Vimal Raj

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.

Regional Thicknesses and Thickening of Compacted and Trabeculated Myocardial Layers of the Normal Left Ventricle Studied by Cardiovascular Magnetic Resonance

Background—We used cardiovascular magnetic resonance (CMR) to study normal left ventricular (LV) trabeculation as a basis for differentiation from pathological noncompaction. Methods and Results—The apparent end-diastolic (ED) and end-systolic (ES) thicknesses and thickening of trabeculated and compacted myocardial layers were measured in 120 volunteers using a consistent selection of basal, mid, and apical CMR short-axis slices. All had a visible trabeculated layer in 1 or more segments. The compacted but not the trabeculated layer was thicker in men than in women (P<0.01 at ED and ES). When plotted against age, the trabeculated and compacted layer thicknesses demonstrated opposite changes: an increase of the compact layer after the fourth decade at both ED and ES (P<0.05) but a decrease of the trabeculated layer. There was age-related preservation of total wall thickness at ED but an increase at ES (P<0.05). The compacted layer thickened, whereas the trabeculated layer thinned with systole, but neither change differed between sexes. With age, the most trabeculated LV segments showed significantly greater systolic thinning of trabeculated layers and, conversely, greater thickening of the compact segments (P<0.05). Total wall thickening is neither sex nor age dependent. There were no sex differences in the trabeculated/compacted ratio at ES or ED, but the ES trabeculated/compacted ratio was smaller in older (50 to 79 years) versus younger (20 to 49 years) groups (P<0.05). Conclusions—We demonstrated age- and sex-related morphometric differences in the apparent trabeculated and compacted layer thicknesses and systolic thinning of the visible trabeculated layer that contrasts with compacted myocardial wall thickening.

Post-mortem computed tomography angiography: past, present and future

The role of imaging has been long established in forensic practice as an adjunct to the conventional autopsy. Recently with the development of MDCT, there has been a large international push towards the development of the so called “near virtual autopsy.” Currently a large obstacle to the acceptance of “near virtual autopsies” is the failure of post-mortem imaging to yield detailed information about the coronary arteries. This is a major deficiency of post-mortem MDCT and MRI compared to conventional autopsy as standard clinical angiography relies on circulation. One possible way to overcome this is by the use of post-mortem MDCT angiography. This review paper considers the past, current and future advances in cadaver cardiac imaging which, if successful, will take radiological imaging one step closer to the widespread introduction of near virtual autopsies.

Phenotyping airways disease: an A to E approach.

The airway diseases asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous conditions with overlapping pathophysiological and clinical features. It has previously been proposed that this heterogeneity may be characterized in terms of five relatively independent domains labelled from A to E, namely airway hyperresponsiveness (AHR), bronchitis, cough reflex hypersensitivity, damage to the airways and surrounding lung parenchyma, and extrapulmonary factors. Airway hyperresponsiveness occurs in both asthma and COPD, accounting for variable day to day symptoms, although the mechanisms most likely differ between the two conditions. Bronchitis, or airway inflammation, may be predominantly eosinophilic or neutrophilic, with different treatments required for each. Cough reflex hypersensitivity is thought to underlie the chronic dry cough out of proportion to other symptoms that can occur in association with airways disease. Structural changes associated with airway disease (damage) include bronchial wall thickening, airway smooth muscle hypertrophy, bronchiectasis and emphysema. Finally, a variety of extrapulmonary factors may impact upon airway disease, including rhinosinusitis, gastroesophageal reflux disease, obesity and dysfunctional breathing. This article discusses the A to E concept in detail and describes how this framework may be used to assess and treat patients with airway diseases in the clinic.

Targeted cardiac post-mortem computed tomography angiography: a pictorial review

With the introduction of targeted coronary artery angiography to post-mortem computed tomography (PMCT) it is now possible to assess the coronary arteries and left ventricle after death without, case dependent, the necessity to undertake an invasive autopsy. The purpose of this pictorial review is to act as a walk through aid memoire and educational learning document for radiologists and pathologists alike who may be new to the use and interpretation of targeted PMCT angiography. By using an example scanning protocol, which uses both positive and negative (air) contrast mediums, this pictorial review provides a systematic approach to vessel and ventricular assessment that is based upon clinical cardiac angiography but adapted to PMCT.

The criminal justice system's considerations of so-called near-virtual autopsies: the East Midlands experience

Background While several research groups champion the potential for postmortem CT (PMCT) to replace the invasive postmortem (PM), many questions still remain. Aims Perhaps the two most important questions are whether PMCT can provide the same level of information as an invasive PM, and arguably more importantly, can it meet the needs of the end users of the PM report. Through a comparative analysis of invasive post-mortem and CT findings and a questionnaire based qualitative thematic analysis, the authors have sought to answer these questions. Results and Conclusion Here, the authors show that PMCT is good at providing accurate causes of death and that the interpretation of cases is not significantly altered by the absence of histology. The authors show that in straightforward trauma deaths such as road traffic incidents, there exists the potential for the replacement of the invasive PM by PMCT examination. However, as yet, PMCT cannot provide all of the information that is expected by the criminal justice system in complex forensic cases.

Diagnostic accuracy of post-mortem CT with targeted coronary angiography versus autopsy for coroner-requested post-mortem investigations: a prospective, masked, comparison study

Summary Background England and Wales have one of the highest frequencies of autopsy in the world. Implementation of post-mortem CT (PMCT), enhanced with targeted coronary angiography (PMCTA), in adults to avoid invasive autopsy would have cultural, religious, and potential economic benefits. We aimed to assess the diagnostic accuracy of PMCTA as a first-line technique in post-mortem investigations. Methods In this single-centre (Leicester, UK), prospective, controlled study, we selected cases of natural and non-suspicious unnatural death referred to Her Majestys (HM) Coroners. We excluded cases younger than 18 years, known to have had a transmittable disease, or who weighed more than 125 kg. Each case was assessed by PMCTA, followed by autopsy. Pathologists were masked to the PMCTA findings, unless a potential risk was shown. The primary endpoint was the accuracy of the cause of death diagnosis from PMCTA against a gold standard of autopsy findings, modified by PMCTA findings only if additional substantially incontrovertible findings were identified. Findings Between Jan 20, 2010, and Sept 13, 2012, we selected 241 cases, for which PMCTA was successful in 204 (85%). Seven cases were excluded from the analysis because of procedural unmasking or no autopsy data, as were 24 cases with a clear diagnosis of traumatic death before investigation; 210 cases were included. In 40 (19%) cases, predictable toxicology or histology testing accessible by PMCT informed the result. PMCTA provided a cause of death in 193 (92%) cases. A major discrepancy with the gold standard was noted in 12 (6%) cases identified by PMCTA, and in nine (5%) cases identified by autopsy (because of specific findings on PMCTA). The frequency of autopsy and PMCTA discrepancies were not significantly different (p=0·65 for major discrepancies and p=0·21 for minor discrepancies). Cause of death given by PMCTA did not overlook clinically significant trauma, occupational lung disease, or reportable disease, and did not significantly affect the overall population data for cause of death (p≥0·31). PMCTA was better at identifying trauma and haemorrhage (p=0·008), whereas autopsy was better at identifying pulmonary thromboembolism (p=0·004). Interpretation For most sudden natural adult deaths investigated by HM Coroners, PMCTA could be used to avoid invasive autopsy. The gold standard of post-mortem investigations should include both PMCT and invasive autopsy. Funding National Institute for Health Research.

Emphysema- and airway-dominant COPD phenotypes defined by standardised quantitative computed tomography

EvA (Emphysema versus Airway disease) is a multicentre project to study mechanisms and identify biomarkers of emphysema and airway disease in chronic obstructive pulmonary disease (COPD). The objective of this study was to delineate objectively imaging-based emphysema-dominant and airway disease-dominant phenotypes using quantitative computed tomography (QCT) indices, standardised with a novel phantom-based approach. 441 subjects with COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages 1–3) were assessed in terms of clinical and physiological measurements, laboratory testing and standardised QCT indices of emphysema and airway wall geometry. QCT indices were influenced by scanner non-conformity, but standardisation significantly reduced variability (p<0.001) and led to more robust phenotypes. Four imaging-derived phenotypes were identified, reflecting “emphysema-dominant”, “airway disease-dominant”, “mixed” disease and “mild” disease. The emphysema-dominant group had significantly higher lung volumes, lower gas transfer coefficient, lower oxygen (PO2) and carbon dioxide (PCO2) tensions, higher haemoglobin and higher blood leukocyte numbers than the airway disease-dominant group. The utility of QCT for phenotyping in the setting of an international multicentre study is improved by standardisation. QCT indices of emphysema and airway disease can delineate within a population of patients with COPD, phenotypic groups that have typical clinical features known to be associated with emphysema-dominant and airway-dominant disease. Standardisation of quantitative CT improves delineation of emphysema and airway phenotypes in a multicentre study http://ow.ly/10zjhV

Demonstrating the origin of cardiac air embolism using post-mortem computed tomography; an illustrated case.

An 83 year old female was found dead in her home. The deceased had been struck repeatedly to the head with at least one weapon, one of which was a hammer. The deceased had suffered both penetrating and non-penetrating blunt trauma to the head as a result of the assault. A multi-detector computed tomography (MDCT) scan was undertaken approximately 12h after death prior to the autopsy examination. This demonstrated the presence of a cardiac air embolus and continuity between the air embolus and the penetrating head injury. Air within the heart is a recognised post-mortem artefact frequently seen on MDCT scans and a common pitfall for inexperienced cadaveric MDCT reporters. This case builds upon a previous report by Kauczor, illustrating how MDCT can be used to demonstrate the origin and route of ingress of a genuine air embolism to the heart.

Cardiac Magnetic Resonance of Acute Myocarditis in an Human Immunodeficiency Virus Patient Presenting With Acute Chest Pain Syndrome

A 34-year-old woman of Afro Caribbean origin presented to the HIV clinic with a few days’ history of chest pain, chills, and malaise. The chest pain was intermittent, severe, central, radiating to the left arm, worse on lying down, and better on sitting forward. This was preceded by an episode of collapse after palpitations a week earlier. On examination, she had a regular pulse of 84 bpm, blood pressure of 131/71 mm Hg, respiratory rate of 20, temperature of 38°C, and oxygen saturation of 99% on air. Cardiovascular, respiratory, abdominal, and neurological examinations were normal. ECG demonstrated anterolateral ischemic changes (Figure 1). Chest radiograph was normal. Figure 1. ECG showing anterolateral ischemic changes. Biochemical profile was as follows: C-reactive protein, 296 mg/dL; troponin, 3.8 ng/mL; CD4 count, 459; viral load, <50; and hemoglobin, 9.1 g/dL. Her antistreptolysin O titer was 1 in 40, and no antistreptolysin antibodies were detected. Viral titers were negative for cytomegalovirus, adenovirus, Coxiella burnetii , chlamydia (group) and Mycoplasma pneumoniae , enterovirus (including echoviruses, coxsackie …