Fatal splenic artery aneurysm rupture at medicolegal autopsy: A case series and review of the literature

Splenic artery aneurysm (SAA) rupture is a deceptive cause of sudden unexpected death presenting significant medicolegal challenges. This retrospective case series and comprehensive literature review analyzes the clinicopathological features of six nontraumatic fatal SAA ruptures. Clinical presentations were predominantly nonspecific, resulting in diagnostic delays and medicolegal inquiries in two cases. A size-rupture paradox was observed, as fatal hemorrhage occurred across a wide diameter spectrum (3-12 cm), proving that small aneurysms also carry lethal potential. The literature review elucidates the multifactorial etiopathogenesis of SAA, encompassing genetic, hormonal, hemodynamic, and inflammatory factors. Furthermore, the clinical trajectory of delayed fatality is explained by the double-rupture phenomenon, which creates a deceptive lucid interval. Histochemical evaluation utilizing Elastic Verhoeff-Van Gieson (EVG) staining was pivotal, demonstrating severe internal elastic lamina loss to confirm spontaneous degenerative rupture and exclude trauma. Consequently, meticulous celiac trunk dissection and routine EVG histochemistry must be integrated into forensic autopsy protocols evaluating unexplained hemoperitoneum to accurately determine the cause of death and address liability disputes.