Claire Robinson

Targeted post-mortem computed tomography cardiac angiography: proof of concept

With the increasing use and availability of multi-detector computed tomography and magnetic resonance imaging in autopsy practice, there has been an international push towards the development of the so-called near virtual autopsy. However, currently, a significant obstacle to the consideration as to whether or not near virtual autopsies could one day replace the conventional invasive autopsy is the failure of post-mortem imaging to yield detailed information concerning the coronary arteries. To date, a cost-effective, practical solution to allow high throughput imaging has not been presented within the forensic literature. We present a proof of concept paper describing a simple, quick, cost-effective, manual, targeted in situ post-mortem cardiac angiography method using a minimally invasive approach, to be used with multi-detector computed tomography for high throughput cadaveric imaging which can be used in permanent or temporary mortuaries.

Anthropological Measurement of Lower Limb and Foot Bones Using Multi-Detector Computed Tomography

Abstract:  Anthropological examination of defleshed bones is the gold standard for osteological measurement in forensic practice. However, multi‐detector computed tomography (MDCT) offers the opportunity of three‐dimensional imaging of skeletal elements, allowing measurement of bones in any plane without defleshing. We present our experiences of the examination of 15 human lower limbs in different states of decomposition using MDCT. We present our method of imaging and radiological measurement of the bones including sex assessment. The radiological measurements were undertaken by three professional groups–anthropology, radiology, and forensic pathology–both at the site of scanning and at a remote site. The results were compared to anthropological oestological assessment of the defleshed bones. We discuss the limitations of this technique and the potential applications of our observations. We introduce the concept of remote radiological anthropological measurement of bones, so‐called tele‐anthro‐radiology and the role that this could play in providing the facility for standardization of protocols, international peer review and quality assurance schemes.

The role of mobile computed tomography in mass fatality incidents.

Abstract:  Mobile multi‐detector computed tomography (MDCT) scanners are potentially available to temporary mortuaries and can be operational within 20 min of arrival. We describe, to our knowledge, the first use of mobile MDCT for a mass fatality incident. A mobile MDCT scanner attended the disaster mortuary after a five vehicle road traffic incident. Five out of six bodies were successfully imaged by MDCT in c. 15 min per body. Subsequent full radiological analysis took c. 1 h per case. The results were compared to the autopsy examinations. We discuss the advantages and disadvantages of imaging with mobile MDCT in relation to mass fatality work, illustrating the body pathway process, and its role in the identification of the pathology, personal effects, and health and safety hazards. We propose that the adoption of a single modality of mobile MDCT could replace the current use of multiple radiological sources within a mass fatality mortuary.

Fimag: The United Kingdom Disaster Victim/Forensic Identification Imaging System

Abstract:  Imaging is an integral diagnostic tool in mass fatality investigations undertaken traditionally by plain X‐rays, fluoroscopy, and dental radiography. However, little attention has been given to appropriate image reporting, secure data transfer and storage particularly in relation to the need to meet stringent judicial requirements. Notwithstanding these limitations, it is the risk associated with the safe handling and investigation of contaminated fatalities which is providing new challenges for mass fatality radiological imaging. Mobile multi‐slice computed tomography is an alternative to these traditional modalities as it provides a greater diagnostic yield and an opportunity to address the requirements of the criminal justice system. We present a new national disaster victim/forensic identification imaging system—Fimag—which is applicable for both contaminated and non‐contaminated mass fatality imaging and addresses the issues of judicial reporting. We suggest this system opens a new era in radiological diagnostics for mass fatalities.

The role of micro-computed tomography in forensic investigations☆

The use of micro-CT within forensic practice remains an emerging technology, principally due to its current limited availability to forensic practitioners. This review provides those with little or no previous experience of the potential roles of micro-CT in forensic practice with an illustrated overview of the technology, and the areas of practice in which micro-CT can potentially be applied to enhance forensic investigations.

Computed tomography of projectile injuries

Computed tomography (CT) is a gold standard in clinical imaging but forensic professions have been slow to embrace radiological advances. Forensic applications of CT are now exponentially expanding, replacing other imaging methods. As post-mortem cross-sectional imaging increases, radiologists will fall under increasing pressure to interpret complex forensic cases involving both living and deceased patients. This review presents a wide variety of weapon and projectile types aiding interpretation of projectile injuries both in forensic and clinical practice.

Perimortem trauma in King Richard III: a skeletal analysis

BACKGROUND Richard III was the last king of England to die in battle, but how he died is unknown. On Sept 4, 2012, a skeleton was excavated in Leicester that was identified as Richard. We investigated the trauma to the skeleton with modern forensic techniques, such as conventional CT and micro-CT scanning, to characterise the injuries and establish the probable cause of death. METHODS We assessed age and sex through direct analysis of the skeleton and from CT images. All bones were examined under direct light and multi-spectral illumination. We then scanned the skeleton with whole-body post-mortem CT. We subsequently examined bones with identified injuries with micro-CT. We deemed that trauma was perimortem when we recorded no evidence of healing and when breakage characteristics were typical of fresh bone. We used previous data to identify the weapons responsible for the recorded injuries. FINDINGS The skeleton was that of an adult man with a gracile build and severe scoliosis of the thoracic spine. Standard anthropological age estimation techniques based on dry bone analysis gave an age range between 20s and 30s. Standard post-mortem CT methods were used to assess rib end morphology, auricular surfaces, pubic symphyseal face, and cranial sutures, to produce a multifactorial narrower age range estimation of 30-34 years. We identified nine perimortem injuries to the skull and two to the postcranial skeleton. We identified no healed injuries. The injuries were consistent with those created by weapons from the later medieval period. We could not identify the specific order of the injuries, because they were all distinct, with no overlapping wounds. Three of the injuries-two to the inferior cranium and one to the pelvis-could have been fatal. INTERPRETATION The wounds to the skull suggest that Richard was not wearing a helmet, although the absence of defensive wounds on his arms and hands suggests he was still otherwise armoured. Therefore, the potentially fatal pelvis injury was probably received post mortem, meaning that the most likely injuries to have caused his death are the two to the inferior cranium. FUNDING The University of Leicester.

The scoliosis of Richard III, last Plantagenet King of England: diagnosis and clinical significance

Richard III was king of England from 1483 to 1485, after declaring his nephew, Edward V, illegitimate. On Aug 20, 1485, Richard was killed in battle with the rebel Lancastrian claimant Henry Tudor at Bosworth. His body was carried back to Leicester and buried in the Greyfriars Minor Friary, where it remained until its excavation in 2012, when it was seen to have a severe scoliosis. Famously, Shakespeare described Richard III as “hunchbacked” in his eponymous play of 1593. There has been considerable disagreement whether this “hunchback” was real or an invention of his enemies after death, with political motivations. However, the chronicler John Rous wrote around 1490 that Richard “was small of stature, with a short face and unequal shoulders, the right higher and the left lower.” This description is compatible with the presence of a rightsided scoliosis. We analysed the skeleton macroscopically for evidence of spinal curvature and related lesions. From CT 3D reconstructions of each bone, we created polymer replicas and built a model of the spine to recreate its alignment in life (fi gure, appendix). The apex of the right-sided thoracic curve noted at excavation was at vertebrae T8–T9. The Cobb angle, determined from vertical excavation photos, was 75° from the upper border of T6 to the lower border of T11. Since this was measured supine, whereas clinical angles are taken standing, we estimate the Cobb angle to have been in the range 70–90° during life. The curve was well balanced, with cervical and lumbar spines reasonably well aligned (King Moe type 3). Abnormalities of individual vertebrae (eg, wedging of vertebral end plates, lateral angulation of spinous processes, asymmetry of facet joints) were restricted to the thoracic region (appendix). The foramen magnum was normal in size and shape. The 3D reconstruction closely matches the 2D images recorded at excavation, and shows the spiral nature of the scoliosis (appendix, video). Determining the cause of Richard’s scoliosis allows us to estimate the age at which it developed, and how it may have aff ected him. Since the spinal ligaments are some of the last to decompose after death, and in this case had partly ossifi ed, the position of the vertebrae should show only minimum change from the time of burial, having been surrounded by soil. Such small change is supported by the similarity to the reconstructed model, which relied on joint morphology to determine each joint position. The absence of structural spinal abnormalities, such as hemivertebrae and unilateral bars, makes congenital scoliosis improbable. Neuromuscular causes, such as cerebral palsy, are unlikely because of the normal structure, muscle markings, and cortical thickness of the legs and hips, compatible with a normal weight-bearing gait. Skeletal changes associated with syndromes such as Marfan’s (eg, high arched palate and tall stature) were not present, and a normal foramen magnum makes a Chiari malformation unlikely. The subtle nature of the changes in vertebral anatomy suggest onset in the last few years of growth, which is compatible with adolescent onset idiopathic scoliosis, probably starting after 10 years of age. The physical disfi gurement from Richard’s scoliosis was probably slight since he had a well balanced curve. His trunk would have been short relative to the length of his limbs, and his right shoulder a little higher than the left. However, a good tailor and custom-made armour could have minimised the visual impact of this. A curve of 70–90° would not have caused impaired exercise tolerance from reduced lung capacity, and we identifi ed no evidence that Richard would have walked with an overt limp, because the leg bones are symmetric and well formed.

Post-mortem computed tomography ventilation; simulating breath holding

Whilst the literature continues to report on advances in the use of post-mortem computed tomography (PMCT), particularly in relation to post-mortem angiography, there are few papers published that address the diagnostic problems related to post-mortem changes in the lungs and ventilation. We present a development of previous methods to achieve ventilated PMCT (VPMCT). We successfully introduced a supraglottic airway in 17/18 cases without causing overt damage, despite rigor mortis. Using a clinical portable ventilator, we delivered continuous positive airway pressure to mimic clinical breath-hold inspiratory scans. This caused significant lung expansion and a reduction in lung density and visible normal post-mortem changes. All thoracic pathology identified at autopsy, including pneumonia, was diagnosed on VPMCT in this small series. This technique provides a rapid form of VPMCT, which can be used in both permanent and temporary mortuaries, allowing for the post-mortem radiological comparison of pre-ventilation and post-ventilation images mimicking expiratory and inspiratory phases. We believe that it will enhance the diagnostic ability of PMCT in relation to lung pathology.

Pump injector system applied to targeted post-mortem coronary artery angiography

Targeted post-mortem computed tomography angiography (PMCTA) is one of several methods described that can be used to investigate the coronary arteries after death. Previously, this particular method has involved the manual injection of contrast media. However, manual systems do not mimic physiological conditions (arterial pressure) and may not provide optimal contrast, as iodinated contrast medium dissipates rapidly from the intra- to the extra-vascular space. To try and overcome these problems, we now report the use of a clinical automatic pump injector for targeted PMCTA. We present our final protocol for this pump system developed from experience of 74 cases, showing how these clinical pumps can be translated from clinical into autopsy practice for the injection of air and positive contrast media to visualise the coronary arteries of cadavers.