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Lombardo P, Lange-Herr N, Hoppe H, Schwendener N, Jackowski C, Klaus J, Zech WD. Diagnostic accuracy of coronary artery stenosis and thrombosis assessment using unenhanced multiplanar 3D post-mortem cardiac magnetic resonance imaging. Forensic Sci Int 2023; 353:111878. [PMID: 37980856 DOI: 10.1016/j.forsciint.2023.111878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/18/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND A 3D sequence was introduced to unenhanced post-mortem cardiac magnetic resonance imaging (PMCMR) to enable multiplanar coronary artery image analysis and to investigate its diagnostic accuracy for the diagnosis of coronary artery stenosis and thrombosis. MATERIALS AND METHODS N = 200 forensic cases with suspected coronary artery pathology underwent 3 Tesla PMCMR (sequence used: T2 weighted transversal 3D turbo spin echo) before autopsy. Main coronary artery stenosis and thrombosis were assessed in PMCMR by multiplanar image analysis by two observers. Coronary artery histology was determined as the gold standard and compared to PMCMR. Sensitivity, specificity, negative (NPV) and positive predictive values (PPV) with 95% confidence intervals were calculated. RESULTS For all coronary arteries combined, sensitivity was 75% (PPV 73%) for the diagnosis of stenosis and 72% (PPV 71%) for the diagnosis of thrombosis. Specificity was 92% (NPV 90%) for correct diagnosis of non-existing stenosis and 97% (NPV 97%) for non-existing thrombosis. Sensitivity for correct diagnosis of different degrees of stenosis ranged between 67% and 80% (PPVs 67-82%); specificity ranged between 96% and 99% (NPVs 96-99%). CONCLUSION Multiplanar PMCMR coronary artery stenosis and thrombosis assessment based on an unenhanced T2 weighted 3D sequence provide moderate sensitivity and high specificity for the diagnosis of coronary artery stenosis and/or thrombosis. Hence, 3D T2w PMCMR cannot reliably detect existing coronary artery stenosis and thrombosis but may be particularly useful for the exclusion of stenosis or thrombosis of the main coronary arteries.
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Affiliation(s)
- Paolo Lombardo
- Institute of Forensic Medicine, University of Bern, Bern, Switzerland; Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Hanno Hoppe
- Department of Radiology, Lindenhofspital Bern, Bern, Switzerland; University of Bern, Bern, Switzerland; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | | | | | - Jeremias Klaus
- Institute of Forensic Medicine, University of Bern, Bern, Switzerland; Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Wolf-Dieter Zech
- Institute of Forensic Medicine, University of Bern, Bern, Switzerland.
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2
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Michaud K, Jacobsen C, Basso C, Banner J, Blokker BM, de Boer HH, Dedouit F, O'Donnell C, Giordano C, Magnin V, Grabherr S, Suvarna SK, Wozniak K, Parsons S, van der Wal AC. Application of postmortem imaging modalities in cases of sudden death due to cardiovascular diseases-current achievements and limitations from a pathology perspective : Endorsed by the Association for European Cardiovascular Pathology and by the International Society of Forensic Radiology and Imaging. Virchows Arch 2023; 482:385-406. [PMID: 36565335 PMCID: PMC9931788 DOI: 10.1007/s00428-022-03458-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 12/25/2022]
Abstract
Postmortem imaging (PMI) is increasingly used in postmortem practice and is considered a potential alternative to a conventional autopsy, particularly in case of sudden cardiac deaths (SCD). In 2017, the Association for European Cardiovascular Pathology (AECVP) published guidelines on how to perform an autopsy in such cases, which is still considered the gold standard, but the diagnostic value of PMI herein was not analyzed in detail. At present, significant progress has been made in the PMI diagnosis of acute ischemic heart disease, the most important cause of SCD, while the introduction of postmortem CT angiography (PMCTA) has improved the visualization of several parameters of coronary artery pathology that can support a diagnosis of SCD. Postmortem magnetic resonance (PMMR) allows the detection of acute myocardial injury-related edema. However, PMI has limitations when compared to clinical imaging, which severely impacts the postmortem diagnosis of myocardial injuries (ischemic versus non-ischemic), the age-dating of coronary occlusion (acute versus old), other potentially SCD-related cardiac lesions (e.g., the distinctive morphologies of cardiomyopathies), aortic diseases underlying dissection or rupture, or pulmonary embolism. In these instances, PMI cannot replace a histopathological examination for a final diagnosis. Emerging minimally invasive techniques at PMI such as image-guided biopsies of the myocardium or the aorta, provide promising results that warrant further investigations. The rapid developments in the field of postmortem imaging imply that the diagnosis of sudden death due to cardiovascular diseases will soon require detailed knowledge of both postmortem radiology and of pathology.
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Affiliation(s)
- Katarzyna Michaud
- University Center of Legal Medicine Lausanne - Geneva, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Christina Jacobsen
- Section of Forensic Pathology, Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Jytte Banner
- Section of Forensic Pathology, Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Hans H de Boer
- Department of Forensic Medicine, Victorian Institute of Forensic Medicine, Monash University, Melbourne, Australia
| | - Fabrice Dedouit
- GRAVIT, Groupe de Recherche en Autopsie Virtuelle et Imagerie Thanatologique, Forensic Department, University Hospital, Rangueil, Toulouse, France
| | - Chris O'Donnell
- Department of Forensic Medicine, Victorian Institute of Forensic Medicine, Monash University, Melbourne, Australia
| | - Carla Giordano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Virginie Magnin
- University Center of Legal Medicine Lausanne - Geneva, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Silke Grabherr
- University Center of Legal Medicine Lausanne - Geneva, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - S Kim Suvarna
- Department of Histopathology, Northern General Hospital, The University of Sheffield, Sheffield, UK
| | - Krzysztof Wozniak
- Department of Forensic Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sarah Parsons
- Department of Forensic Medicine, Victorian Institute of Forensic Medicine, Monash University, Melbourne, Australia
| | - Allard C van der Wal
- Department of Pathology, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands.
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Arnold I, Schwendener N, Lombardo P, Jackowski C, Zech WD. 3Tesla post-mortem MRI quantification of anatomical brain structures. Forensic Sci Int 2021; 327:110984. [PMID: 34482282 DOI: 10.1016/j.forsciint.2021.110984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/04/2021] [Accepted: 08/17/2021] [Indexed: 01/31/2023]
Abstract
Quantitative post-mortem magnetic resonance imaging (PMMR) allows for measurement of T1 and T2 relaxation times and proton density (PD) of brain tissue. Quantitative PMMR values may be used for advanced post-mortem neuro-imaging diagnostics such as computer aided diagnosis. So far, the quantitative T1, T2 and PD post-mortem values of regular anatomical brain structures were unknown for a 3 Tesla PMMR application. The goal of this basic research study was to evaluate the quantitative values of post-mortem brain structures for a 3 T post-mortem magnetic resonance application with regard to various corpse temperatures. In 50 forensic cases, a quantitative PMMR brain sequence was applied prior to autopsy. Measurements of T1 (in ms), T2 (in ms), and PD (in %) values of cerebrum (Group 1: frontal grey matter, frontal white matter, thalamus, caudate nucleus, globus pallidus, putamen, internal capsule) brainstem and cerebellum (Group 2: cerebral peduncle, substantia nigra, red nucleus, pons, middle cerebellar peduncle, cerebellar hemisphere, medulla oblongata) were conducted in synthetically calculated axial PMMR brain images. Assessed quantitative values were corrected for corpse temperature. Temperature dependence was observed mainly for T1 values. ANOVA testing resulted in significant differences of quantitative values between the investigated anatomical brain structures in both groups. It can be concluded that temperature corrected 3 Tesla PMMR T1, T2 and PD values are feasible for characterization and discrimination of regular anatomical brain structures. This may provide a base for future advanced diagnostics of forensically relevant brain lesions and pathology.
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Affiliation(s)
- Isabel Arnold
- Institute of Forensic Medicine, University of Bern, Switzerland
| | | | - Paolo Lombardo
- Institute of Forensic Medicine, University of Bern, Switzerland; Department of Diagnostic, Interventional and Pediatric Radiology, University of Bern, Inselspital Bern, Switzerland
| | | | - Wolf-Dieter Zech
- Institute of Forensic Medicine, University of Bern, Switzerland.
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4
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Michaud K, Basso C, d'Amati G, Giordano C, Kholová I, Preston SD, Rizzo S, Sabatasso S, Sheppard MN, Vink A, van der Wal AC. Diagnosis of myocardial infarction at autopsy: AECVP reappraisal in the light of the current clinical classification. Virchows Arch 2020; 476:179-194. [PMID: 31522288 PMCID: PMC7028821 DOI: 10.1007/s00428-019-02662-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/21/2019] [Accepted: 08/28/2019] [Indexed: 01/24/2023]
Abstract
Ischemic heart disease is one of the leading causes of morbidity and death worldwide. Consequently, myocardial infarctions are often encountered in clinical and forensic autopsies, and diagnosis can be challenging, especially in the absence of an acute coronary occlusion. Precise histopathological identification and timing of myocardial infarction in humans often remains uncertain while it can be of crucial importance, especially in a forensic setting when third person involvement or medical responsibilities are in question. A proper post-mortem diagnosis requires not only up-to-date knowledge of the ischemic coronary and myocardial pathology, but also a correct interpretation of such findings in relation to the clinical scenario of the deceased. For these reasons, it is important for pathologists to be familiar with the different clinically defined types of myocardial infarction and to discriminate myocardial infarction from other forms of myocardial injury. This article reviews present knowledge and post-mortem diagnostic methods, including post-mortem imaging, to reveal the different types of myocardial injury and the clinical-pathological correlations with currently defined types of myocardial infarction.
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Affiliation(s)
- Katarzyna Michaud
- University Center of Legal Medicine Lausanne - Geneva, Lausanne University Hospital and University of Lausanne, Chemin de la Vulliette 4, CH - 1000, Lausanne 25, Switzerland.
| | - Cristina Basso
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulia d'Amati
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - Carla Giordano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Rome, Italy
| | - Ivana Kholová
- Pathology, Fimlab Laboratories and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Stefania Rizzo
- Cardiovascular Pathology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Sara Sabatasso
- University Center of Legal Medicine Lausanne-Geneva, Geneva University Hospital and University of Geneva, Geneva, Switzerland
| | - Mary N Sheppard
- Department of Cardiovascular Pathology, Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's Medical School, London, UK
| | - Aryan Vink
- University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Allard C van der Wal
- Amsterdam UMC, Academic Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
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Stanley SA, Rutty GN, Rutty JE. Postmortem Computed Tomography: An Overview for Forensic Nurses Involved in Death Investigation. JOURNAL OF FORENSIC NURSING 2020; 16:90-98. [PMID: 32433192 DOI: 10.1097/jfn.0000000000000288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The traditional invasive autopsy has been considered the "gold standard" for death investigation worldwide. However, this has now been challenged by a new minimally invasive approach that utilizes cross-sectional radiological imaging to investigate the death. Globally, postmortem computed tomography is the most commonly used modality and is becoming increasingly available throughout the world. Forensic nurses working in association with coroners and medical examiners' offices, as well as mass fatality incidents, now need to update their knowledge base to understand these innovative techniques, the advantages and disadvantages to their use, and how they impact on medicolegal death investigation and the care of the deceased and bereaved. Using the example of the coroner system of England and Wales, this article provides a comparison between the traditional invasive autopsy and postmortem radiological alternatives and presents the impact postmortem radiology is now having on death investigation.
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Affiliation(s)
| | - Guy N Rutty
- East Midlands Forensic Pathology Unit, University of Leicester
| | - Jane E Rutty
- Faculty of Health and Life Sciences, De Montfort University
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6
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Webb B, Manninger M, Leoni M, Widek T, Dobrovnik M, Scherr D, Stollberger R, Schwark T. T 2 and T 2∗ mapping in ex situ porcine myocardium: myocardial intravariability, temporal stability and the effects of complete coronary occlusion. Int J Legal Med 2019; 134:679-690. [PMID: 31848700 DOI: 10.1007/s00414-019-02211-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 11/13/2019] [Indexed: 11/25/2022]
Abstract
Diagnosis of ischaemia-related sudden cardiac death in the absence of microscopic and macroscopic ischaemic lesions remains a challenge for medical examiners. Medical imaging techniques increasingly provide support in post-mortem examinations by detecting and documenting internal findings prior to autopsy. Previous studies have characterised MR relaxation times to investigate post-mortem signs of myocardial infarction in forensic cohorts. In this prospective study based on an ex situ porcine heart model, we report fundamental findings related to intramyocardial variability and temporal stability of T2 as well as the effects of permanent coronary occlusion on T2 and T2∗ relaxation in post-mortem myocardium. The ex situ porcine hearts included in this study (n= 19) were examined in two groups (Ss, n= 11 and Si, n= 8). All magnetic resonance imaging (MRI) examinations were performed ex situ, at room temperature and at 3 T. In the Ss group, T2 mapping was performed on slaughterhouse porcine hearts at different post-mortem intervals (PMI) between 7 and 26 h. Regarding the intramyocardial variability, no statistically significant differences in T2 were observed between myocardial segments (p= 0.167). Assessment of temporal stability indicated a weak negative correlation (r=- 0.21) between myocardial T2 and PMI. In the Si group, animals underwent ethanol-induced complete occlusion of the left anterior descending artery. T2 and T2∗ mapping were performed within 3 h of death. Differences between the expected ischaemic and remote regions were statistically significant for T2 (p= 0.007), however not for T2∗ (p= 0.062). Our results provide important information for future assessment of the diagnostic potential of quantitative MRI in the post-mortem detection of early acute myocardial infarction.
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Affiliation(s)
- Bridgette Webb
- Ludwig Boltzmann Institute for Clinical Forensic Imaging, Graz, Austria.
- BioTechMed, Graz, Austria.
| | - Martin Manninger
- Division of Cardiology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Marlene Leoni
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Thomas Widek
- Ludwig Boltzmann Institute for Clinical Forensic Imaging, Graz, Austria
- BioTechMed, Graz, Austria
| | - Martin Dobrovnik
- Division of Cardiology, Department of Medicine, Medical University of Graz, Graz, Austria
| | - Daniel Scherr
- Division of Cardiology, Department of Medicine, Medical University of Graz, Graz, Austria
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rudolf Stollberger
- BioTechMed, Graz, Austria
- Institute of Medical Engineering, Graz University of Technology, Graz, Austria
| | - Thorsten Schwark
- Ludwig Boltzmann Institute for Clinical Forensic Imaging, Graz, Austria
- Institute of Forensic Medicine, Medical University Graz, Graz, Austria
- Laboratoire National de Santé, Dudelange, Luxembourg
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Madea B, Doberentz E, Jackowski C. Vital reactions - An updated overview. Forensic Sci Int 2019; 305:110029. [PMID: 31726327 DOI: 10.1016/j.forsciint.2019.110029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/26/2019] [Accepted: 10/27/2019] [Indexed: 01/27/2023]
Abstract
The question whether an injury was sustained during life or not is one of the most important subjects in forensic medicine. Therefore, vital reactions have been a main research topic in forensic medicine for a long period and many renowned forensic pathologists have devoted important papers to this field. The research area ranges from macroscopically visible organ reactions, over tissue alterations (enzyme histochemistry, later on immunohistochemistry with a wide range of enzymes and other analytes, molecular pathology) to biochemical responses to injury. Especially in the field of immunohistochemistry and molecular pathology much progress has been achieved in the last years (e.g. heat-shock-proteins or positive aquaporine3-staining in mechanical skin trauma). Furthermore, 20 years after its implementation postmortem imaging also contributes to the detection and visualization of vital signs. The aim of the present review is to provide an update on forensically relevant vital signs/vital reactions. Systemic vital reactions especially of the circulatory and respiratory system as well as local vital reactions will be addressed. Vital reactions of different organ systems will be discussed in detail regarding pathogenesis and possible postmortem evolution. Current research on immunohistochemically detectable vital reactions (heat-shock-protein expression, aquaporine3-staining in mechanical trauma of the skin) will be addressed as well as biochemical vital reactions (agonochemical stress reaction, myoglobine in electrocution death, hypoxanthine as marker of hypoxia).
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Affiliation(s)
- Burkhard Madea
- Institute of Forensic Medicine, University of Bonn, Stiftsplatz 12, D-53111 Bonn, Germany.
| | - Elke Doberentz
- Institute of Forensic Medicine, University of Bonn, Stiftsplatz 12, D-53111 Bonn, Germany
| | - Christian Jackowski
- Institute of Forensic Medicine, University of Bern, Bühlstrasse 20, CH-3012 Bern, Switzerland
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Michaud K, Genet P, Sabatasso S, Grabherr S. Postmortem imaging as a complementary tool for the investigation of cardiac death. Forensic Sci Res 2019; 4:211-222. [PMID: 31489387 PMCID: PMC6713140 DOI: 10.1080/20961790.2019.1630944] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 12/26/2022] Open
Abstract
In the past 2 decades, modern radiological methods, such as multiple detector computed tomography (MDCT), MDCT-angiography, and cardiac magnetic resonance imaging (MRI) were introduced into postmortem practice for investigation of sudden death (SD), including cases of sudden cardiac death (SCD). In forensic cases, the underlying cause of SD is most frequently cardiovascular with coronary atherosclerotic disease as the leading cause. There are many controversies about the role of postmortem imaging in establishing the cause of death and especially the value of minimally invasive autopsy techniques. This paper discusses the state of the art for postmortem radiological evaluation of the heart compared to classical postmortem examination, especially in cases of SCD. In SCD cases, postmortem CT is helpful to estimate the heart size and to visualize haemopericardium and calcified plaques and valves, as well as to identify and locate cardiovascular devices. Angiographic methods are useful to provide a detailed view of the coronary arteries and to analyse them, especially regarding the extent and location of stenosis and obstruction. In postsurgical cases, it allows verification and documentation of the patency of stents and bypass grafts before opening the body. Postmortem MRI is used to investigate soft tissues such as the myocardium, but images are susceptible to postmortem changes and further work is necessary to increase the understanding of these radiological aspects, especially of the ischemic myocardium. In postsurgery cases, the value of postmortem imaging of the heart is reportedly for the diagnostic and documentation purposes. The implementation of new imaging methods into routine postmortem practice is challenging, as it requires not only an investment in equipment but, more importantly, investment in the expertise of interpreting the images. Once those requirements are implemented, however, they bring great advantages in investigating cases of SCD, as they allow documentation of the body, orientation of sampling for further analyses and gathering of other information that cannot be obtained by conventional autopsy such as a complete visualization of the vascular system using postmortem angiography.Key pointsThere are no established guidelines for the interpretation of postmortem imaging examination of the heartAt present, postmortem imaging methods are considered as less accurate than the autopsy for cardiac deathsPostmortem imaging is useful as a complementary tool for cardiac deathsThere is still a need to validate postmortem imaging in cardiac deaths by comparing with autopsy findings.
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Affiliation(s)
- Katarzyna Michaud
- Lausanne University Hospital and University of Lausanne, University Center of Legal Medicine Lausanne-Geneva, Lausanne, Switzerland
| | - Pia Genet
- Lausanne University Hospital and University of Lausanne, University Center of Legal Medicine Lausanne-Geneva, Lausanne, Switzerland
- Geneva University Hospital, University Center of Legal Medicine Lausanne-Geneva, Geneva, Switzerland
| | - Sara Sabatasso
- Geneva University Hospital, University Center of Legal Medicine Lausanne-Geneva, Geneva, Switzerland
| | - Silke Grabherr
- Lausanne University Hospital and University of Lausanne, University Center of Legal Medicine Lausanne-Geneva, Lausanne, Switzerland
- Geneva University Hospital, University Center of Legal Medicine Lausanne-Geneva, Geneva, Switzerland
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