Patricia M. Flach

Sudden Death after Chest Pain: Feasibility of Virtual Autopsy with Postmortem CT Angiography and Biopsy

PURPOSE To determine the potential of minimally invasive postmortem computed tomographic (CT) angiography combined with image-guided tissue biopsy of the myocardium and lungs in decedents who were thought to have died of acute chest disease and to compare this method with conventional autopsy as the reference standard. MATERIALS AND METHODS The responsible justice department and ethics committee approved this study. Twenty corpses (four female corpses and 16 male corpses; age range, 15-80 years), all of whom were reported to have had antemortem acute chest pain, were imaged with postmortem whole-body CT angiography and underwent standardized image-guided biopsy. The standard included three biopsies of the myocardium and a single biopsy of bilateral central lung tissue. Additional biopsies of pulmonary clots for differentiation of pulmonary embolism and postmortem organized thrombus were performed after initial analysis of the cross-sectional images. Subsequent traditional autopsy with sampling of histologic specimens was performed in all cases. Thereafter, conventional histologic and autopsy reports were compared with postmortem CT angiography and CT-guided biopsy findings. A Cohen κ coefficient analysis was performed to explore the effect of the clustered nature of the data. RESULTS In 19 of the 20 cadavers, findings at postmortem CT angiography in combination with CT-guided biopsy validated the cause of death found at traditional autopsy. In one cadaver, early myocardial infarction of the papillary muscles had been missed. The Cohen κ coefficient was 0.94. There were four instances of pulmonary embolism, three aortic dissections (Stanford type A), three myocardial infarctions, three instances of fresh coronary thrombosis, three cases of obstructive coronary artery disease, one ruptured ulcer of the ascending aorta, one ruptured aneurysm of the right subclavian artery, one case of myocarditis, and one pulmonary malignancy with pulmonary artery erosion. In seven of 20 cadavers, CT-guided biopsy provided additional histopathologic information that substantiated the final diagnosis of the cause of death. CONCLUSION Postmortem CT angiography combined with image-guided biopsy, because of their minimally invasive nature, have a potential role in the detection of the cause of death after acute chest pain.

Imaging in forensic radiology: an illustrated guide for postmortem computed tomography technique and protocols

Forensic radiology is a new subspecialty that has arisen worldwide in the field of forensic medicine. Postmortem computed tomography (PMCT) and, to a lesser extent, PMCT angiography (PMCTA), are established imaging methods that have replaced dated conventional X-ray images in morgues. However, these methods have not been standardized for postmortem imaging. Therefore, this article outlines the main approach for a recommended standard protocol for postmortem cross-sectional imaging that focuses on unenhanced PMCT and PMCTA. This review should facilitate the implementation of a high-quality protocol that enables standardized reporting in morgues, associated hospitals or private practices that perform forensic scans to provide the same quality that clinical scans provide in court.

Postmortem CT Angiography: Capabilities and Limitations in Traumatic and Natural Causes of Death

Whole-body postmortem computed tomographic (CT) angiography is a promising new development in forensic radiology that has the potential to improve vascular and soft-tissue imaging beyond levels currently achievable with unenhanced postmortem CT. Postmortem access to the vascular system and injection of contrast medium are different from those steps in clinical (antemortem) radiology. Because there is no circulation in a corpse that could transport or dilute a contrast medium, the injection must be performed by using a roller pump to fill the vasculature (arterial and venous) with a mixture of a water-soluble iodized contrast medium and polyethylene glycol. In contrast to a classic autopsy, postmortem CT angiography is a minimally invasive procedure. It allows the diagnosis of vascular lesions without the disruption or destruction of anatomic structures, which could result in a loss of evidence in a criminal investigation. Furthermore, postmortem CT angiography facilitates the display of vascular pathologic conditions in areas that are not typically covered with autopsy alone, such as the craniocervical junction and the small pelvis. Therefore, postmortem CT angiography adds substantial value to the classic forensic autopsy; cross-sectional data can be reevaluated objectively at any time and are fully reproducible as counterexpertise, which is as useful in the fields of forensic medicine and pathology as in clinical research. Familiarity with the capabilities of postmortem CT angiography may help radiologists working with forensic cases improve their diagnostic performance.

Times Have Changed! Forensic Radiology—A New Challenge for Radiology and Forensic Pathology

OBJECTIVE The ongoing development of imaging and the recent integration of cross-sectional imaging methods into the medicolegal workflow have resulted in an increasing number of forensic institutes acquiring dedicated CT and MRI scanners. The purpose of this article is to evaluate the different aspects of postmortem imaging and to detail the necessary cooperation between radiologists and forensic pathologists for mutual learning and accurate science to form a new subspecialty: forensic radiology. CONCLUSION; Forensic radiology must integrate the expertise of forensic pathologists and radiologists. The challenge is to unite these two disciplines first by direct and intense communications and second by a basic understanding of forensic pathology by radiologists as well as a foundational knowledge of postmortem imaging by forensic pathologists, in combination with the establishment of educational and reporting guidelines.

A new approach in virtopsy: Postmortem ventilation in multislice computed tomography

Although postmortem imaging has gained prominence in the field of forensic medicine, evaluation of the postmortem lung remains problematic. Specifically, differentiation of normal postmortem changes and pathological pulmonary changes is challenging and at times impossible. In this study, five corpses were ventilated using a mechanical ventilator with a pressure of 40 mbar (40.8 cm H(2)O). The ventilation was performed via an endotracheal tube, a larynx mask or a continuous positive airway pressure mask. Postmortem computed tomographic images of the lungs before and with a ventilation of 40 mbar (40.8 cm H(2)O) were evaluated and the lung volumes were measured with segmentation software. Postmortem ventilation led to a clearly visible decrease of both the density in the dependant parts of the lungs and ground glass attenuation, whereas consolidated areas remained unchanged. Furthermore, a mean increase in the lung volume of 2.10 l was seen. Pathological changes such as septal thickening or pulmonary nodules in the lung parenchyma became more detectable with postmortem ventilation. Intracorporal postmortem mechanical ventilation of the lungs appears to be an effective method for enhancing detection of small pathologies of the lung parenchyma as well as for discriminating between consolidation, ground glass attenuation and position-dependent density.

Postmortem whole-body MRI in traumatic causes of death

OBJECTIVE The aim of this study was to determine the sensitivity and specificity of postmortem whole-body MRI for typical injuries resulting from traumatic causes of death. MATERIALS AND METHODS Forty cases of accidental death were evaluated with postmortem whole-body MRI. Imaging was conducted according to a standard protocol, and each examination had an average duration of 90 minutes. The imaging findings were correlated with the autopsy findings, which served as the reference standard. RESULTS MRI showed the main pathologic process leading to death in 39 of the 40 cases. The sensitivity of postmortem MRI ranged from 100% (pneumothorax) to 40% (fractures of the upper extremities). In general, MRI had a high level of performance for depicting soft-tissue lesions, such as subcutaneous hematoma (e.g., galeal hematoma with a sensitivity 95%). The sensitivity of MRI was remarkably lower for lesions of the upper abdominal organs (liver, 80%; spleen, 50%; pancreas, 60%; kidneys, 66%). CONCLUSION Postmortem whole-body MRI had overall good performance for depicting traumatic findings in corpses and therefore may serve an important role as an adjunct to classic autopsy for the forensic examination of cases of traumatic cause of death. However, the reduced sensitivity of postmortem MRI for lacerations of the upper abdominal organs and the observed superimposition of antemortem findings and postmortem findings (e.g., in the pulmonary tissue) in this retrospective study suggest that whole-body postmortem MRI not be recommended as a replacement for classic autopsy.

Postmortem Whole-Body Computed Tomography Angiography Visualizing Vascular Rupture in a Case of Fatal Car Crash

In addition to the increasingly significant role of multislice computed tomography in forensic pathology, the performance of whole-body computed tomography angiography provides outstanding results. In this case, we were able to detect multiple injuries of the parenchymal organs in the upper abdomen as well as lesions of the brain parenchyma and vasculature of the neck. The radiologic findings showed complete concordance with the autopsy and even supplemented the autopsy findings in areas that are difficult to access via a manual dissection (such as the vasculature of the neck). This case shows how minimally invasive computed tomography angiography can serve as an invaluable adjunct to the classic autopsy procedure.

Postmortem ventilation: a new method for improved detection of pulmonary pathologies in forensic imaging.

Postmortem imaging has gained prominence in the field of forensic pathology. Even with experience in this procedure, difficulties arise in evaluating pathologies of the postmortem lung. The effect of postmortem ventilation with applied pressures of 10, 20, 30 and 40 mbar was evaluated in 10 corpses using simultaneous postmortem computed tomography (pmCT) scans. Ventilation was performed via a continuous positive airway pressure mask (n=5), an endotracheal tube (n=4) and a laryngeal mask (n=1) using a portable home care ventilator. The lung volumes were measured and evaluated by a segmentation technique based on reconstructed CT data. The resulting changes to the lungs were analyzed. Postmortem ventilation at 40 mbar induced a significant (p<0.05) unfolding of the lungs, with a mean volume increase of 1.32 l. Small pathologies of the lung such as scarring and pulmonary nodules as well as emphysema were revealed, while inner livores were reduced. Even though lower ventilation pressures resulted in a significant (p<0.05) volume increase, pathologies were best evaluated when a pressure of 40 mbar was applied, due to the greater reduction of the inner livores. With the ventilation-induced expansion of the lungs, a decrease in the heart diameter and gaseous distension of the stomach was recognized. In conclusion, postmortem ventilation is a feasible method for improving evaluation of the lungs and detection of small lung pathologies. This is because of the volume increase in the air-filled portions of the lung and reduced appearance of inner livores.

Post-mortem imaging of laryngohyoid fractures in strangulation incidents: First results

Fractures and soft-tissue injuries of the neck are of great importance in forensic pathology, as they help in assessing whether strangulation took place, and if so, how severely. In this study, we examined the usefulness of post-mortem imaging with multislice computed tomography (MSCT) in detecting lesions of the laryngohyoid structures and the surrounding soft-tissues. For this purpose, we examined MSCT images of the neck of eight deceased persons who had suffered different types of strangulation and compared the findings with those obtained at the subsequent forensic autopsy. In six of the eight cases (75%), the fracture findings at autopsy were concordant with those found with MSCT. In the two non-congruent cases, MSCT revealed fractures, which were not discovered at autopsy. Soft-tissue haemorrhages were detected by autopsy in five cases, but only in one case with MSCT. MSCT does not suffice in detecting soft-tissue injuries. These preliminary results are promising regarding the detection of fractures in strangulation cases. If these results can be confirmed in larger studies, we believe that post-mortem MSCT may serve - in combination with a thorough external examination and a profound incident-scene investigation - as a useful decision-making tool regarding the necessity of further examinations, i.e. autopsy.

Format preferences of district attorneys for post-mortem medical imaging reports: Understandability, cost effectiveness, and suitability for the courtroom: A questionnaire based study

AIMS The objective of this study was to explore the perception of the legal authorities regarding different report types and visualization techniques for post-mortem radiological findings. METHODS A standardized digital questionnaire was developed and the district attorneys in the catchment area of the affiliated Forensic Institute were requested to evaluate four different types of forensic imaging reports based on four cases examples. Each case was described in four different report types (short written report only, gray-scale CT image with figure caption, color-coded CT image with figure caption, 3D-reconstruction with figure caption). The survey participants were asked to evaluate those types of reports regarding understandability, cost effectiveness and overall appropriateness for the courtroom. RESULTS AND CONCLUSION 3D reconstructions and color-coded CT images accompanied by written report were preferred regarding understandability and cost/effectiveness. 3D reconstructions of the forensic findings reviewed as most adequate for court.