Common Postmortem Computed Tomography Findings Following Atraumatic Death: Differentiation between Normal Postmortem Changes and Pathologic Lesions

Computed tomography (CT) is widely used in postmortem investigations as an adjunct to the traditional autopsy in forensic medicine. To date, several studies have described postmortem CT findings as being caused by normal postmortem changes. However, on interpretation, postmortem CT findings that are seemingly due to normal postmortem changes initially, may not have been mere postmortem artifacts. In this pictorial essay, we describe the common postmortem CT findings in cases of atraumatic in-hospital death and describe the diagnostic pitfalls of normal postmortem changes that can mimic real pathologic lesions.

Comparison of attenuation of striated muscle between postmortem and antemortem computed tomography: results of a longitudinal study

Objective

We evaluated the postmortem changes of striated muscle by comparing computed tomography (CT) images obtained postmortem and antemortem in the same patients.

Materials and Methods

We studied 33 consecutive patients who underwent antemortem CT, postmortem CT, and pathological autopsy in our tertiary care hospital between April 2009 and December 2010. Postmortem CT was performed within 20 h after death and was followed by pathological autopsy. Pathological autopsy confirmed the absence of muscular diseases such as amyotrophic lateral sclerosis, muscular dystrophy, myositis, and myasthenia, in all of the patients. The CT attenuation values of four cardiac muscle sites (anterior wall of the left ventricle, left ventricular free wall, posterior wall of the left ventricle, and the ventricular septum) and two skeletal muscle sites (the pectoralis major muscle and the erector spinae muscle) were compared between antemortem and postmortem CT using paired t test.

Results

Striated muscle had significantly greater attenuation on postmortem CT than on antemortem CT (P<0.001) in all six tissue sites. No significant association was found between postmortem change in the CT attenuation of striated muscle and gender, age, or elapsed time since death.

Conclusion

This is the first longitudinal study to show hyperattenuation of striated muscle on postmortem CT images compared with antemortem CT images in the same patients.

Sudden onset of sleep due to hypothalamic lesions in neuromyelitis optica spectrum disorder positive for anti-aquaporin-4 antibody

We report a patient with neuromyelitis optica spectrum disorders who presented with sudden onset of sleep as the sole manifestation. Magnetic resonance imaging investigation revealed lesions in the hypothalamus bilaterally, which vanished completely after methylprednisolone pulse therapy.

Early postmortem volume reduction of adrenal gland: initial longitudinal computed tomographic study

We aimed to confirm whether postmortem adrenal volumetric changes occur by measuring adrenal volumes on computed tomography (CT). Fifty-five adrenal glands from 28 subjects who died were included. All subjects underwent antemortem CT (AMCT) and postmortem CT (PMCT) within 94-1,191 min after death, followed by conventional autopsy. CT volumetry was performed using freely-available software. Differences between AMCT and PMCT adrenal volumes were evaluated statistically along with differences in the degree of volume change, elapsed time to PMCT, and presence of underlying malignant disease. The mean volume of the right adrenal gland decreased from 3.8 cm(3) on AMCT to 2.6 cm(3) on PMCT (P < 0.001); the left adrenal gland decreased from 4.2 cm(3) on AMCT to 3.1 cm(3) on PMCT (P < 0.001). Conventional autopsy revealed decreased intracellular lipid components in portions of the adrenal glands. No correlation between the adrenal gland reduction rate and the elapsed time from AMCT to death or from death to PMCT was observed (P = 0.99 and 0.79; P = 0.28 and 0.59 for the right and left adrenal glands, respectively). Significant differences in both the bilateral adrenal gland reduction rates and underlying malignant disease were found for the left adrenal gland (P = 0.015), but not for the right (P = 0.74). Adrenal volume reduction was observed on PMCT compared to AMCT. This highlights the need to further elucidate the mechanism of adrenal shrinkage during the agonal stage and after death. This may be explained by pathological findings of intracellular lipid depletion.

Greater thickness of the aortic wall on postmortem computed tomography compared with antemortem computed tomography: the first longitudinal study

OBJECTIVES

To evaluate postmortem changes of the aorta on postmortem computed tomography (CT) in comparison with those on antemortem CT obtained in the same patients.

MATERIALS AND METHODS

We studied 57 consecutive patients who had undergone antemortem CT, postmortem CT, and pathological autopsy in our tertiary care hospital between April 2009 and December 2010. Postmortem CT was performed within 20 h after death, followed by pathological autopsy. Pathological autopsy confirmed the absence of cardiovascular disease such as aortic aneurysm, aortic dissection, or Marfan syndrome in all patients. Aortic wall thickness and aortic cross-sectional areas were measured on both antemortem CT and postmortem CT. Difference in aortic wall thickness between antemortem CT with and without contrast medium, and between antemortem CT and postmortem CT, and in cross-sectional area of the aortic wall between antemortem CT and postmortem CT was evaluated statistically.

RESULTS

No significant difference in aortic wall thickness was observed on antemortem CT in comparison of contrasted and non-contrasted images. The aortic wall was significantly thicker on postmortem CT than on antemortem CT (p < 0.0001). No significant difference in cross-sectional area of the aortic wall was observed between antemortem CT and postmortem CT measurements.

CONCLUSION

This is the first longitudinal study to confirm greater thickness of the aortic wall on postmortem images compared with antemortem images in the same patients and to show no change in cross-sectional area of the aortic wall between before and after death.

Heart wall is thicker on postmortem computed tomography than on antemortem [corrected] computed tomography: the first longitudinal study

Objective

To evaluate the postmortem changes of the heart wall on postmortem (PM) computed tomography (CT) in comparison with those on ante mortem CT (AMCT), and in comparison with the pathological findings, obtained in the same patients.

Materials and Methods

We studied 57 consecutive patients who had undergone AMCT, PMCT, and pathological autopsy in our tertiary care hospital between April 2009 and December 2010. PMCT was performed within 20 hours after death, followed by pathological autopsy. The cardiac chambers were measured at five sites on both AMCT and PMCT by two board-certified radiologists who were not provided with clinical information. The differences in heart wall thickness between AMCT with and without contrast medium, between AMCT and PMCT, and between PMCT and pathological anatomy were evaluated statistically. Confounding factors of postmortem change such as gender, presence of arteriosclerosis, the organ related to cause of death, age, and elapsed time since death were examined statistically.

Results

No significant differences were observed on AMCT in comparison of contrasted and non-contrasted images. The heart wall was significantly thicker on PMCT than on AMCT (p < 0.0001) at all five measurement sites. The heart wall was significantly thicker on PMCT than on pathology specimens when measured in accordance with pathological standard mensuration. However, no significant difference was observed between PMCT measurements and those of pathology specimens at any site when the papillary muscles and epicardial fat were included. No significant association was found between postmortem change in heart wall thickness and gender, presence of arteriosclerosis, the organ related to cause of death, age, or elapsed time since death.

Conclusion

This is the first longitudinal study to confirm greater thickness of heart wall on postmortem images compared with ante mortem images, in the same patients. Furthermore, the postmortem changes on CT were supported by the pathological findings.

Muscle metabolism in patients with polymyositis simultaneously evaluated by using 31P-magnetic resonance spectroscopy and near-infrared spectroscopy

Simultaneous measurements of muscle energy metabolism using (31)P-magnetic resonance spectroscopy ((31)P-MRS) and the kinetics of muscular oxygen metabolism using near-infrared spectroscopy (NIRS) were conducted in polymyositis (PM) patients. The subjects were 12 PM patients (age 45 +/- 12 years) and 12 normal controls (age 41 +/- 12 years). The muscle phosphocreatine (PCr) index and intracellular pH (pHi) were determined with (31)P-MRS and the changes in intramuscular oxygenated (oxy-Hb), deoxygenated (deoxy-Hb), and total haemoglobin (total Hb) were evaluated with NIRS . The pHi and PCr index before steroid therapy in PM patients were significantly lower during exercise than in normal controls, and their recovery was statistically significantly delayed compared with the controls. The pattern of changes in NIRS over time before steroid therapy in PM patients differed from that in normal controls. There were smaller changes in deoxy-Hb and oxy-Hb during exercise, and total Hb decreased during exercise. In contrast, the kinetics of muscular metabolism after steroid therapy showed changes similar to those seen in normal controls. Simultaneous (31)P-MRS and NIRS measurements to determine the kinetics of muscular metabolism are expected to be useful as a noninvasive approach for the evaluation of treatment effects in PM patients.

Salivary bisphenol-A levels detected by ELISA after restoration with composite resin

Bisphenol-A diglycidylether methacrylate (Bis-GMA), which is synthesized from bisphenol-A (BPA), a compound with exogenous endocrine disrupter action, is widely used as a dental material. During clinical filling with sealants and composite resins, the compounds are solidified by polymerization and then used. However, it has been noted that unpolymerized monomers may become dissolved in saliva. In this study using a competitive ELISA system, we investigated the changes in the BPA concentration in saliva after restoration with composite resins. Commercial composite resins from nine companies were tested. Mixed saliva was collected from 21 subjects. Based on the dynamics of salivary BPA detected by this ELISA system, we concluded that several tens to 100 ng/ml of BPA were contained in saliva after filling teeth with composite resin but that sufficient gargling can remove it from the oral cavity. Our data suggest that sufficient gargling after treatment is important for risk management.

[Experimental retinal branch vein occlusion. 4. Pathological changes in the middle and late stage]

Retinal branch vein occlusion in macaca monkeys (Macaca irus) was produced by dye laser photocoagulation, and observed histopathologically from five days to one year after photocoagulation. Ten days later, retinal edema and hemorrhage observed at an early stage gradually decreased. Two weeks later, capillary bed closure areas were observed in fluorescein angiography. The capillary closure was not reversible when disturbance of the retinal circulation continued for more than three or four days after photocoagulation. Three months later, dry retina was observed in the capillary bed closure areas. One year later, the retina was severely degenerated and thinned. In these retinal areas, capillary lumens observed microscopically were occluded by cellular components. Sheathing of large veins was observed in these retinal areas. The walls of these large veins were thick and fell into hyaline degeneration. Their lumens were narrowed or obstructed. During the period of observation, retinal neovascularization was not observed.

[Recanalization of venule following experimental retinal branch vein occlusion]

Retinal branch vein occlusion was experimentally produced in monkey (macaca irus) by dye laser photocoagulation. Venous dilatation, retinal edema and punctate hemorrhages were the ophthalmoscopic changes immediately after the occurrence of venous occlusion by photocoagulation. Fluorescein angiography revealed delay of retinal circulation and dye leakage from these venules. Fluorescein angiography on the 2nd day revealed caliber irregularities in the venules distal to the photocoagulated points. Histopathologically, thrombus formation and partial defect of the endothelial cells were observed in the venules in the areas which showed recovery with immature endothelial cells on the 4th day. Young endothelial cells proliferating along the endothelial basement membrane, which remained around the thrombi, and recanalization were observed on the 7th day. These results reveals a process of recanalization in the thrombogenous retinal venous occlusion.

[Experimental retinal branch vein occlusion]

Experimental retinal branch vein occlusion in monkeys (macaca irus) were produced by yellow wavelength (577nm) dye laser photocoagulation. The clinical sequence was observed in terms of the structural and ultrastructural findings occurring during the natural history of experimental branch vein occlusion, particularly in the early stage. Immediately after the occlusion, venous dilatation and retinal edema and hemorrhage appeared. Extravascular leakage of dye in fluorescein angiography and hemorrhage appeared from small venules at an early stage. Leakage from the larger vessels was observed later. Opening of the intercellular junctional complexes, which signifies breakdown of the blood-retinal barrier was detected by electron microscopy. Subsequently degenerative or necrotic changes in endothelial cells appeared with the formation of intravascular thrombi and extravascular leakage of blood components appeared from these vessels.

Biosensor system for continuous flow determination of enzyme activities. II. Simultaneous determination of plural enzyme activities

A biosensor system for continuous flow determination of plural enzyme activities was prepared from the combination of two pyruvate sensors, a prereactor and a flow cell. This system was applied to the simultaneous determination of lactic dehydrogenase (LDH) and glutamic-pyruvic transaminase (GPT) activities in the same sample. These enzyme activities can be determined by measuring pyruvate produced by the enzyme reactions as follows. The amount of pyruvic acid can also be determined from the amount of oxygen consumed upon oxidation of pyruvic acid by pyruvate oxidase. (Formula: see text). Therefore, both of the detectors for the determination of lactic dehydrogenase and glutamic-pyruvic transaminase activities were prepared from the combination of a pyruvate oxidase membrane and an oxygen electrode. Pyruvate oxidase was covalently immobilized on a membrane prepared from cellulose triacetate. A linear relation was obtained between the output current and LDH or GPT activities in the range of 50 to 3,600 IU l-1 or 6 to 1,000 IU l-1, respectively. Each assay of these enzyme activities was completed within 15 min. The results obtained had a precision of ca. 4%. The sensor was stable for more than 25 days at 5 degrees C.

Transition of physical fitness in wheelchair marathon competitors over several years

Twenty eight stress tests for 14 wheelchair marathon competitors were performed to determine their physical fitness just before the Oita International wheelchair marathon since 1984. All the subjects were wheelchair-bound Japanese males and workers at Sun Industry. Oxygen consumption at the maximal workload was significantly larger than that of non-athletic paraplegics and the mean values were 35.0 +/- 4.8 ml/kg in competitors and 22.6 +/- 5.0 ml/min/kg in non-athletic paraplegics. Eight competitors had more than 2 stress tests and 6 of them had 3 tests from 1984 to 1987. The oxygen consumption at the maximal workload of their third test was very high (46.5 +/- 6.8 ml/min/kg) equal to highly trained paraplegics, and was larger than the result of the first test significantly. Their physical fitness was reduced significantly during the off season, however their physical fitness was maintained at a satisfactory higher level than that of non-athletes. This study demonstrated that individual training for wheelchair marathoners had improved the competitors' physical fitness over several years.

[Experimental retinal branch vein occlusion]

Experimental retinal branch vein occlusion was produced in monkeys (macaca irus) by dye laser photocoagulation (yellow wavelength 577nm The 920 ARGON/DYE Laser System, Coherent Radiation). The Clinical process was observed based on ophthalmoscopic and fluorescein angiographic alterations which occur during the natural history of experimental branch vein occlusion. Immediately after occlusion, venous dilatation, retinal edema and punctate hemorrhage, were recognized by ophthalmoscopy, and leakage of dye from postcapillary venules, followed later by additional leakage from large veins were observed frequently by fluorescein angiography. Circulatory disturbances remained over 3-4 days, and the retinal branch vein occlusion were persisted. Ten days later, a non-perfusion area was observed by fluorescein angiography. More than 1 year later, these nonperfusion area remained.

Physical fitness of paraplegics in full wheelchair marathon racing

The wheelchair marathon is one of the most difficult sports for participants with much uncertainty regarding the security of the paraplegics. The physical fitness of paraplegics has been examined regularly since The Oita International Wheelchair Marathon (half marathon) was inaugurated (1981). A full marathon (42.195 km) was adopted at The 3rd Meeting (1983). The individual equations between heart rate (HR) and oxygen consumption VO2 were drawn from the preliminary test on the subjects who were expected to be among the top finishers in these races. VO2 during these races was indirectly estimated and showed a fairly low value (35.0 +/- 3.8 ml/kg/min in the full race, 32.7 +/- 6.3 ml/kg/min in the half race respectively) in comparison with able-bodied elite runners. However, the paraplegic participants had extremely high HR (171.6 +/- 20.5 beats/min, 168.1 +/- 9.8) continuously throughout the race. Though the ratio of active muscle mass of arms to legs in paraplegic athletes may approximate to near equal, paraplegic arms seem to exert physiologically and mechanically less efficient power. There were no significant differences in physical fitness between the full and the half marathon elite finishers. The cardiovascular function of paraplegic athletes may well be ranked among those of able-bodied athletes in their fitness. Full wheelchair marathon seems to be safe if it is held in an appropriate environment.

Long-term prognosis of behavior therapy in practice

A prognosis study was carried out on 30 cases of patients treated with behavior therapy. The treatments, which took more than three years before the study, averaged four years and eight months. The results are as follows: (1) The improvement achieved by therapy was maintained or further improved in 29 cases during the post-therapeutic period of more than three years. (2) The prognosis largely depended on the grade of improvement at the end of therapy. A complete disappearance of symptoms at the end of therapy did not necessarily mean that it was a fair prognosis. (3) There was no relation between the prognosis and the length of history of illness or the situation of therapy terminated. (4) The impression is that long-term prognoses are different depending on the main symptoms.

A case of hypogonadotropic eunuchoidism associated with familiar periodic paralysis--induction of paralytic attacks by testosterone administration

A case report was made of a 24-year-old man suffering from hypogonadotropic eunuchoidism associated with a hypokalemic type of familiar periodic paralysis. The attacks were observed only during the period of continual administration of the oil solution of 115.7 mg of testosterone enanthate and 20.0 mg of testosterone propionate, intramuscularly as a depot. From the findings on this patient, it was concluded that testosterone might possibly play a role in the occurrence of attacks in the case of periodic paralysis.