic Science Regulation Unit

– Forensic Pathology Unit

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 – British Medical Association

• British Neuropathological Society.

The information used to develop this guideline was obtained by undertaking a systematic
search of PubMed. Previous versions of this guideline were also used to inform this
update. Key terms searched included traumatic brain injury, cerebral contusion, diffuse
axonal injury, diffuse vascular injury, post mortem and autopsy between January 2010 and
December 2022. Much of the content of the document represents custom and practice and
is based on substantial clinical experience. Consensus of evidence in the guideline was
achieved by expert review. Gaps in the evidence will be identified by College members via
feedback received during consultation. The sections of this autopsy guideline that indicate
compliance with each of the AGREE II standards are indicated in Appendix B.

No major organisational changes or cost implications have been identified that would
hinder the implementation of the guidelines.

A formal revision cycle for all guidelines takes place on a 5-yearly cycle. The College will
ask the authors of the guideline, to consider whether the guideline needs to be revised. A
full consultation process will be undertaken if major revisions are required. If minor
revisions or changes are required, whereby a short note of the proposed changes will be
placed on the College website for 2 weeks for members’ attention. If members do not
object to the changes, the short notice of change will be incorporated into the guideline
and the full revised version (incorporating the changes) will replace the existing version on
the College website.

The guideline has been reviewed by the Professional Guidelines team, Death Investigation
Committee, Specialty Advisory Committee and Lay Advisory Group. It was placed on the
College website for consultation with the membership from 29 March to 26 April 2023. All
comments received from the membership were addressed by the author to the satisfaction
of the Clinical Lead for Guideline Review.

This guideline was developed without external funding to the writing group. The College
requires the authors of guidelines to provide a list of potential conflicts of interest; these
are monitored by the Professional Guidelines team and are available on request. The
authors of this document have declared that there are no conflicts of interest.

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1 Introduction
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality. Each year,
~1.4 million patients attend emergency departments in England and Wales with a recent
head injury.1

Traumatic brain injuries encompass a range of pathologies, which can be classified,

pathologically, as anatomical or pathophysiological; the former will be used in this
guideline, which separates pathologies into focal and diffuse. Focal injuries include scalp
contusions and lacerations, skull fractures, brain contusions and lacerations and
intracranial haemorrhages. Diffuse injuries include diffuse traumatic axonal injuries, diffuse
vascular injuries, ischaemia and brain swelling.2–4

Post-mortem cases of TBI will usually fall under the jurisdiction of the Coroner or
Procurator Fiscal and the examination will be under their instruction. In many instances,
the post-mortem examination will be performed by a histopathologist or forensic
pathologist. However, referral of the brain +/- spinal cord to a neuropathologist is of benefit
to gather information about the nature of trauma, mechanism and timing.

This guideline does not cover repetitive traumatic injury as seen in chronic traumatic
encephalopathy.

1.1 Target users and health benefits of this guideline

The target primary users of this guideline are histopathologists and neuropathologists
performing consented and Coroner’s/Procurators Fiscal’s post-mortem examinations in
persons with TBI. The recommendations will also be of value to specialty registrars,
especially those in histopathology considering the Certificate of Higher Autopsy Training
(CHAT) and those in diagnostic neuropathology preparing for the FRCPath Part 2. In
addition, the guideline will be of use to those undertaking forensic post-mortem
examinations.

2 The role of the autopsy

• To establish a cause of death.

• To establish whether death is related to TBI.

• To provide a detailed description of the intracranial, intracerebral and spinal

pathologies.

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• To provide, in cases of criminality, additional information relating to the mechanism
and timing of the injuries.

• To provide correlation with clinical and radiological information.

• To provide accurate national statistical information regarding the incidence of the

various pathologies seen in TBI.

• To support research into the mechanisms of pathology seen in TBI.

• To provide closure to the family.

[Level of evidence D – Evidence from case series.]

3 Brain pathology encountered at post-mortem

examination
As described above, the typical neuropathological classification separates the head injury
pathology into focal and diffuse (Table 1).

Table 1: Pathological classification of TBI.2–4

Focal Diffuse
Scalp contusions and lacerations Diffuse traumatic axonal injury
Skull fractures Diffuse vascular injury
Brain contusions and lacerations Diffuse ischaemic brain injury
Intracranial haemorrhage Brain swelling

3.1 Focal
3.1.1 Scalp injuries
The distribution of bruising and lacerations is important to document in relation to the face
and cranium. Photography may be a useful aid for documentation purposes. Bruising
suggests a contact injury and, dependent on location, may provide information to any
underlying intracranial lesions. In addition, there may be surgical incisions if there has
been neurosurgical intervention.

3.1.2 Skull fractures

The frequency of skull fractures is associated with the severity of the head injury. Skull
fractures are commonly seen in fatal traumatic head injuries.

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3.1.3 Contusions and lacerations
A contusion represents a localised injury and is seen by bruising to the surface of the
brain, wherein the pia mater remains intact, in comparison to a laceration where it is
disrupted. There are two types of contusion – direct (coup) and indirect (contrecoup)
contusions, which can be distinguished by their relation to the site of impact. In direct
(coup) contusions, the damaged brain tissue is seen beneath the point of impact and can
be anywhere in the brain. It is usually associated with some scalp bruising and sometimes
with a skull fracture. In indirect (contrecoup) contusions, the damaged brain tissue is said
to occur in an area directly opposite to the point of impact and commonly is seen at the
base of the brain in the anterior and inferior aspects of the frontal and temporal lobes.

3.1.3 Intracranial haemorrhage

Intracranial haemorrhages can be classified as extradural, subdural, subarachnoid,
intracerebral and intraventricular.

Extradural haematomas are frequently associated with scalp contusions and skull
fractures. They typically occur following fractures to the squamous temporal bone that
damage the underlying middle meningeal artery.

Subdural haematomas (SDHs) are usually associated with damage to the bridging veins
and can occur following mild trauma.

The size (volume) and site of the extradural and/or SHD should be measured. A volume
exceeding 40–50 ml is usually associated with pressure effect on the brain. More than
100–120 ml is usually fatal and associated with macroscopic brain midline shift with
herniation. The examination should also investigate whether there are any secondary
features such as pressure-effects causing midline shift, brain herniation or brainstem
haemorrhage.

Traumatic subarachnoid haemorrhages are commonly seen in cases of TBI and may be
associated with contusions and lacerations. They can also arise from traumatic injury to
the vertebral arteries in the form of rupture or dissection. Of course, they should not be
confused with other causes of subarachnoid haemorrhage, including rupture of a berry
aneurysm or vascular malformation.

At post mortem, a comprehensive examination of the cerebral blood vessels is essential

and should be done at the time of autopsy examination to exclude any aneurysm or
vascular malformation. The intracranial and intraspinal parts of the vertebral arteries

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should then be examined for any traumatic tear or damage. The vertebral arteries are best
examined in situ by careful dissection of the vertebral canal in the cervical spinal column,
the dissection extending all the way upwards to the point where the artery enters through
the dura at the foramen magnum and downwards to the subclavian artery.5,6 Any fresh
blood should be carefully cleared. The arteries should be carefully removed and processed
for serial sectioning.

[Level of evidence – C.]

3.2 Diffuse injuries

A range of diffuse injuries may be seen, some of which are obvious macroscopically while
others require microscopy.

3.2.1 Diffuse traumatic axonal injury

Diffuse traumatic axonal injury is seen in relation to both linear acceleration-deceleration
and/or rotational mechanical forces of the head. The severity can range from focal injury
with a few scattered axons to widespread axonal damage.3,7 In either case, microscopy is
required to make a diagnosis. Diffuse traumatic axonal injury is graded as described in
Table 2.

Table 2: Grading of diffuse traumatic axonal injury.2–4

Grade 1 Microscopic axonal damage in the supra- or infratentorium

Grade 2 As Grade 1, with additional small haemorrhages in the corpus callosum
Grade 3 As Grade 2, with additional small haemorrhages in the brainstem

3.2.2 Diffuse vascular injury

This is an extreme form of linear or rotational injury in which there is damage to the small
white matter vessels, particularly in the frontal and temporal lobes and brainstem
structures. Larger haemorrhages may be seen in parasagittal white matter (gliding
contusions) and in relation to the basal ganglia. White matter petechial haemorrhage is
seen macroscopically. The clinical picture is often that of immediate unconsciousness
without neurological recovery.

3.2.3 Diffuse ischaemic brain injury

This is a common finding in fatal TBI and results from reduced or absent cerebral
perfusion. This may be secondary to cardiac arrest associated with other injuries or may
be secondary to raised intracranial pressure preventing adequate cerebral perfusion. If

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there has been survival of at least several days, laminar necrosis may be seen
macroscopically. If there has been a survival of less than a few hours, microscopic
examination is unlikely to show any definite neuronal ischaemic injury.

3.2.4 Diffuse brain swelling

Most commonly, brain swelling is secondary to ischaemic injury, although swelling may
also be seen in relation to contusions or in the setting of diffuse traumatic axonal injury.

As can be seen from the above discussion, the diagnosis of head injury, while sufficient for
national data, gives little information regarding the actual pathology responsible for, or
significantly contributing to, the death of the individual.

[Level of evidence – C.]

4 Specific health and safety aspects

No specific precautions beyond standard protocols are generally required in TBI post-
mortem examinations. Local guidelines for the mortuary should be followed in each case
to assess the risk based on available clinical information from the Coroner or Procurator
Fiscal and medical records. Personal protective equipment should be used as appropriate
to minimise risks. There may be incidental medical devices present, which should be dealt
with in line with local guidelines.

[Level of evidence – GPP.]

5 Clinical information relevant to the autopsy

Most of the information will come from the Coroner’s or Procurator Fiscal’s office and
through police reports. In some circumstances, this may be supplemented by GP and
hospital records.

As with any post-mortem examination, knowledge of past medical history is important. It is

useful to have details in relation to the following:

• previous head injury: it is useful to know if there have been one or many episodes of
previous head injury, their significance and whether they required neurosurgical
intervention. Chronic subdural membranes are more prone to bleed with lesser trauma
due to the fragile macro-capillaries found within these membranes.

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• social and medical history: recurrent falls are more common among the elderly and
alcoholic populations, which may lead to a range of bruises and cuts. Patients on
warfarin treatment or with liver disorders are more prone to greater bleeding. Any
significant medical history, such as hypertension, should be noted.

• circumstances at the time of death: it is important to have as much detail as possible

relating to the incident that caused the fatal head injury. In the setting of a road traffic
collision, for example, was the deceased the driver, a passenger or a pedestrian? If
within a vehicle, was the deceased wearing a seatbelt? It is important to be aware of
other injuries documented at the time of autopsy examination and the results from any
studies during life, including any radiological and neurosurgical interventions.

• in criminal cases, information via the police about witnesses or other findings may be
very important. All available information should be documented or recorded in the
neuropathology report.

[Level of evidence – GPP.]

6 The autopsy procedure

The post-mortem examination should be performed in the standard way. If tissue is
referred for further neuropathological examination, a draft copy of the autopsy report
should be provided. If available, a set of photographs of the autopsy may be informative
and neuroradiology, if available, should be examined.

The College has produced a useful document outlining an approach to medicolegal

specimens and preserving the chain of evidence.

6.1 External examination

There should be thorough documentation of any external injuries; for example, in road
traffic collisions, there may be bruising indicating that a seatbelt was worn or there may be
bruising related to the head or face indicating a point of impact. Photography is strongly
recommended for future reference, particularly in criminal cases. Any surgical intervention
should also be documented.

6.2 Internal examination

There should be consideration for the use of post-mortem imaging, whether this is in
conjunction with or in place of a standard invasive post mortem. Imaging can often

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demonstrate the nature and extent of skeletal injuries better than an invasive autopsy.8
Please see section 12 below for further information.

When an invasive post mortem is performed, there should be a standard macroscopic

description for each organ system, including documentation of the organ weights. Morbid
anatomical causes of death that are visible at the time of post mortem should be sought
and, where necessary, supported by histological confirmation; for example, a road traffic
collision may have been secondary to a myocardial infarction. It is important to realise that
cases of head injury are frequently associated with injury to other organs, soft tissue and
bone. All these should be carefully recorded.

[Level of evidence – GPP.]

7 Specific organ systems to be considered

7.1 Head and neck

The scalp and skull should be carefully examined for signs of impact injury. Any skull
fractures should be carefully documented and, if appropriate, an illustration should be
recorded, either photographic or drawn. When reflecting the dura, the bridging veins
should be studied and any obvious tears documented.

The spinal column and in particular the cervical spine should be carefully examined. Any
soft tissue haemorrhages or fractures to the spinal column should be documented and the
underlying cord should be examined.

Where available, we would encourage radiological imaging of the neck in cases of

suspected bony injury.

[Level of evidence – GPP.]

8 Organ retention
The optimum process is for brain retention to allow complete neuropathological
examination. Ordinarily, this involves brain fixation in 10% formalin for a minimum of 2
weeks, but preferably for 4–6 weeks;6 however, it is understood that current practice may
involve a modified approach. It remains that in all cases of criminality, involving significant
head injury, the recommendation remains that the brain is retained for prolonged fixation
prior to examination. The Coroner/Procurator Fiscal and, through their office, the

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deceased’s family should be informed that a completed neuropathological examination will
be provided within a period of approximately 3 months from the time of death.

The following are offered as compromises in situations where there is no consent for
retention of the brain for prolonged fixation.

• There are many situations where the macroscopic pathology alone is informative and
allows a confident discussion of the pathophysiology of the cause of death. An
example would be an accidental fall with SDH and mass effect associated with axial
displacement.

• The brain may be retained in fixative for a period of not more than 24 hours and then
sliced in the standard way and samples taken for histological analysis. This provides a
reasonable degree of fixation and makes sectioning of the brain easier than in the
fresh state. The brain can then be returned to the body for burial or cremation. 9

• Retention of a mid-region coronal section of brain and sections of brainstem and

cerebellum. In this scenario, the brain is examined and sectioned in the fresh state. A
single section of the cerebrum beginning approximately 1 cm caudal to the mamillary
bodies is retained. This section should be approximately 1 cm in thickness. A block of
anterior corpus callosum, a section of left and right cerebellar hemispheres and
sections of midbrain, pons and medulla should also be retained for histological
examination. It should be made clear to the Coroner/Procurator Fiscal that all tissue
retained in this slice will be processed for histological examination and that no tissues
will be retained out with paraffin blocks, or that any retained small fragments of tissue
will be disposed of in line with Human Tissue Act/Human Tissue (Scotland) Act.
Histology blocks should also be taken from any other pathological lesion. If the spinal
cord has been retained, representative sections of cervical, thoracic, lumbar and
sacral regions should be put directly into histology cassettes for fixation.

In whichever method is used, it is preferable that the brain is photographed. The

photographs should be labelled and stored with case files for future reference (within
standard record retention periods).

[Level of evidence – GPP.]

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9 Histological examination
In many cases, histology is not required as the macroscopic examination can provide all
the information required. Histology is most useful in the assessment of diffuse injury, or
where assessment of a focal lesion may provide additional information regarding timing of
an injury.

The following is suggested for a minimum approach to the investigation of TBI.

9.1 General histology

Representative histology should be taken, if relevant to the cause of death, as felt
appropriate and determined by the findings at the post-mortem examination; for example,
myocardium may be taken if there has been a suspected myocardial infarction.

9.2 Neuropathology
9.2.1 Focal pathology
Any focal pathology identified at the time of post-mortem may be examined
microscopically. Extradural or SDHs should be sampled in the form of a dural roll. This
requires a section of dura to be rolled up and cut to a thickness of no more than 1 cm
before being placed into a histology cassette. Sampling of these lesions may allow a rough
estimate at timing if the clinical history is incomplete. Take extra blocks from different
regions if more than 1 episode of bleeding is suspected by the history or gross
examination.

9.2.2 Diffuse pathology

Diffuse lesions should always be considered when the patient has been unconscious in
the absence of any focal mass lesion. The commonest diffuse pathologies are diffuse
traumatic axonal injury and global ischaemic injury. The following is recommended as part
of the assessment of diffuse lesions within the brain (Table 3). The blocks should be taken
from both the right and left side (see Appendix A).

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Table 3: Recommended blocks to be taken in cases of diffuse TBI.2,4,10

1 Parasagittal anterior frontal white matter and genu of the corpus callosum
(at the level of the head of the caudate nucleus)
2 Anterior watershed

3 Deep grey watershed

4 Basal ganglia, including the posterior limb of the internal capsule

(at the level of the mid thalamus)
5 Temporal lobe to include the hippocampus
(at the level of the lateral geniculate body)
6 Parasagittal parietal white matter and splenium of the corpus callosum

7 Posterior watershed

8 Occipital cortex

9 Midbrain, including the decussation of the superior cerebellar peduncle

10 Pons, including the superior or middle cerebellar peduncles

11 Cerebellar hemisphere

Also Medulla
consider Spinal cord (cervical, thoracic, lumbar, sacral) – if retained
Focal lesions – if present

If large blocks cannot be processed, two or more smaller contiguous samples could be
taken from a particular region.

9.2.3 Spinal cord

The most common scenario where the spinal cord is examined is in the setting of cervical
spine injury with damage to the underlying cord. Only a small segment of cervical cord
should be examined in this setting and the sampling should be related to the areas of bony
injury.

9.3 Staining
In extra- or SDHs, the sections of dura may be stained with H&E, Perls’ stain and CD68,
which are useful to age the haematoma.

The brain sections may be stained with H&E and, when required, beta amyloid precursor
protein (βAPP) and CD68.

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Diffuse axonal injury is best demonstrated by βAPP immunohistochemical staining. βAPP
staining for traumatic axonal injury should be differentiated from staining associated with
ischaemic injury (vascular axonal injury), such as those seen in cases of a space
occupying lesion (e.g. SDH) with increase in the intracranial pressure and brain shifting.2–
4,11,12

[Level of evidence – D.]

10 Paediatric head injury13,14

Neuropathologists may face cases of paediatric head injury, including non-accidental child
death with head injury. The same clinical rules of examination of the brain in child head
trauma as in adults should be followed with the following additional recommendations:

• the dura should be examined thoroughly and sampled from different locations if SDH
is present

• the brainstem and cervicomedullary region should be sampled extensively to

investigate axonal injury

• the whole spinal cord should be examined and sampled thoroughly (blocks are taken
as mentioned in 9.2.2) and examined for focal lesions, axonal injury in the white matter
and spinal nerve roots. Subdural and subarachnoid haemorrhage in the spinal cord
also needs to be documented.

[Level of evidence – D.]

11 Toxicology and other relevant samples

Toxicology and other relevant samples may be required in discussion with the Coroner or
Procurator Fiscal. In deaths following assaults or road traffic collisions, alcohol and other
drugs may need to be assessed.

[Level of evidence – GPP.]

12 Imaging
Imaging post-mortems have been implemented by some coronial jurisdictions to
supplement or replace the standard invasive post mortem.15 They are useful in
documenting the nature and extent of traumatic injuries, for example skull fractures and

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intracranial haemorrhage; however, base of skull fractures may be difficult to detect if they
are non-displaced.

Imaging post mortems should never be undertaken without an external examination

performed by a GMC-registered pathologist.8

[Level of evidence – D.]

13 Clinicopathological summary
The clinicopathological summary needs to be clear and concise and the pathologist must
remember that this is likely to form part of a medicolegal document. Therefore, only
relevant statements of fact should be provided. The pathologist should clearly outline their
macroscopic and microscopic observations. This should be considered in light of the
clinical history provided. An overall summary should be made to correlate the pathological
findings with the clinical history provided and, in particular, to highlight consistencies or
inconsistencies between them. It is important for the pathologist to highlight areas of
certainty and uncertainty, in particular in relation to mechanism and timing of injuries.

[Level of evidence – D.]

14 Summary of post-mortem brain examination with

head injury
• Contusions

– site: temporal, frontal, other site (coup and countercoup)

– measurement: may be related to severity of head injury.

• Subarachnoid haemorrhage

– distribution (diffuse or localised)

– if basal, exclude possibility of berry aneurysm and examine vertebral arteries

(intracranial and intraspinal courses) for traumatic tear.

• Brain herniation

– uncal herniation (remove brainstem and cerebellum for better assessment),

bilateral or unilateral

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 – tonsillar herniation, usually associated with haemorrhage and necrosis rather than
only bulging

– subfalcine herniation

– brain shifting – corpus callosum and lateral ventricle.

• Brain swelling.

• Corpus callosum and fornix.

• Infarction and ischaemia

– site

– arterial territory.

• Intracranial haemorrhage

– related to an expanding contusion

– deep structure of brain like white matter and basal ganglia.

• Brainstem

– diffuse traumatic axonal injury (small bleeding: dorso-lateral quadrants and

superior cerebellar peduncle)

– diffuse vascular injury (small bleeding: subependymal and around fourth ventricles
and aqueduct)

– ↑ ICP (haemorrhage in midline).

[Level of evidence – D.]

15 Examples of cause of death opinions/statements

1a) Head injuries following a fall from height.

1a) Raised intracranial pressure with brainstem compression.

1b) SDH.
1c) Traumatic head injury.

1a) Subarachnoid haemorrhage.

1b) Vertebral artery dissection.
1c) Rotational head injury.

1a) Diffuse axonal injury.

1b) Road traffic collision.

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16 Criteria for audit
The following standards are suggested criteria that might be used in periodic reviews to
ensure a post-mortem report for coronial autopsies conducted at an institution comply with
the national recommendations provided by the 2006 NCEPOD study:

• supporting documentations:

– standards: 95% of supporting documentation was available at the time of the

autopsy

– standards: 95% of autopsy reports documented are satisfactory, good or excellent.

• reporting internal examination:

– standards: 100% of the autopsy report must explain the description of internal
appearance

– standards: 100% of autopsy reports documented are satisfactory, good or

excellent.

• reporting external examination:

– standards: 100% of the autopsy report must explain the description of external
appearance

– standards: 100% of autopsy reports documented are satisfactory, good or

excellent.

A template for coronial autopsy audit can be found on The Royal College of Pathologists’
website.

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17 References
1. National Institute for Health and Clinical Excellence. Guidance. Head injury: triage,
assessment, investigation and early management of head injury in children, young
people and adults. London, UK: National Institute for Health and Care Excellence,
2014.

2. Al-Sarraj S. The pathology of traumatic brain injury (TBI): a practical approach. Diagn
Histopathol 2016;22:318–326.

3. Ellison D, Love S, Lowe J, Vinters H, Harding BN, Chimelli L et al. Neuropathology: a

Reference Text of CNS Pathology (3rd edition). Edinburgh, UK: Mosby/Elsevier, 2013.

4. Love S, Budka H, Ironside JW, Perry A. Greenfield’s Neuropathology (9th edition).

Boca Raton, USA: CRC Press Routledge, 2015.

5. Bromilow A, Burns J. Technique for removal of the vertebral arteries. J Clin Pathol
1985;38:1400–1402.

6. Dawson TP, Llewellyn L, Thomas C, Neal JW. Neuropathology Techniques. London,

UK: Arnold, 2003.

7. McKee AC, Daneshvar DH. The neuropathology of traumatic brain injury. Handb Clin
Neurol 2015;127:45–66.

8. Osborn M, Roberts I, Rutty G, Traill Z. Morgan B. Guidelines for post-mortem cross-

sectional imaging in adults for non-forensic deaths. London, UK: The Royal College of
Pathologists, 2021. Available at: www.rcpath.org/profession/guidelines/autopsy-
guidelines-series.html

9. Scott IS, MacDonald AW. An evaluation of overnight fixation to facilitate

neuropathological examination in Coroner’s autopsies: our experience of over 200
cases. J Clin Pathol 2013;66:50–53.

10. Geddes JF, Whitwell HL, Graham DI. Traumatic axonal injury: practical issues for
diagnosis in medico-legal cases. Neuropathol Appl Neurobiol 2000;26:105–116.

11. Reichard RR, Smith C, Graham DI. The significance of βAPP immunoreactivity in
forensic practice. Neuropathol Applied Neurobiol 2005:31;304–313.

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12. Graham DI, Smith C, Reichard R, Leclercq PD, Gentleman SM. Trials and tribulations
of using beta-amyloid precursor protein immunohistochemistry to evaluate traumatic
brain injury in adults. Forensic Sci Int 2004;146:89–96.

13. Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of
inflicted head injury in children. I: Patterns of brain damage. Brain 2001;124:1290–
1298.

14. Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell HL.
Neuropathology of inflicted head injury in children. II: Microscopic brain injury in infants.
Brain 2001;124:1299–1306.

15. The Coroner’s Society of England and Wales. Chief Coroner. Guidance No.32 Post-
mortem examinations including second post-mortem examinations. Accessed April
2022. Available at: https://www.coronersociety.org.uk/announcements/chief-coroner-
guidance-32--post-mortem-examination-including-2nd-post-mortems/

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Appendix A Recommended blocks to assess diffuse
traumatic brain injury

1 6
5

2
7
3 11
9

4 10
8

1 Anterior frontal white matter and genu of the corpus callosum.

2 Anterior watershed.
3 Deep grey watershed.
4 Basal ganglia, including the posterior limb of the internal capsule.
5 Temporal lobe to include the hippocampus.
6 Parietal white matter and splenium of the corpus callosum.
7 Posterior watershed.
8 Occipital cortex.
9 Midbrain.
10 Pons.
11 Cerebellar hemisphere.

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Appendix B Summary table – Explanation of grades
of evidence
(modified from Palmer K et al. BMJ 2008; 337:1832)

Grade (level) of Nature of evidence

evidence
Grade A At least one high-quality meta-analysis, systematic review
of randomised controlled trials or a randomised controlled
trial with a very low risk of bias and directly attributable to the
target population
or
A body of evidence demonstrating consistency of results
and comprising mainly well-conducted meta-analyses,
systematic reviews of randomised controlled trials or
randomised controlled trials with a low risk of bias, directly
applicable to the target cancer type.
Grade B A body of evidence demonstrating consistency of results
and comprising mainly high-quality systematic reviews of
case-control or cohort studies and high-quality case-control or
cohort studies with a very low risk of confounding or bias and
a high probability that the relation is causal and which are
directly applicable to the target population
or
Extrapolation evidence from studies described in A.
Grade C A body of evidence demonstrating consistency of results
and including well-conducted case-control or cohort studies
and high- quality case-control or cohort studies with a low
risk of confounding or bias and a moderate probability that
the relation is causal and which are directly applicable to the
target population
or
Extrapolation evidence from studies described in B.
Grade D Non-analytic studies such as case reports, case series or
expert opinion
or
Extrapolation evidence from studies described in C.
Good practice point Recommended best practice based on the clinical experience
(GPP) of the authors of the writing group.

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Appendix C AGREE II guideline monitoring sheet
The autopsy guidelines of The Royal College of Pathologists comply with the AGREE II
standards for good quality clinical guidelines. The sections of this autopsy guideline that indicate
compliance with each of the AGREE II standards are indicated in the table.
AGREE standard Section of guideline
Scope and purpose
1 The overall objective(s) of the guideline is (are) specifically described Introduction
2 The health question(s) covered by the guideline is (are) specifically described Introduction
3 The population (patients, public, etc.) to whom the guideline is meant to apply
Foreword
is specifically described
Stakeholder involvement
4 The guideline development group includes individuals from all the relevant
Foreword
professional groups
5 The views and preferences of the target population (patients, public, etc.) have
Foreword
been sought
6 The target users of the guideline are clearly defined Introduction
Rigour of development
7 Systematic methods were used to search for evidence Foreword
8 The criteria for selecting the evidence are clearly described Foreword
9 The strengths and limitations of the body of evidence are clearly described Foreword
10 The methods for formulating the recommendations are clearly described Foreword
11 The health benefits, side effects and risks have been considered in formulating Foreword and
the recommendations Introduction
12 There is an explicit link between the recommendations and the supporting
2–15
evidence
13 The guideline has been externally reviewed by experts prior to its publication Foreword
14 A procedure for updating the guideline is provided Foreword
Clarity of presentation
15 The recommendations are specific and unambiguous 2–15
16 The different options for management of the condition or health issue are
2–15
clearly presented
17 Key recommendations are easily identifiable 2–15
Applicability
18 The guideline describes facilitators and barriers to its application Foreword
19 The guideline provides advice and/or tools on how the recommendations can
2–15
be put into practice
20 The potential resource implications of applying the recommendations have
Foreword
been considered
21 The guideline presents monitoring and/or auditing criteria 16
Editorial independence
22 The views of the funding body have not influenced the content of the guideline Foreword
23 Competing interest of guideline development group members have been
Foreword
recorded and addressed

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