Forensic clinical anatomy: A new field of study with application to medicolegal issues

The transversoclasiotome: a novel instrument for examining the vertebral artery

Opening the foramen transversarium of the cervical vertebrae is necessary for accessing the vertebral vessels. There are no specialist tools for cutting the anterior lamina of the transverse processes, and alternatives lead to questionable results. A novel tool, the transversoclasiotome, is described and tested. The literature and patent databases were systematically reviewed. A blueprint of the transversoclasiotome was created, and the prototype was tested through autopsy on ten fresh-frozen cadavers within our Body Donation Program. The transversoclasiotome consists of two delicate branches mounted as a scissor, one a cutting jaw and the other a knocker with a rounded tip, both angled 30° to the principal axis. The jaws shut, facing each other in parallel. The cutting jaw corresponds to a slit on the knocker profile without protruding beyond it even when entirely closed. It acts by cutting and wedging. The testing autopsies demonstrated its suitability for its purpose, with an adequate response to the pressure exerted on the bone lamina. The section cut cleanly, without sliding off while closing on the bone. The vertebral vessels were not injured either during instrument insertion or cutting. Their morphological features are described. The transversoclasiotome has been proven appropriate for sectioning the anterior lamina of transverse processes of the cervical vertebrae. It meets the needs of clinical anatomy in teaching and training clinicians or surgeons, forensic clinical anatomy during medico-legal investigation, and research.

Brainstem anatomy with 7-T MRI: in vivo assessment and ex vivo comparison

BACKGROUND

The brainstem contains grey matter nuclei and white matter tracts to be identified in clinical practice. The small size and the low contrast among them make their in vivo visualisation challenging using conventional magnetic resonance imaging (MRI) sequences at high magnetic field strengths. Combining higher spatial resolution, signal- and contrast-to-noise ratio and sensitivity to magnetic susceptibility (χ), susceptibility-weighted 7-T imaging could improve the assessment of brainstem anatomy.

METHODS

We acquired high-resolution 7-T MRI of the brainstem in a 46-year-old female healthy volunteer (using a three-dimensional multi-echo gradient-recalled-echo sequence; spatial resolution 0.3 × 0.3 × 1.2 mm3) and in a brainstem sample from a 48-year-old female body donor that was sectioned and stained. Images were visually assessed; nuclei and tracts were labelled and named according to the official nomenclature.

RESULTS

This in vivo imaging revealed structures usually evaluated through light microscopy, such as the accessory olivary nuclei, oculomotor nucleus and the medial longitudinal fasciculus. Some fibre tracts, such as the medial lemniscus, were visible for most of their course. Overall, in in vivo acquisitions, χ and frequency maps performed better than T2*-weighted imaging and allowed for the evaluation of a greater number of anatomical structures. All the structures identified in vivo were confirmed by the ex vivo imaging and histology.

CONCLUSIONS

The use of multi-echo GRE sequences at 7 T allowed the visualisation of brainstem structures that are not visible in detail at conventional magnetic field and opens new perspectives in the diagnostic and therapeutical approach to brain disorders.

RELEVANCE STATEMENT

In vivo MR imaging at UHF provides detailed anatomy of CNS substructures comparable to that obtained with histology. Anatomical details are fundamentals for diagnostic purposes but also to plan a direct targeting for a minimally invasive brain stimulation or ablation.

KEY POINTS

• The in vivo brainstem anatomy was explored with ultrahigh field MRI (7 T). • In vivo T2*-weighted magnitude, χ, and frequency images revealed many brainstem structures. • Ex vivo imaging and histology confirmed all the structures identified in vivo. • χ and frequency imaging revealed more brainstem structures than magnitude imaging.

Reference centers for tissue and body donations: Compulsory requirements in Italy

Recent Italian legislation (Law No. 10/2020) establishes the legal, ethical and technical requirements governing how individuals can donate their bodies or tissues post-mortem for study, training, and scientific research purposes. A ministerial working group has recently approved some of the law's implementing rules relating to technical issues. The rules for implementing the new legislation, retrieved from the legal databases and translated into English, are discussed. For the first time in Italy, the law establishes compulsory requirements and minimum characteristics-in terms of logistics, safety, availability of staff, space, and equipment-for institutions to be recognized as reference centers for the conservation and use of bodies and tissues donated post-mortem for study, training and scientific research purposes. This makes it possible to standardize the features of such reference centers nationwide, and to coordinate their activities and potential future development, while ensuring basic operational efficiency and workplace safety, the provision of adequate facilities, buildings and equipment, and staff training. The law and its implementing rules discussed here are the first to establish criteria and compulsory requirements for centers receiving body and tissue donations in Italy. This is a step forward for the whole anatomy community, providing practical guidelines for body donation programs and related facilities in other countries too.

Clinical Anatomy and Medical Malpractice-A Narrative Review with Methodological Implications

Anatomical issues are intrinsically included in medico-legal methodology, however, higher awareness would be needed about the relevance of anatomy in addressing medico-legal questions in clinical/surgical contexts. Forensic Clinical Anatomy has been defined as "the practical application of Clinical Anatomy to the ascertainment and evaluation of medico-legal problems". The so-called individual anatomy (normal anatomy, anatomical variations, or anatomical modifications due to development, aging, para-physiological conditions, diseases, or surgery) may acquire specific relevance in medico-legal ascertainment and evaluation of cases of supposed medical malpractice. Here, we reviewed the literature on the relationships between anatomy, clinics/surgery, and legal medicine. Some methodological considerations were also proposed concerning the following issues: (1) relevant aspects of individual anatomy may arise from the application of methods of ascertainment, and they may be furtherly ascertained through specific anatomical methodology; (2) data about individual anatomy may help in the objective application of the criteria of evaluation (physio-pathological pathway, identification-evaluation of errors, causal value, damage estimation) and in final judgment about medical responsibility/liability. Awareness of the relevance of individual anatomy (risk of iatrogenic lesions, need for preoperative diagnostic procedures) should be one of the principles guiding the clinician; medico-legal analyses can also take advantage of its contribution in terms of ascertainment/evaluation.

Forensic Implications of Anatomical Education and Surgical Training With Cadavers

Anatomical education and surgical training with cadavers are usually considered an appropriate method of teaching, above all for all surgeons at various levels. Indeed, in such a way they put into practice and exercise a procedure before performing it live, reducing the learning curve in a safe environment and the risks for the patients. Really, up to now it is not clear if the nonuse of the cadavers for anatomical education and surgical training can have also forensic implications. A substantial literature research was used for this review, based on PubMed and Web of Science database. From this review, it is clear that the cadaveric training could be considered mandatory, both for surgeons and for medical students, leading to a series of questions with forensic implications. Indeed, there are many evidences that a cadaver lab can improve the learning curve of a surgeon, above all in the first part of the curve, in which frequent and severe complications are possible. Consequently, a medical responsibility for residents and surgeons which perform a procedure without adequate training could be advised, but also for hospital, that has to guarantee a sufficient training for its surgeons and other specialists through cadaver labs. Surely, this type of training could help to improve the practical skills of surgeons working in small hospitals, where some procedures are rare. Cadaver studies can permit a better evaluation of safety and efficacy of new surgical devices by surgeons, avoiding using patients as ≪guinea pigs≫. Indeed, a legal responsibility for a surgeon and other specialists could exist in the use of a new device without an apparent regulatory oversight. For a good medical practice, the surgeons should communicate to the patient the unsure procedural risks, making sure the patients' full understanding about the novelty of the procedure and that they have used this technique on few, if any, patients before. Cadaver training could represent a shortcut in the standard training process, increasing both the surgeon learning curve and patient confidence. Forensic clinical anatomy can supervise and support all these aspects of the formation and of the use of cadaver training.

Post-traumatic aneurysmal rupture involving the circle of Willis affected by fibromuscular dysplasia. A case report and systematic review

The fatal rupture of a saccular aneurysm at the junction between the left anterior cerebral artery and anterior communicating artery affected by fibromuscular dysplasia (FMD) is a rare condition. Here is reported the case of a subject involved in a road traffic accident a few minutes before the death, which opened the debate on the real cause of death in a forensic setting. By autopsy, the examination of the brain revealed subarachnoid haemorrhage with flooding of the ventricles due to the breached saccular aneurysm of the junction between the left anterior cerebral artery and anterior communicating artery, in FMD mainly affecting the circle of Willis arteries. A spontaneous aneurysmal rupture was excluded on the basis of probabilistic analysis, in the presence of alternative hypotheses that could explain the facts. The passenger's delayed loss of consciousness may be explained as much by a hypertension-linked rupture of the aneurysm triggered by the emotional stress experienced, as by the traumatic shaking/impact of the aneurysm against the bony skull structures, in a subject predisposed to aneurysm frailty due to FMD. Overall, the concausal role of both the road traffic accident, typified by high kinetic energy, and the presence of a pre-existing aneurysmatic weakness due to FMD is fully recognized. The identification of anatomical variants, jointly with uncommon diseases at the examination of the brain base arteries in any case of isolated basal subarachnoid haemorrhage, may avoid wrong legal consequences even when the cause of death seems to be obviously of simple traumatic origin.

Brunetti's chisels in anterior and posterior rachiotomy

Rachiotomy entails vertebral surgical incision, generally followed by exposure of the spinal cord, and is performed primarily for educational, research, or medicolegal purposes. Over time, several tools have been developed for this procedure, but Lodovico Brunetti designed the first effective prototypes in the mid-nineteenth century. To show the technical details of and the necessary maneuvers to be performed for Brunetti's rachiotomies to succeed, a computer-aided systematic literature review of online databases was performed to identify publications concerning Brunetti's chisels used for rachiotomy. Additional references from the studies and treatises included held in the Historical Section of the Medical Library at the University of Padova were checked manually for pertinent information. The known variants of Brunetti's chisels were reported in detail from the first to the third versions produced and intended for both posterior (first and third prototypes) and anterior (second prototype) vertebral dissection. Further evolution that led to the current commercialized model devoted to posterior use also was described. The models' strengths and weaknesses were assessed, as well as the nature of the changes Brunetti introduced over time and their motivation. In conclusion, these tools could represent an alternative to the use of electric saws, particularly for dissectors who prefer to have greater manual control in incising the vertebrae. Clin. Anat. 33:355-364, 2020. © 2019 Wiley Periodicals, Inc.

Symmetrical Apophyses on the Posterior Margins of the Thyroid Cartilage: A Previously Undescribed Anatomical Variation With Potential Forensic Implications

Differential diagnosis between normal/variant anatomy and pathological/traumatic findings represents one of the main matters of investigation of the so-called forensic clinical anatomy. In the literature, many anatomical variations of the laryngeal thyroid cartilage have been reported, with potential implications in forensic pathology. They include triticeal cartilages, foramen thyroideum, asymmetry, segmentation or agenesis of the superior thyroid horns, bone connections with the hyoid bone, absence of cricothyroid facets, hypertrophy of the inferior thyroid tubercle, and asymmetries in the thyroid notch, isthmus, or length of the inferior horn. In this report, we describe a laryngeal anatomical variation never described before, consisting of 2 apophyses symmetrically arising from the posterior margins of the thyroid laminae. Postmortem computed tomography performed on the laryngeal visceral block excluded previous traumatic injuries or natural pathologies of the laryngeal cartilages, confirming the congenital origin of the finding. An "omega epiglottis" and 3 laryngeal cysts in the piriform sinuses also coexisted, suggesting the possibility of underlying common developmental mechanisms.

A Virtual Reality Environment to Visualize Three-Dimensional Patient-Specific Models by a Mobile Head-Mounted Display

INTRODUCTION

With the availability of low-cost head-mounted displays (HMDs), virtual reality environments (VREs) are increasingly being used in medicine for teaching and clinical purposes. Our aim was to develop an interactive, user-friendly VRE for tridimensional visualization of patient-specific organs, establishing a workflow to transfer 3-dimensional (3D) models from imaging datasets to our immersive VRE.

MATERIALS AND METHODS

This original VRE model was built using open-source software and a mobile HMD, Samsung Gear VR. For its validation, we enrolled 33 volunteers: morphologists (n = 11), trainee surgeons (n = 15), and expert surgeons (n = 7). They tried our VRE and then filled in an original 5-point Likert-type scale 6-item questionnaire, considering the following parameters: ease of use, anatomy comprehension compared with 2D radiological imaging, explanation of anatomical variations, explanation of surgical procedures, preoperative planning, and experience of gastrointestinal/neurological disorders. Results in the 3 groups were statistically compared using analysis of variance.

RESULTS

Using cross-sectional medical imaging, the developed VRE allowed to visualize a 3D patient-specific abdominal scene in 1 hour. Overall, the 6 items were evaluated positively by all groups; only anatomy comprehension was statistically significant different among the 3 groups.

CONCLUSIONS

Our approach, based on open-source software and mobile hardware, proved to be a valid and well-appreciated system to visualize 3D patient-specific models, paving the way for a potential new tool for teaching and preoperative planning.

Friar Leopold Mandic (1866-1942): the computed tomography of the body of a saint

PURPOSE

In forensic clinical anatomy computed tomography (CT) is used in post-mortem radiological investigation as an objective nondestructive documentation of the body surface and of the interior of the body. This technique is applied also in paleopathology, in particular in mummy studies, with the aim of providing a permanent record of the mummy's features, investigating the embalming procedure employed and analyzing the extent of the preservation in detail.

METHODS

For the Extraordinary Jubilee of Mercy, the mortal remains of Saint Leopold Mandic and Saint Pio da Pietralcina, as examples of Mercy known by everyone, have been brought to Rome in February 2016. During the survey that preceded the preparation for transport to Rome, a whole-body CT was performed on the mummified corpse of Leopold Mandic, Capuchin Saint of Padova, Italy.

RESULTS

The CT examination demonstrated the presence of osteoarthritis at the level of the vertebral column, of the left knee and of the left hand. Moreover, CT showed the preservation of skeleton and partial preservation of the some viscera, such as remnants of the brain, heart, oesophagus, urinary bladder, plexuses and spinal nerves, ear ossicles, major arterial vessels (aorta and carotid arteries). It is to emphasize the fact that Saint Leopold was not subjected before the CT to any conservative treatment.

CONCLUSIONS

Computed tomography demonstrated to be a non-destructive method to investigate Saint Leopold, in order to maintain the integrity of the body and to acquire data on his pathologies and on his preservation. CT allows not only the acquisition of sectional images but also, thanks to dedicated software, the post-processing and reconstruction of three-dimensional models, that can be used also for public displays.

Ischemic colitis following left antegrade sclerotherapy for idiopathic varicocele

The Tauber procedure, i.e., antegrade sclerotherapy for varicocele, can lead to ischemic colitis. The pathogenesis can involve an atypical systemic-portal communication, which could represent an infrequently reported (rare) anatomical variant. The aim of this study is to review clinical cases from the literature to highlight the anatomical bases of such complications. A computer-aided and hand-checked review of the literature was used to identify relevant publications. Also, the computed tomography (CT) examination of a clinical case with medico-legal implications due to severe vascular complication following Tauber's procedure was reviewed. Although specific references to this complication have appeared since the 19th century, reports in the contemporary literature include only a few clinical cases of ischemic colitis following Tauber's procedure. The CT scan images of a filed lawsuit revealed traces suggesting a significant communication between the testicular and left colic veins, forming part of the systemic-portal anastomoses. An anatomical variation consisting of a communication between the testicular and left colic veins has been described from the clinical point of view, corresponding to a significant anatomical finding identified in the past that has been under-reported and its clinical importance subsequently underestimated. For the first time we have demonstrated its pathophysiological significance in a real clinical scenario, linking the anatomical variation to the clinical complication. This demonstrates the importance of raising scientific awareness on this issue to prevent possibly devastating complications in daily clinical practice. Clin. Anat. 31:774-781, 2018. © 2018 Wiley Periodicals, Inc.

The utility of plastinates in court: a case of firearm homicide

Plastination is a technique renowned for its use in the preservation of human tissues or organs, and is mainly employed in anatomical training and in research regarding various scientific fields. The advantages of this method are related to the natural appearance, absence of odor, and easy-handling of the plastinated products. The use of plastinates in forensic sciences, their potential role in personal identification, and their usefulness in interpretation of post-mortem findings has been described, although literature on this topic is poor. The present paper is the first report of a firearm homicide where the brain of the victim was plastinated and presented in court as documentary evidence. Three dimensional examination of the brain during the trial allowed the judge to directly evaluate the pathway of the projectile and to compare it with the information that was presented based on depositions, post mortem data and police investigations, in a more straightforward manner. The important role played by plastination in the reported case in assisting with the final verdict could be a catalyst to extend the use of this technique to other criminal cases.