Two autopsy cases of superficial siderosis: ultrastructural similarity across traumatic and non-traumatic contexts and forensic uncertainties.

Superficial siderosis of the central nervous system (SSCNS) is increasingly recognized radiologically but remains rarely documented in medicolegal autopsies, where its role in the cause and manner of death is often uncertain. We aimed to characterize the neuropathological features and medicolegal implications of SSCNS in two autopsy cases. We examined two men with SSCNS, one with a remote traumatic subarachnoid hemorrhage and one diagnosed with idiopathic SSCNS. In both cases, the brain and upper cervical cord showed symmetrical brown discoloration of the cerebellum and brainstem, with widespread subpial and perivascular hemosiderin deposition, marked Purkinje cell loss, and gliosis. No dural defect, vascular malformation, mass lesion, or other structural bleeding source was identified, although the cervicothoracic dura was not systematically examined. In the first case, aspiration pneumonia in the setting of prolonged immobility was certified as the immediate cause of death, with SSCNS listed as a contributory disease in a natural manner of death. In the second case, positional asphyxia with aspiration of gastric contents after a fall from a wheelchair was the immediate cause, and SSCNS was recorded as a background condition predisposing to the fatal event in an unintentional injury. Forensic pathologists may integrate SSCNS into the causal chain as a contributory factor and consider targeted cervicothoracic spinal dissection when SSCNS is suspected.