6.Renee Stonebridge — Direct

RENEE STONEBRIDGE: I do.

RENEE STONEBRIDGE: Thank you.

RENEE STONEBRIDGE: Good afternoon.

RENEE STONEBRIDGE: Yes. My name is Renee Stonebridge, R-E-N-E-E S-T-O-N-E-B-R-I-D-G-E.

RENEE STONEBRIDGE: I work at the Commonwealth of Massachusetts at the Boston office.

RENEE STONEBRIDGE: I work for the Chief Medical Examiner's office.

RENEE STONEBRIDGE: I have worked there since July of 2017.

RENEE STONEBRIDGE: Yes. I did four years of college at SUNY at Stony Brook in New York. I was a double major in German languages and literature and biology. And then I did four years at the American University of Antigua, where I got my medical degree. I also graduated with honors, magna cum laude. After that, I did a four-year combined anatomic and clinical pathology residency program at NYU Winthrop Hospital in Long Island, New York. I also served as chief resident during my final year there, so 2016 to 2017. After that, I did a one-year forensic pathology fellowship at the Boston office of the Chief Medical Examiner. And then after that, I did a two-year neuropathology fellowship program through Brown University at Rhode Island Hospital, and I am board certified in forensic pathology and anatomic pathology, clinical pathology, and neuropathology.

RENEE STONEBRIDGE: Neuropathology is the study of the brain, the dura, the eyes, and spinal cord, and muscle.

RENEE STONEBRIDGE: My role there is the director of cardiac and neuropathology. I'm also a medical examiner, but my primary focus is brains and hearts.

RENEE STONEBRIDGE: Yes.

RENEE STONEBRIDGE: We have certain criteria that is followed in order for a neuropathology consult to occur. Some occasions are any children under the age of two, I am to receive the brain, typically the spinal cord, depends on circumstances, the eyes and the dura as well. Also, if there's any suspicion of some type of homicidal injury to the head, blunt trauma typically, those cases will typically come to me as well. Sometimes there are cases in which it may just be something that is a surprise. A person, one of the MEs is doing the autopsy, the head is opened up, and they see something unexpected. They see something that may be hard to diagnose as someone who is not neuropathology trained, or it may be something like a tumor that is unexpected or a rare neurologic disease, a neurodegenerative disease that requires further neuropathologic evaluation.

RENEE STONEBRIDGE: Yes.

RENEE STONEBRIDGE: For Cora Clancy, I examined the eyes.

RENEE STONEBRIDGE: The findings when I examined the eyes were that there was acute hemorrhage of the extraocular muscles and adipose tissue. So when the eyes are taken out, this happens after the brain comes out of the skull, and there is a thin portion of bone in the bottom frontal portion of the skull where that bone is broken, and the eyes can then be examined on the inside of the head. Obviously, they are examined also on the outside of the head as well. But you can look at the optic nerve, and you can look at the tissue that is surrounding the eyes. So the eyes are within the head with some muscle and some adipose tissue. So there was hemorrhage in these portions of adipose tissue and muscle that is surrounding the eye itself. And then also one of the findings was that the optic nerve sheath on the left side has some punctate hemorrhage. So the eyes, they're sitting in the head, and then there's the optic nerve that connects to the back of the eye and goes to the brain, which sends these signals so people can see. And there was some hemorrhage in this portion surrounding the nerve that connects the left eye.

RENEE STONEBRIDGE: Hemorrhages themselves are a very general finding. However, given the entirety of the case, knowing what I know from the autopsy findings, I can say it is consistent with something asphyxial.

RENEE STONEBRIDGE: Yes, it can be.

RENEE STONEBRIDGE: What happens when there's some sort of asphyxial element to a person, it could be from many different things, but what happens is the blood in the head, if there's, say, some type of compression of the neck or something else that causes asphyxia—there's many things—but if there's some sort of compression, the blood basically gets kind of stuck in the head area. And because the blood can't flow back down through the body, what happens is there's little tiny blood vessels. They're in the eyes, they're in the skin, in the mouth, all, all over the head region. They basically get blocked up with this blood because it can't move, and these little blood vessels will burst, which leads to these little hemorrhages.

RENEE STONEBRIDGE: For Dawson Clancy, I examined the eyes as well.

RENEE STONEBRIDGE: The findings were that there was also some acute hemorrhages in these muscle and adipose tissue surrounding the eyes. And then the right eye had some small, small hemorrhages in the posterior retina and the optic nerve sheath. So at the back of the eye, there's the retina within the eye, and the retina connects with the optic nerve at the back portion of the eye. And in this case, there was a little bit of hemorrhage at that connection point where the retina connects to the optic nerve.

RENEE STONEBRIDGE: Hemorrhage itself is just blood that is no longer contained in a blood vessel.

RENEE STONEBRIDGE: Correct.

RENEE STONEBRIDGE: For Callan Clancy, I examined the brain, the dura, the spinal cord, and the eyes.

RENEE STONEBRIDGE: The findings were that there was hypoxic ischemic changes. Essentially, that means that there has been some sort of incident which has caused the brain to have a certain period of time in which blood and oxygen flow were not appropriate. So in this case, there was a timeframe in which there was no blood going to the brain, there wasn't enough oxygen going to the brain, and the brain will show certain findings in these sort of circumstances. One of the things I note is that there's edema. Edema is when the brain starts to swell. Edema is also a very general finding. It can happen in many instances, but the edema basically means that the brain starts to swell, so you don't have the nice kind of bumpy pattern on the brain. It starts to swell up, and it gets a little more flattened because the brain is encased in the skull, so now it's pressing against the skull because it's swelling up and getting bigger. One of the other things I noted with that was that there was compression of the ventricles. So the ventricles are almost like a tunnel system inside the brain that allow for the cerebral spinal fluid to flow through the brain and go into the spinal cord. And when the brain starts to swell up, it not only swells up outwards, but swells inwards on itself as well. So these ventricles that are located in the inside portion of the brain are starting to get kind of squashed because the brain is swelling. Another thing I noted was that the brain was diffusely friable, meaning that it's very soft. So one of the things I do on all my brain cases is they go into formalin. The formalin allows them to fix, which basically firms up the tissue, and it makes the tissue more easy to manipulate. A fresh brain coming out of a skull is very soft.

RENEE STONEBRIDGE: It's very easy to damage it. It's very easy to put your fingers through it if you're not careful. So one of the things that gets done is these brains will go into formalin. I typically will let them fix for about two weeks or so. And sometimes, regardless of the fixation time of the formalin, sometimes the brain still will not firm up the way it should. Because if I'm receiving a brain and it's already has hypoxic-ischemic changes, the formalin is only gonna penetrate the tissue so much because the tissue is essentially already dead. So-

RENEE STONEBRIDGE: Yes.

RENEE STONEBRIDGE: Hypoxic-ischemic changes is when you are getting lack of blood and oxygen flow. So hypoxic is the oxygen portion and ischemic is the blood portion.

RENEE STONEBRIDGE: Correct, yes.

RENEE STONEBRIDGE: Correct, yes.

RENEE STONEBRIDGE: It varies based on different sources. Most sources say it's between about six to eight minutes. If there's no oxygen flow, then the brain will essentially start dying. It depends on, you know, if there's resuscitation that occurs afterwards, but it's generally in the frame of six to eight minutes or so.

RENEE STONEBRIDGE: Correct, yes.

RENEE STONEBRIDGE: You're welcome.