Noel Woodford

Post-mortem radiology—a new sub-speciality?

Computed tomography (CT) and magnetic resonance imaging (MRI) examinations of deceased individuals are increasingly being utilized in the field of forensic pathology. However, there are differences in the interpretation of post-mortem and clinical imaging. Radiologists with only occasional experience in post-mortem imaging are at risk of misinterpreting the findings if they rely solely on clinical experience. Radiological specialists working in a co-operative environment with pathologists are pivotal in the understanding of post-mortem CT and MRI, and its appropriate integration into the autopsy. This has spawned a novel subspecialty called post-mortem radiology or necro-radiology (radiology of the deceased). In the future it is likely that whole-body CT will be incorporated into the routine forensic autopsy due its ability to accurately detect and localise abnormalities commonly seen in forensic practice, such as haematoma, abnormal gas collections, fractures, and metallic foreign bodies. In the next 5-10 years most forensic institutes will seek regular access to such CT facilities or install machines into their own mortuaries. MRI is technically more problematic in the deceased but the improved tissue contrast over CT means that it is also very useful for investigation of pathology in the cranial, thoracic, and abdominal cavities, as well as the detection of haematoma in soft tissue. In order for radiologists to be an integral part of this important development in forensic investigation, radiological organizations must recognize the subspecialty of post-mortem radiology and provide a forum for radiologists to advance scientific knowledge in the field.

Contribution of postmortem multidetector CT scanning to identification of the deceased in a mass disaster: Experience gained from the 2009 Victorian bushfires ☆

CT scanning of the deceased is an established technique performed on all individuals admitted to VIFM over the last 5 years. It is used primarily to assist pathologists in determining cause and manner of death but is also invaluable for identification of unknown deceased individuals where traditional methods are not possible. Based on this experience, CT scanning was incorporated into phase 2 of the Institutes DVI process for the 2009 Victorian bushfires. All deceased individuals and fragmented remains admitted to the mortuary were CT scanned in their body bags using established protocols. Images were reviewed by 2 teams of 2 radiologists experienced in forensic imaging and the findings transcribed onto a data sheet constructed specifically for the DVI exercise. The contents of 255 body bags were examined in the 28 days following the fires. 164 missing persons were included in the DVI process with 163 deceased individuals eventually identified. CT contributed to this identification in 161 persons. In 2 cases, radiologists were unable to recognize commingled remains. CT was utilized in the initial triage of each bags contents. If radiological evaluation determined that bodies were incomplete then this information was provided to search teams who revisited the scenes of death. CT was helpful in differentiation of human from non-human remains in 8 bags, recognition of human/animal commingling in 10 bags and human commingling in 6 bags. In 61% of cases gender was able to be determined on CT using a novel technique of genitalia detection and in all but 2 cases this was correct. Age range was able to be determined on CT in 94% with an accuracy of 76%. Specific identification features detected on CT included the presence of disease (14 disease entities in 13 cases), medical devices (26 devices in 19 cases) and 274 everyday metallic items associated with the remains of 135 individuals. CT scanning provided useful information prior to autopsy by flagging likely findings including the presence of non-human remains, at the time of autopsy by assisting in the localization of identifying features in heavily disfigured bodies, and after autopsy by retrospective review of images for clarification of issues that arose at the time of pathologist case review. In view of the success of CT scanning in this mass disaster, DVI administrators should explore the incorporation of CT services into their disaster plans.

Forensic aspects of the 2009 Victorian Bushfires Disaster.

The 2009 Victorian Bushfires Disaster started on a record hot day in February 2009 and resulted in over 300 separate fires with a death toll of 173 and over 400 presentations to hospital emergency departments. This occurred a little over a week after a heat wave in which over 400 people were thought to have died prematurely in southeastern Australia. The Victorian Institute of Forensic Medicine in collaboration with the police force and the State Coroners Office and over 100 colleagues from all over Australia, Indonesia, New Zealand and Japan implemented a DVI process based on Interpol guidelines to identify the deceased persons. CT scanning was conducted on all remains collected and played a pivotal role in the identification processes in conjunction with experts in pathology, anthropology, forensic odontology and molecular biology. This paper outlines the scale of the disaster and the work, from a forensic medical perspective, to identify the deceased.

Cocaine in sudden and unexpected death: a review of 49 post-mortem cases.

Cocaine is a potent sympathomimetic drug that is associated with cardiotoxicity, including ventricular arrhythmia, systemic hypertension, acute myocardial infarction and left ventricular hypertrophy. The use of cocaine in Australia has risen steadily since the late 1990s. What remains unclear in the literature is whether cocaine-associated death can occur in the absence of other contributing factors, such as concomitant drug use or natural disease. A search was conducted on the National Coroners Information System database, to identify all deaths occurring in Victoria, Australia, between January 2000 and December 2011, where cocaine or its metabolites were detected by post-mortem toxicological analysis. All cases were closed by the Coroner. These cases were examined with regards to case circumstances, pathology and toxicology results, and coronial findings, to determine the prevalence of cardiotoxicity and the involvement of cocaine in the deaths compared with other contributing factors. There were 49 cases where cocaine, benzoylecgonine, ecgonine methyl ester, methylecgonine or cocaethylene, were detected in the 11-year period. The individuals ranged in age from 16 to 70 years (median 30). There were 36 males. In 22 cases the cause of death was determined to be drug toxicity, 22 were external injury and 5 were attributed to natural disease. The concentration of cocaine in the cases was relatively low (range 0.01-3 mg/L, median 0.1 mg/L). Cocaine metabolites were detected frequently in blood and urine: benzoylecgonine (46 cases); ecgonine methyl ester (12 cases); cocaethylene (8 cases); and methylecgonine (9 cases). Opioids were commonly detected (23 cases), in addition to amphetamines (15 cases), ethanol (17 cases) and benzodiazepines (12 cases). Of the 43 cases receiving a full autopsy, there were 14 cases involving significant heart disease. This included coronary artery disease (11 cases), an enlarged heart (5 cases), myocarditis and contraction band necrosis. Cocaine is detected relatively infrequently in Victorian coronial cases. However it appears to be associated with a significant degree of cardiotoxicity, particularly coronary artery disease and ventricular hypertrophy, independent of cocaine concentration.

Sudden death due to aortic rupture complicating undiagnosed coarctation of the aorta in a teenager – A case report and review of the literature

Coarctation of the aorta is one of the more common congenital cardiac defects accounting for between 5 and 10% of cases of congenital heart disease. It has traditionally been divided into infantile (pre-ductal) and adult (ductal) types. Prior to the development of surgical treatment for coarctation, the condition was associated with significant morbidity and mortality with the most common causes of death being aortic rupture, congestive cardiac failure, endocarditis and intracerebral haemorrhage. Presentation of undiagnosed aortic coarctation as sudden and unexpected death is today a distinctly uncommon phenomenon. We report one such case, that of an adolescent male who at autopsy was noted to have coarctation of ductal type with aortic dissection and haemopericardium. The presence of this condition should be considered by the forensic pathologist confronted with aortic dissection, particularly in a young person.

Deaths linked to synthetic cannabinoids

Over the last 5 years there has been an influx of novel designer drugs (mostly illegal) which are intended to mimic the effects of cannabis (synthetic cannabinoids). Many of these compounds are created by research groups attempting to find an analog of cannabis that can be used therapeutically to treat pain and other conditions. PB-22 (1-pentyl-8-quinolinyl ester-1H-indole-3-carboxylic acid) is a relatively new synthetic cannabinoid which has cannabis like activity and possibly other as yet unknown effects. There is no published data on the pharmacodynamics, pharmacokinetics or toxicology of PB-22. However, a recent publication has reported 4 deaths associated with use of 5F-PB-22 which is a derivative of PB-22 [1]. Although synthetic cannabinoids have been reported in association with sudden death, the precise pathophysiological mechanisms by which death occurs remain obscure. We have identified three cases in Victoria over a recent 4 month period all of which have PB-22 as the main toxicological finding. In all three cases the cause of death was unascertained following the performance of a full autopsy with ancillary investigations. The subsequent identification of this substance raises the question of its possible involvement in the deaths, particularly in the absence of a competing cause of death. We remain unsure about the contribution of PB-22 to these deaths however all 3 deaths (ages 15–35) occurred at home in the setting of using this drug with no other competing cause of death identified. We feel it important that practitioners be aware so they can alert patients who may be experimenting with or using designer drugs such as synthetic cannabinoids. The safety of these substances is largely unknown; and those with an existing heart condition may be at risk of sudden death when using drugs which can produce unwanted increases in heart rate and blood pressure. We thank the State Coroner of Victoria, Judge Ian Gray for allowing this issue to be publicized, and the staff pathologists of the Victorian Institute of Forensic Medicine.

Virtual autopsy: time for a clinical trial

In this paper we put forward the idea that forensic pathologists need to start thinking differently about our core activity. It may now be time to move beyond the classical autopsy and embrace a new approach. However, the present discussion is only applicable to death investigation systems that have, or can develop, capacity in postmortem CT/MR imaging. Over the last 50 years, hospital autopsy rates have declined. Although many pathologists lament this situation, the decline has had no practical adverse effect on medical education or the quality of patient care. Hospital autopsies are still performed when there is a specific clinical interest aimed at improving patient care (e.g., when death occurs after cardiovascular surgery, bone marrow transplantation, or during clinical trials). Furthermore, the targeted medical autopsy is thriving as a clinical and basic science research tool (e.g., ‘‘brain only’’ autopsies in neurodegenerative disease). The autopsy as a teaching tool is essentially defunct at the undergraduate level, as most medical schools have prioritized other aspects of the curriculum due to the huge increase in medical knowledge. Legal and forensic medicine is often only briefly mentioned in the medical curriculum. In addition, there is a widespread movement in forensic pathology to embrace postmortem imaging, or virtual autopsy. There is a range of opinion on the utility of this approach, or if it is a beneficial development. However, if the history of medical technology is a guide, the net effect of the use of postmortem imaging will be to reduce the number of classical autopsies performed. Furthermore, there is a persistent societal tendency to reduce the number of autopsies. In fact, most medicolegal death investigation systems are developing policies or legislation to permit objection to autopsies by families. Cost containment is also a driver of autopsy rate reduction in many jurisdictions. Furthermore, the magnitude of problems with organ retention is increased by higher autopsy rates. In the jurisdictions with the highest medicolegal autopsy rate, studies have shown that these autopsies are often quite poorly performed and/or reported. In addition, many jurisdictions have never had a high medicolegal autopsy rate (e.g., Netherlands and Germany) and yet have not suffered systemic ill-effects in society as a result. Prospective audit of medicolegal autopsy quality have shown that deficiencies in autopsy results in cases of natural, accidental and suicidal death have little, if any, impact on the outcomes in the case. This seems to occur because some medicolegal autopsies are performed as a matter of policy or customary practice, rather than a way to add specific value to the death investigation. Despite these issues, it would probably be universally agreed that classical medicolegal autopsies are critically important in cases of: the unexpected death of infants and children; homicide or suspected homicide; death in police custody; sudden death in the young (e.g., possible genetic disease); and deaths related to patient safety issues and therapeutic complications. These data suggest that we need to consider re-defining the modern medicolegal autopsy as a forensic medical procedure. Perhaps this new approach should start with a new definition: the modern medicolegal autopsy is the least invasive medical examination of a dead body to answer all the relevant, reasonably foreseeable questions that derive from applicable legislation, the criminal justice system and the health care of the family. M. S. Pollanen (&) N. Woodford Ontario Forensic Pathology Service, Toronto, Canada e-mail: Michael.Pollanen@ontario.ca

Rupture of a splenic artery aneurysm during pregnancy with maternal and foetal death

Aneurysms of the splenic artery are rare although they are the most common of the so-called visceral artery aneurysms. First described by Beaussier in 1770, approximately 400 cases have now been reported in the literature. There is a strong association with pregnancy and since Corsons first description of the death of a mother in the third trimester from rupture of a splenic artery aneurysm, some 25% of reported cases have involved pregnant women. Arterial rupture is an obstetric emergency and associated with maternal and foetal mortality rates approaching 75% and 95% respectively. There are only 14 reported instances where both mother and baby survived. The clinical presentation is protean and in most cases splenic artery aneurysm is identified unexpectedly at angiography, laparotomy or post-mortem examination.

Automobile door entrapment--a different form of vehicle-related crush asphyxia.

Crush asphyxia involving motor vehicles usually occurs when a victim is trapped beneath a vehicle that slips from a jack while being worked on, or beneath a car that has rolled over during a crash. Two cases are reported where crush asphyxia resulted from quite different circumstances. Case 1: A 58-year-old woman was found dead trapped between her car door and frame. As she was alighting from the vehicle it had rolled forward trapping her between the semi-opened door and car frame when the door had wedged against a second parked vehicle. Case 2: A second 58-year-old woman was found dead, also trapped between her car door and frame. She had been leaning out of her car trying to pick up a newspaper when the car rolled forward. The open drivers door wedged against an adjacent pillar trapping her between the door and the frame. Both victims died from crush asphyxia. This form of automobile door entrapment represents a distinct subset of automobile-related asphyxial deaths and illustrates a particular and unusual set of circumstances that may result in unexpected traumatic death. Getting, or leaning, out of a vehicle that does not have the handbrake engaged may result in wedging of the victim between the semi-opened door and car frame if the car rolls forward and the door impacts against a nearby unyielding object. Correlation of the physical dimensions of the door and frame with markings on the victims body will assist in reconstructing the terminal events.

The development of a protocol for post-mortem management of Ebola virus disease in the setting of developed countries.

The management of the recent Ebola virus disease (EVD) epidemic continues to pose currently insuperable challenges to health care providers in the resource-deprived countries of West Africa. In an age where air travel facilitates rapid movement of people between countries and continents, there is an urgent requirement for health systems around the globe to develop management strategies and protocols in the event that EVD cases are suspected or confirmed. Departments of forensic pathology play an important, and underestimated, role in public health service delivery, particularly at times of novel infectious disease emergence. This role can include disease identification, characterization, and notification, as well as close engagement with agencies responsible for disease surveillance and treatment provision. A mass outbreak of EVD in the Western world is considered highly unlikely; however, there is clear responsibility on departments of forensic pathology to develop protocols for rapid assessment of sporadic or suspected cases while ensuring the health and safety of mortuary and pathology personnel. The Ontario Forensic Pathology Service and the Victorian Institute of Forensic Medicine have collaborated on the development of a protocol for management of EVD cases presenting at a scene or in the mortuary. It is hoped that this trans-national, inter-departmental exercise will serve as a model for future co-operative endeavors. The protocol has been distributed to forensic pathology departments around Australia and may be modified to accommodate local resource capabilities.