Keywords
intracranial hemorrhage - sudden deaths - intracerebral hemorrhage - obesity - obesity
paradox - unexpected deaths - cardiovascular diseases - autopsy - BMI
Introduction
Recently, there has been a noticeable surge in sudden and unexpected deaths in India.[1] These affected individuals showed no signs of recent or past illnesses and died
suddenly during routine activities like walking, standing, or working. Due to the
abrupt nature of these deaths, investigations and diagnoses are not possible, leading
to postmortem examinations to determine the cause of death. Nontraumatic brain hemorrhages,
such as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), are significant
contributors to sudden and unexpected deaths. The 30-day mortality rate ranges from
35 to 52%, with nearly half of these deaths occurring within the initial 24 hours.[2]
[3] Recognized risk factors include arterial hypertension, hypercholesterolemia, diabetes
mellitus, cardiomyopathy, excessive consumption of tobacco or alcohol, environmental
air pollution, high-risk diet, and obesity.[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
Globally, obesity, the second leading cause of preventable death, poses a public health
concern due to the widespread prevalence of its risk factors and a considerable rise
in associated consequences.[9]
[11]
[12]
[13]
[14] Some studies have shown that obesity predisposes individuals to a heightened risk
of hemorrhagic and ischemic stroke,[15]
[16]
[17]
[18]
[19] with each unit increase beyond a BMI of 20 correlating with a 5% increase in ischemic
stroke risk.[15]
[16] Contrary to these assumptions, other studies have suggested that obesity does not
have any relationship with stroke.[6]
[16]
[20]
[21]
[22]
[23]
[24] Some studies have shown that extremes of body mass index (BMI; both low and high)
are associated with an increased risk of ICH,[25]
[26]
[27]
[28]
[29] challenging any clear evidence of a higher prevalence or incidence of hemorrhagic
stroke in obese individuals. The “obesity paradox theory” proposes that patients with
a higher BMI may exhibit better prognoses than leaner patients in terms of clinical
outcomes for cardiovascular diseases.[7]
[9]
[23]
[30]
[31]
[32]
The aim of this study is to identify nontraumatic brain hemorrhage in sudden and unexpected
death and to investigate the patterns, prevalence, and possible risk factors such
as obesity. This study was conducted on autopsies of sudden deaths in individuals
without prior illnesses. By exploring factors such as obesity prevalence and temporal
patterns, this study contributes valuable information to the ongoing discussion about
unexpected sudden deaths recently. This study stands out as a pioneering and unique
contribution to the existing literature as no autopsy-based investigations have been
conducted on this topic to date.
Materials and Methods
This prospective cross-sectional observational study was conducted using autopsy cases
in a tertiary care hospital in Surat, India, from April 2023 to January 2024. This
study included autopsies in which the cause of death was identified as nontraumatic
brain hemorrhage ([Fig. 1]). These cases were classified as sudden and unexpected deaths, occurring in various
settings, including homes, workplaces, and public spaces.
Fig. 1 (A–F) Intracerebral, subarachnoid, and intraventricular hemorrhage.
Inclusion Criteria
-
Sudden and unexpected deaths, irrespective of age or gender, occurring in nontraumatic
circumstances.
-
Autopsies where the primary cause of death was identified as nontraumatic brain hemorrhage.
Exclusion Criteria
-
Autopsies where the cause of death was due to trauma, external injuries, or poisoning.
-
Cases where the autopsy findings were inconclusive, or the cause of death could not
be definitively attributed to brain hemorrhage.
-
Decomposed body.
Demographic details, medical history, and circumstances surrounding the death were
collected during the autopsy from inquiries, relatives, and any available medical
records. The height and weight were recorded in centimeter and kilogram, respectively.
We classified the cases according to the World Health Organization (WHO) BMI classification
as follows:
-
Underweight: BMI of less than 18.5.
-
Normal weight: BMI of 18.5 to 24.9.
-
Overweight: BMI of 25 to 29.9.
-
Obesity (class 1): BMI of 30 to 34.9.
-
Obesity (class 2): BMI of 35 to 39.9.
-
Obesity (class 3): BMI of ≥40.
Results
During the study period, we identified 10 cases ([Table 1]) in which nontraumatic brain hemorrhage ([Fig. 1]) was the cause of sudden and unexpected death. The key findings are summarized in
the following subsections
Table 1
Case details
|
Age
|
Sex
|
Height (cm)
|
Weight (kg)
|
Symptoms
|
Time of event
|
BMI
|
Obesity class
|
|
48
|
Male
|
165
|
74
|
Unconscious
|
14:30
|
27.2
|
Overweight
|
|
69
|
Male
|
165
|
62
|
Chest pain, dyspnea
|
20:00
|
22.8
|
Normal weight
|
|
40
|
Male
|
160
|
98
|
Fever
|
07:00
|
38.3
|
II
|
|
49
|
Male
|
170
|
88
|
Unconscious
|
21:00
|
30.4
|
I
|
|
61
|
Male
|
175
|
88
|
Unconscious
|
20:00
|
28.7
|
Overweight
|
|
28
|
Male
|
174
|
62
|
Unconscious
|
21:00
|
20.5
|
Normal weight
|
|
41
|
Male
|
170
|
98
|
Weakness
|
21:45
|
33.9
|
I
|
|
61
|
Male
|
164
|
78
|
Uneasiness
|
06:00
|
29.0
|
Overweight
|
|
58
|
Male
|
154
|
95
|
Unknown
|
Unknown
|
40.1
|
III
|
|
28
|
Male
|
176
|
94
|
Dyspnea
|
20:00
|
30.3
|
I
|
Case 1
A 48-year-old male suddenly became unconscious at home for an unknown reason and died.
He was not suffering from any illness. He was transferred to the hospital where the
duty doctor declared him brought dead. Postmortem examination revealed that the body
was overweight, with a weight of 74 kg. Internal examination revealed ICH over the
right temporal lobe and the basal surface. Further pathological examination revealed
extensive areas of myocardial infarction with grade VII atherosclerosis. His BMI was
27.
Case 2
A 69-year-old man was suffering from chest pain, difficulty in breathing, and weakness
for 1 day. He was admitted to the hospital where he died within 6 hours despite receiving
intensive medical care. His blood pressure was 114/82 mm Hg. His chest X-ray showed
haziness over the lower zone bilaterally and mild cardiomegaly. Postmortem examination
revealed a body weight of 62 kg, and internal examination revealed thickening of the
coronary arteries. Pathological examination of the organs revealed myocardial infarction
with grade VII atherosclerosis, pneumonia, SAH, and ICH. His BMI was 23.
Case 3
A 40-year-old man was suffering from fever for 5 days. The patient was unconscious
in the morning and declared dead on arrival at the hospital. A postmortem examination
was performed to determine the cause of death. An external examination revealed a
weight of 98 kg. Internal examination revealed a large intraventricular hemorrhage
(IVH) in both the lateral ventricles. The coronary arteries were also thickened. His
BMI was 38.
Case 4
A 49-year-old man suddenly became unconscious during bathing. He was transferred to
the hospital but died before treatment was started. During the autopsy, the external
features showed a weight of 88 kg. Internal examination revealed ICH in both the frontal
and parietal lobes, IVH, edematous lungs, and calcified coronaries. His BMI was 30.
Case 5
A 60-year-old man was found unconscious at home upon entering the house. He was transferred
to the hospital, where the on-duty doctor declared him dead. He did not suffer from
any illness in the past or recently. During the autopsy, his weight was 88 kg on external
examination. Internal findings revealed a large ICH over both the parietal and occipital
lobes. His BMI was 29.
Case 6
A 28-year-old man suddenly died at home. His relative transferred him to the hospital,
but he did not survive, and his body was sent for postmortem. During the autopsy,
no specific external findings were found. His weight was 62 kg. Internal examination
revealed profuse SAH over both the temporal and parietal lobes, basal surface, and
IVH in both lateral ventricles. His BMI was 20.
Case 7
A 41-year-old man was suffering from weakness for 4 days. Primary blood investigations
were performed, but the results were inconclusive. He suddenly collapsed at home and
was immediately transferred to the hospital, but he did not survive before the onset
of treatment. During postmortem, his weight was 98 kg. In the internal examination,
bilateral parietal, temporal, and occipital lobes showed SAH. The brain was edematous.
His BMI was 34.
Case 8
A 61-year-old man was feeling uneasiness in the morning and suddenly became unconscious
within an hour. He was transferred to the hospital but died before the start of treatment.
The patient had a 3-year history of diabetes and was on regular medication. During
the autopsy, his weight was found to be 78 kg. Internal examination revealed a large
SAH over the parietal, temporal, and occipital surfaces and an IVH in both lateral
ventricles. His BMI was 29.
Case 9
An unknown male dead body of approximately 58 years of age was found by the roadside.
A past or present history of illness could not be found because of the absence of
relatives. During the autopsy, his weight was 85 kg. Internal examination revealed
an ICH in both the temporal and parietal lobes. The brain was edematous. The coronary
arteries were calcified and thickened. His BMI was 40.
Case 10
A 28-year-old man was suffering from shortness of breath for 6 to 8 hours. Suddenly,
the patient deteriorated and was transferred to the hospital. He was in a gasping
state at the time of admission and his blood pressure was not recordable. The patient
suddenly collapsed and eventually died. During the autopsy, his weight was 94 kg.
Internal examination showed profuse SAH over the whole brain surface, with greater
thickness over the frontal lobes. The brain was edematous. The coronary arteries were
also thickened. His BMI was 30.
All these cases had no history of hypertension or incidence of hemorrhagic or ischemic
stroke. A computed tomography (CT) scan or magnetic resonance imaging (MRI) examination
was not performed due to the abrupt nature of the death. There was a lack of vital
examination data, including pulse and blood pressure readings, as the majority of
individuals were brought dead to the hospital.
Observations
-
Eight out of 10 cases were obese or overweight.
-
Deaths occurred predominantly between 8 p.m. and midnight.
-
All cases were males, and nine cases were married.
-
Age distribution was equal and nonspecific.
-
All the individuals died without significant prior illness or medical history.
-
The circumstances of death were sudden and uneventful, with no trauma to the body.
Discussion
Nontraumatic brain hemorrhages, such as ICH and SAH, are identified as important contributors
to these sudden deaths and the 30-day mortality rate ranges from 35 to 52%, with nearly
half of these deaths occurring within the initial 24 hours.[3]
[4] Obesity, the second leading cause of preventable death globally, has been associated
with an increased risk of brain hemorrhage in some studies.[9]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19] On the contrary, some studies showed that it does not have any relation to ischemic
or hemorrhagic stroke.[6]
[16]
[20]
[21]
[22]
[23]
[24] The “obesity paradox theory” introduces the idea that patients with a higher BMI
may have better prognoses in cardiovascular diseases.[7]
[9]
[23]
[30]
[31]
[32]
This study stands out as a unique contribution to the existing literature because
no autopsy-based investigations have been conducted on this topic to date. This research
explored nontraumatic brain hemorrhage as a cause of death in sudden and unexpected
deaths without prior illnesses. During the study period, 10 cases were identified
in which nontraumatic brain hemorrhage was the cause of sudden and unexpected death.
The cases exhibited various characteristics, such as sudden unconsciousness, chest
pain, fever, and weakness. Autopsy findings revealed ICH and SAH as major causes of
death along with myocardial infarction, pneumonia, and other pathological conditions.
The demographic analysis showed that 8 out of the 10 cases were obese or overweight,
deaths occurred predominantly between 8 p.m. and midnight, and all cases were males.
This study provides valuable insights into the impact of obesity on brain hemorrhage
in sudden death, along with a higher incidence in males. This emphasizes the need
for further research on the relationship between obesity and nontraumatic brain hemorrhage.
The results of this study enhance our understanding of recent sudden deaths offering
insights that could guide preventive measures particularly in the Asian population.
This could involve the development of health policies aimed at identifying individuals
with obesity and implementing weight loss programs. Additionally, raising awareness
among this demographic about the potential risks and encouraging regular health checkups
may prove effective in preventing the occurrence of brain hemorrhages and subsequent
sudden deaths. The temporal pattern of deaths (predominantly occurring between late
evening hours) suggests that circadian factors or daily routines may influence the
onset of fatal brain hemorrhages. Further studies in the Asian population could investigate
these patterns more closely to understand their implications and improve early detection
strategies.
The study supports the need for updated clinical guidelines that incorporate obesity-related
risk factors into the evaluation of patients, even those without prior illness, who
might be at risk of sudden brain hemorrhages. The findings from this study underscore
the importance of heightened awareness among emergency care physicians when dealing
with sudden and unexpected deaths. In the cases where individuals present with symptoms
such as sudden unconsciousness, chest pain, or unexplained weakness, particularly
those with no significant prior medical history, physicians should consider nontraumatic
brain hemorrhage (ICH or SAH) as a differential diagnosis. This is especially true
in patients who are overweight or obese, given the observed association between obesity
and brain hemorrhage in this study.
Limitations
The limitations of the study include the following:
-
Small sample size: With only 10 cases included, the sample size is relatively small, limiting the ability
to generalize the findings to a broader population. A larger study would provide a
more robust assessment of the association between obesity and brain hemorrhage in
sudden and unexpected deaths.
-
Short observation period: The study was conducted over less than a year, which may limit the understanding
of seasonal or temporal variations in the occurrence of sudden brain hemorrhages.
A longer observation period could reveal more accurate trends and patterns.
-
Absence of imaging data: Due to the abrupt nature of the death in many cases, no premortem imaging data (CT,
MRI) were available. The lack of such diagnostic tools limits the ability to correlate
the autopsy findings with the clinical presentations, which would have strengthened
the study's conclusions.
-
Geographical limitation: The study is based on cases from a single tertiary care hospital in Surat, India.
As such, the findings may not be representative of other regions or countries, where
genetic, environmental, or lifestyle factors may differ.
Conclusion
This study sheds light on the significant association of obesity as risk factor with
nontraumatic brain hemorrhages, particularly ICH and SAH, in sudden and unexpected
deaths. This study stands out as a novel endeavor, being the first of its kind to
specifically investigate the autopsies of individuals who died suddenly and unexpectedly
without prior history or diagnosis of brain hemorrhage. The findings of this research
reveal a strong association between brain hemorrhage and obesity, especially among
males. Notably, the incidence of these occurrences peaked during late evening hours,
adding a temporal dimension to the observed patterns. This result underscores the
need for further in-depth studies to explore the complexities of sudden and unexpected
deaths attributed to brain hemorrhage. The findings of this study have broad implications
for public health policy, suggesting the importance of targeted strategies for preventing
mortality, particularly within the Asian community.
