Editor’s Note: The authors of the following cold-case file have asked for help from the members of the American Association of Neurological Surgeons in identifying the man described. The medical examiner’s evaluation of the body revealed a history of significant neurosurgical intervention; as such, a neurological surgeon or surgical team may be able to identify the man based on the results of his autopsy. If you would like to help with identification, e-mail Benjamin J. Figura, PhD, Office of the Chief Medical Examiner, New York, at bfigura@ocme.nyc.gov or call him at 212-447-7884. You also can e-mail Kathryn Ko, MD, FAANS, St. Barnabas Hospital, Section of Neurosurgery and Academy Art University, New York, at kko10021@yahoo.com or call her at 718-960-3788.

Introduction
In September of 2003, the body of an unidentified white male was found wrapped in plastic garbage bags in an industrial section of the Bronx. The deceased was in an advanced state of decomposition. The individual was 5’10” and, based on anthropological analysis, estimated to be between 40 and 60 years old. He was notably wearing a light-colored “Brooks Brothers” shirt with a laundry tag labeled “Felix.” The police investigation of this man’s death remains open. The New York City Medical Examiner’s evaluation has left the cause and manner of death as undetermined, but the probability of homicide is low. Of particular interest in this case is evidence of significant prior neurosurgical intervention. As all attempts to identify this individual through forensic methods have failed, the authors are presenting this case with the hope that members of the readership may be able to provide information leading to his identification.

Background and Importance
Cranial plates and screws commonly are utilized to affix the bone flap to the calvarium after craniotomy or trauma. Based on the configuration of the bone flap and accompanying plates and screws, it is possible to suggest what type of surgery a person has undergone and assist in ascertaining the medical history. Thus, metallic implants in this case and in general use throughout the body can be helpful in the identification of the unknown deceased (Figures 1, 2a and 2b).

Figure 1. Frontal view painting of the cranium (acrylic on canvas).

Clinical Presentation
Autopsy revealed that this person underwent an antemortem bifrontal craniotomy, with evidence of rewiring of the right orbit inferiorly and laterally at the orbital-zygomatic process. Additionally, there are plates and screws overlying the anterior wall of the frontal sinus. The frontal sinus has a 1-by-2.5-cm area of erosion on the posterior wall toward the right. The anterior fossa is intact, as is the crista galli. The nasal septum is asymmetrical, possibly a result of trauma. The orbital floor on the right is compromised with an area of missing bone. Additionally, there is evidence of bone growth and remodeling of the burr holes. In one of the dural tacking holes, a remnant of the non-dissolving suture can be found.

The plates and screws have been identified as manufactured by Medtronic (Minneapolis) and appear to have self-drilling tips, possibly originating in the mid- to late-1990s. A survey of New York City hospitals using Medtronic implants of this type did not yield further information on this person. Some screws are blue-colored — presumably “rescue” screws with slightly larger diameters than the silver screws. The full frontal view of the cranium is depicted in Figure 1. Oblique frontal photographs are shown in Figures 2a and 2b. A CT scan did not yield additional information.

Figure 2a and Figure 2b. Oblique frontal photographs of the cranium.

Conclusion
This unknown male underwent extensive cranial surgery that predated his death. Due to the scrupulous nature of medical record-keeping and the comparative infrequency of this type of operation, we are confident that someone with access to this review may have information leading to the identification of this man. It is evident that this person received the highest level of care from his neurosurgical team. It is hoped that this same neurosurgeon may once again intervene on his behalf to bring this cold case to final resolution. Individuals with information pertaining to this matter are urged to contact the authors.

References

1. Bennett JL, Benedix DC. Positive identification of cremains recovered from an automobile based on the presence of an internal fixation device. J Forensic Sci 1999; 44 (6): 1296–8.

2. Clarkson J, Schaefer M. Surgical intervention. In: ThompsonT, BlackS, editors. Forensic human identification: an introduction. Bocca Raton, FL: CRC Press, 2007; 127-46.