There is always a proof: Brain Examination

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After weighing, a decision has to be made whether to examine the brain immediately - the so-called 'wet-cutting' – or to suspend it in formalin until fixed, a process which takes at least several weeks. The advantage of fixation is, of course, that the firmness of the tissue allows thinner and more accurate knife-cut sections to be taken, as well as better histological preservation. Where neurological issues are involved, either traumatic or from natural disease, it is almost mandatory for the brain to be fixed before cutting. Even the impatience of the investigative authorities can usually be overcome if the advantages of a higher standard of opinion are explained.

 

 In the majority of autopsies there is no real need for fixation if no cerebral lesions are either expected or apparent on external examination of the brain. Here, 'wet-cutting' is sufficient, though if any unexpected lesions are found, the process can be stopped and the slices of brain fixed by placing them in a large volume of formalin, on cotton wool pads, to prevent distortion.

 

Whether the brain is examined 'wet' or fixed, the sequence is the same. The weight is first considered, the normal for a young male adult being between about 1300 and 1450 g, the female equivalent being around 100 g less. More details are given in Appendix 1. It should be noted that formalin fixation adds about 8 per cent to the original weight.

 


The general symmetry of the brain is then noted as well as any depression of the cortex from skull or meningeal masses. An estimate of cerebral oedema is made, partly from the weight, but mainly from flattening of the gyri, filling of the sulci and evidence of hippocampal herniation through the tentorial aperture. In lesser degree this may be seen as grooving of one or both unci, though a normal slight anatomical groove is often present. True uncal herniation is marked and often discolored as a result of incipient infarction. Similarly, herniation or coning of the cerebellar tonsils through the foramen magnum must be distinguished from the common anatomical pouting of many tonsils: true pressure coning is often discolored by local infarction. After careful inspection of the basal vessels and the exterior of the brain, and palpation for any fluctuant masses under the cortex such as internal hemorrhage, abscesses or cystic tumors, the organ is cut.

 

Though more common in clinical autopsies than forensic work, culture samples for 'bacteriology', virology and (rarely) fungi may be needed. Either plain swabs or swabs immersed in a transport medium can be employed for sampling a wide variety of sites at autopsy. Alternatively, tissue samples may be collected in sterile containers and this is the usual method for virological culture of lung and brain, for example. Blood cultures may be desired, and it is best to take blood with a sterile needle and syringe from a large vessel, such as the femoral vein, before starting the autopsy with its attendant inevitably widespread contamination with putrefactive organisms. Alternatively, blood can be taken from a freshly opened heart chamber using sterile instruments.

 

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