Virtopsy versus digital autopsy: virtual autopsy

Advances in Technologies in Crime Scene Investigation

Crime scene investigation (CSI) is the complex act of reconstructing the dynamics that led to a crime and the circumstances of its perpetration. Crystallizing the CSI is a difficult task for the forensic pathologist; however, it is often requested by the public prosecutor and many judicial cases remain unsolved precisely for this reason. Recent years have seen an improvement in the ability of 3D scanning technology to obtain dense surface scans of large-scale spaces, for surveying, engineering, archaeology, and medical purposes such as forensics. The applications of this new technology are growing every day: forensic measurement of wounds in clinical reports, for example, reconstruction of traffic accidents, bullet trajectory studies in gunshot wounds, and 3D bloodstain pattern analysis. A retrospective analysis was conducted across all crime scene investigations performed by the forensic staff of the Department of Forensic Pathology of the University of Catania from January 2019 to June 2022. Inclusion criteria were the use of a laser scanner (LS), the use of a camera, a full investigative scene, and collection of circumstantial data thanks to the help of the judicial police. Cases in which the LS was not used were excluded. Out of 200 CSIs, 5 were included in the present study. In case number 1, the use of the LS made it possible to create a complete scale plan of the crime scene in a few hours, allowing a ship to be quickly returned to the judicial police officer. In case 2 (fall from a height), the LS clarified the suicidal intent of the deceased. In case number 3 it was possible to reconstruct a crime scene after many years. In case 4, the LS provided a great contribution in making a differential diagnosis between suicide and homicide. In case 5, the LS was fundamental for the COVID team in planning the study of COVID-19 pathways and areas within a hospital with the aim of reduction of nosocomial transmission. In conclusion, the use of the LS allowed the forensic staff to crystallize the investigative scene, making it a useful tool.

Postmortem computed tomography plus forensic autopsy for determining the cause of death in child fatalities

BACKGROUND

Postmortem computed tomography (CT) and magnetic resonance imaging have been gradually introduced to forensic pathology centres over the past two decades, with varying results in comparison to autopsy.

OBJECTIVE

The purpose of this study was to determine the accuracy of postmortem CT in determining a cause of death in children who died of unnatural causes.

MATERIALS AND METHODS

This was a prospective recruitment of 30 children (< 18 years) who underwent postmortem CT and a forensic autopsy. A cause of death was independently assigned by two experienced paediatric radiologists and compared to that of the forensic autopsy.

RESULTS

A correct cause of death was assigned by reviewers 1 and 2 in 70% (n = 21/30) and 67% (n = 20/30) of cases, respectively. For gunshot injuries and blunt force head injuries, there was 91% (n = 10/11) and 100% (n = 6/6) agreement between forensic autopsy and both reviewers, respectively. No cause of death could be assigned by reviewers 1 and 2 in 27% (n = 8) and 30% (n = 9) of cases, respectively. An incorrect cause of death was assigned by both reviewers in one case (3%). The Cohen Kappa level of agreement between the forensic autopsy and reviewers 1 and 2 was k = 0.624 (95% confidence interval [CI]: 0.45-0.80, P = 0) and k = 0.582 (95% CI 0.41-0.76, P = 0), respectively. There was near perfect agreement between reviewers 1 and 2 (k = 0.905) (95% CI 0.78-1.00, P = 0).

CONCLUSION

Postmortem CT has good diagnostic accuracy for identifying a cause of death related to trauma, but it has poor accuracy for children dying from causes not associated with apparent physical injury.

Sudden Cardiac Death and Ex-Situ Post-Mortem Cardiac Magnetic Resonance Imaging: A Morphological Study Based on Diagnostic Correlation Methodology

During the last years, post-mortem imaging has gradually been assumed within research in the field of forensic pathology. This role appears to be clearly and simply applied in the trauma field with the use of conventional radiography or Post Mortem Computed Tomography (PMCT). Recently, particular attention was paid to cardiovascular imaging using Post Mortem Magnetic Resonance Imaging (PMMRI). The present experimental study aims to: (i) confirm the efficacy of a Post Mortem Cardiac Resonance Imaging (PMCRI) study protocol for the study of human hearts collected during the autopsy; (ii) apply the defined protocol on subjects who died of “SCD (sudden cardiac death)”, to identify alterations that could guide subsequent sampling. Two hearts of healthy subjects (A: male 22 years; B: female 26 years), who died from causes other than SCD were collected and compared to hearts that belonged to SCD individuals (C: male, 47 years old; D: female, 44 years old; E: male; 72 years old). The exams were performed on a 1.5 T scanner (Philips Intera Achieva, Best, the Netherlands) on hearts collected during autopsy and after a 30-day formalin fixation. Two readers analyzed the obtained images blindly and after randomization. From the comparison between the data from imaging and the macroscopic and histological investigations carried out, the present study proved the effectiveness of a PMMRI protocol to study ex-situ hearts. Moreover, it suggested the following semeiology in post-mortem SCD cases: the hyperintense area with indistinct margins in the Short Tau Inversion Recovery (STIR) sequence was linked to edema or area of pathological fibers, whereas the hypointense area in the T2-FFE sequences was linked to fibrosis. PMMRI can provide a valuable benefit to post-mortem investigations, helping to distinctly improve the success rate of histological sampling and investigations, which remains the gold standard in the diagnosis of sudden death.

Mapping Biological Risks Related to Necropsy Activities: Old Concerns and Novel Issues for the Safety of Health Professionals

Nowadays only a few studies on biological and environmental risk among healthcare workers are available in literature. The present study aims to assess the health operator’s risk of contact with microorganisms during necropsy activities, to evaluate the efficiency of current protections, to identify possible new sources of contact, and to point out possible preventive measures. In addition, considering the current pandemic scenario, the risk of transmission of SARS-CoV-2 infection in the dissection room is assessed. The objectives were pursued through two distinct monitoring campaigns carried out in different periods through sampling performed both on the corpses and at the environmental level.

The Role of a Good Quality Autopsy in Pediatric Malpractice Claim: A Case Report of an Unexpected Death in an Undiagnosed Thymoma

Thymomas are extremely rare in the first 20 years of life, with different clinical presentations: from asymptomatic mediastinal masses to compressive and paraneoplastic syndromes. In pediatric population, the respiratory disorders have a higher incidence. The overall thymoma mortality rate is described as 40% and metastasized tumors are more aggressive. This case report describes a compressive syndrome caused by a thymoma in which symptoms were exacerbated by a concurrent pulmonary infection, thus leading an affected infant to sudden death despite medical treatment. In this case, patient's death occurred just before the differential diagnostic process got completed. Malpractice claim was based on the missing diagnosis as well as the suspect of inadequate provided care. Consequently, autopsy played a crucial post-mortem role to find out the cause of death, and to exclude any professional liability. Despite modern diagnostic techniques, autopsies are still the best available forensic tool. It is useful to remember that death is a fact of life, therefore not always preventable.

Role of post-mortem multi-slice computed tomography in the evaluation of single gunshot injuries

Post-mortem multi-slice computed tomography (MSCT) is a new approach in forensic pathology for gunshot injuries. This study determines the role of MSCT in the characterisation of single gunshot injuries. We report three cases. In the first case, an 80-year-old man was found dead in his bedroom with a gun. External examination showed devastating head injuries. In the second case, an 81-year-old man was found dead in his apartment, without a gun. External examination showed gunshot injuries. In the third case, a 56-year-old man was found dead on a road. MSCT and autopsy were performed in all these cases. MSCT not only allowed the determination of entrance and exit wounds but also showed some artefacts. In conclusion, radiology is fundamental for the reconstruction of gunshot injuries, and the manner of death can only be ascertained by autopsy.

Post-mortem computed tomography (PMCT) radiological findings and assessment in advanced decomposed bodies

PURPOSE

The aim of the study is to report radiological findings and features in advanced decomposed bodies obtained by post-mortem computed tomography (PMCT) with autopsy correlation.

MATERIALS AND METHODS

This retrospective descriptive multicentric study included 41 forensic cases examined between May 2013 and November 2016. All the bodies were PMCT-scanned prior to autopsy, and internal putrefactive state was determined using the radiological alteration index (RAI) by a radiologist with expertise in forensic radiology and a forensic pathologist trained in forensic imaging. After PMCT scans, grade of external putrefaction (GEP) was assigned during the external examination and the complete autopsy was performed by forensic pathologists.

RESULTS

The PMCT images evaluation revealed that the RAI index was > 61 in all bodies, corresponding to a moderate-massive presence of putrefactive gas. The gas grade was > II in correspondence of the major vessels, heart cavities, liver parenchyma, vertebra L3 and subcutaneous pectoral tissues, and varied from I to III in correspondence of the kidney. Cadaveric external examination revealed the presence of advanced transformative phenomena, with a GEP3 and GEP4 in most of the cases, with body swelling, eyes and tongue protrusion, body fluids expulsion and fat liquefaction.

CONCLUSION

Radiological imaging by PMCT as an adjunct to autopsy in advanced decomposed bodies represents a useful tool in detecting post-mortem gas, even in very small amounts. A correct interpretation process of the PMCT data is essential to avoid images pitfalls, due to natural decomposition that can be mistaken for pathologic processes.

Postmortem computed tomography angiography (PMCTA) and traditional autopsy in cases of sudden cardiac death due to coronary artery disease: a systematic review and meta-analysis

INTRODUCTION

Several studies have been performed to assess the efficacy of postmortem computed tomography angiography (PMCTA) in solving cases of sudden cardiac death, even in comparison with the traditional autopsy. However, the results were often inconsistent and inconclusive. Therefore, a global discussion on the subject through a systematic review of the literature and a meta-analysis is necessary.

METHODS

A systematic search of PubMed was performed up to April 23, 2018. Studies exploring the role of PMCTA in cases of sudden cardiac death and the accuracy of this method in diagnosing the cause of death compared to traditional autopsy were included.

RESULTS

The overall sensitivity and specificity of the seven included studies, using conventional autopsy as a reference standard, were 92% and 95%, respectively. The positive and negative likelihood ratios were, respectively, 20.76 (95% CI 1.16-370.2) and 0.08 (95% CI 0.03-0.17), showing that PMCTA represents a strong indicator of the posttest probability of disease. The diagnostic odds ratio and the area under the curve were, respectively, 261.54 (95% CI 1.87-5760.53) and 0.93 (95% CI 0.90-0.95), indicating a high diagnostic power of the test.

CONCLUSION

PMCTA demonstrated a high accuracy in the diagnosis of parietal and luminal coronary changes but was less effective in detecting myocardial ischemia and necrosis. Therefore, the only radiological investigation is often insufficient to determine the cause of sudden death and the conventional autopsy remains the gold standard. However, PMCTA can improve the performance of the autopsy, serving as an aid and guide in the sampling phase for histopathological investigations.

Virtopsy: An integration of forensic science and imageology

In an era where noninvasive and minimally invasive techniques are heralding medical innovations and health science technology, necrological analysis is not bereft of this wave. Virtopsy is virtual autopsy. It is a new-age complimentary documentation approach to identify and analyze the details of demise. Utilizing virtual autopsy for orofacial forensic examination is an emerging specialty which holds a plethora of potential for future trends in forensic science. Being a noninvasive technique, it is a rapid method which facilitates the medicolegal process and aids in the delivery of justice. The present article is an overview of this emerging methodology.

Evolution of post-mortem coronary imaging: from selective coronary arteriography to post-mortem CT-angiography and beyond

Since the 1970s, remarkable efforts have been made in the post-mortem coronary study, especially by angiography, as an added tool to diagnose heart-related deaths. In more recent times, post-mortem CT (PMCT) and post-mortem CT-angiography (PMCTA) have become an established practice in numerous forensic units, because of the undeniable advantages these diagnostic instruments can offer: data acquisition times are increasingly fast, costs have become lower and, once acquired, data can be re-utilized and re-evaluated at any given time. This review aims to chart the history of post-mortem cardiac imaging, highlighting its evolution both in terms of methodology and technology as well as the contribution that forensic radiology has been able to offer to forensic pathology, not as an alternative to autopsy but as a guide and aid when performing one. Finally, the latest advances in the study of cardiac deaths are explored, namely by cardiac post-mortem MRI (PMMR), able to visualize all the various stages of a myocardial infarction, post-mortem MRI-angiography (PMMRA), useful in investigating coronary artery pathology and post-mortem cardiac micro-CT, able to provide near-histological levels of myocardial, coronary and valvular detail.

Forensic Radiology: An Update

Forensic radiology is a specialized area of medical imaging using radiological techniques to assist physicians and pathologists in matters related to the law. The forensic application of diagnostic medical radiology can be applied in many fields; the prime target of evaluation is the osseous skeleton, but soft tissues and abdominal and thoracic viscera may offer key findings. The technological progress in clinical radiology provides a lot of potential tools to forensic radiology, allowing wider fields of applications in this matter.

Modern post-mortem imaging: an update on recent developments

Modern post-mortem investigations use an increasing number of digital imaging methods, which can be collected under the term "post-mortem imaging". Most methods of forensic imaging are from the radiology field and are therefore techniques that show the interior of the body with technologies such as X-ray or magnetic resonance imaging. To digitally image the surface of the body, other techniques are regularly applied, e.g. three-dimensional (3D) surface scanning (3DSS) or photogrammetry. Today's most frequently used techniques include post-mortem computed tomography (PMCT), post-mortem magnetic resonance imaging (PMMR), post-mortem computed tomographic angiography (PMCTA) and 3DSS or photogrammetry. Each of these methods has specific advantages and limitations. Therefore, the indications for using each method are different. While PMCT gives a rapid overview of the interior of the body and depicts the skeletal system and radiopaque foreign bodies, PMMR allows investigation of soft tissues and parenchymal organs. PMCTA is the method of choice for viewing the vascular system and detecting sources of bleeding. However, none of those radiological methods allow a detailed digital view of the body's surface, which makes 3DSS the best choice for such a purpose. If 3D surface scanners are not available, photogrammetry is an alternative. This review article gives an overview of different imaging techniques and explains their applications, advantages and limitations. We hope it will improve understanding of the methods.

Post-mortem magnetic resonance foetal imaging: a study of morphological correlation with conventional autopsy and histopathological findings

The aim of the present study is to offer our experience concerning post-mortem magnetic resonance (PMMR) in foetal death cases and an evaluation of the differences between the findings acquired by PMMR and by forensic autopsy. Fifteen foetuses were recruited from July 2014 to December 2015. These had suffered intrauterine death in women in the 21st to 38th week of gestation who were treated in the emergency department for non-perception of foetal movements. We performed a PMMR on foetuses, 3 ± 1 days on average from the time of death, and then a complete forensic autopsy was performed. All 15 foetuses were examined with a whole-body study protocol, starting from the skull, down to and including the lower limbs. The total time of examination ranged from 20 to 30 min in each case. The external evaluation and description of post-mortem phenomena (maceration), record of the weight and detection and the various measurements of foetal diameters were evaluated before performing autopsy. A complete histopathological study was performed in each case. Out of 15 cases examined, eight were negative for structural anatomical abnormalities and/or diseases, both in the preliminary radiological examination and the traditional autopsy. In the remaining seven cases, pathological findings were detected by PMMR with corresponding results at autopsy. PMMR can provide useful information on foetal medical conditions and result in improved diagnostic classification. It may enable the planning of a more suitable technique before proceeding to autopsy, including focusing on certain aspects of organ pathology otherwise not detectable. The association between PMMR, post-mortem examination and related histological study of the foetus-placenta unit could help reduce the percentage of cases in which the cause of foetal death remains unexplained. Lastly, it may allow a selective sampling of the organ in order to target histological investigations.

Postmortem-computed tomography and postmortem-computed tomography-angiography: a focused update

The use of multidetector CT (MDCT) represents a reality routinely used in several forensic institutes, for the numerous advantages that this diagnostic tool can provide; costs are becoming increasingly lower; data acquisition is always faster and once acquired may be revalued at any time. However, there are also some diagnostic limitations, for example, the visualization of the vascular system or a limited soft tissue contrast. In order to overcome these limitations, in recent years, contrast medium has been introduced in postmortem cases, with the development of several techniques of PMCT angiography (PMCTA) and standardized protocols to make them easily reproducible. The aim of this review is to highlight the advantages and pitfalls of PMCT and PMCTA in forensic investigation, taking into consideration the broad spectrum of applications both for natural and unnatural deaths and the numerous methods currently used. Secondly, in the light of the considerable progress in this field and the attempt to develop standardized protocols of PMCTA, the authors aim to evaluate the diagnostic value of PMCTA in comparison both to PMCT and conventional autopsy.

Application of contrast media in post-mortem imaging (CT and MRI)

The application of contrast media in post-mortem radiology differs from clinical approaches in living patients. Post-mortem changes in the vascular system and the absence of blood flow lead to specific problems that have to be considered for the performance of post-mortem angiography. In addition, interpreting the images is challenging due to technique-related and post-mortem artefacts that have to be known and that are specific for each applied technique. Although the idea of injecting contrast media is old, classic methods are not simply transferable to modern radiological techniques in forensic medicine, as they are mostly dedicated to single-organ studies or applicable only shortly after death. With the introduction of modern imaging techniques, such as post-mortem computed tomography (PMCT) and post-mortem magnetic resonance (PMMR), to forensic death investigations, intensive research started to explore their advantages and limitations compared to conventional autopsy. PMCT has already become a routine investigation in several centres, and different techniques have been developed to better visualise the vascular system and organ parenchyma in PMCT. In contrast, the use of PMMR is still limited due to practical issues, and research is now starting in the field of PMMR angiography. This article gives an overview of the problems in post-mortem contrast media application, the various classic and modern techniques, and the issues to consider by using different media.

"Lupara Bianca" a way to hide cadavers after Mafia homicides. A cemetery of Italian Mafia. A case study

The Gargano, also known as the 'Spur of Italy', is a sub-region of Italy which is located in North of Puglia, in the Province of Foggia. A ravine located in this area was used as a dumping ground in past. During a clearing operation, a team of speleologists discovered human skeletal remains, which led to an official investigation by the local prosecutor's office. The prosecutor called a team of forensic specialist for a scene investigation to recover and identify the human skeletal remains. Four different human skeletal remains located at four different levels of depth underground were found and were in different conditions. A complete forensic investigation was initiated and comprised of radiological imaging with DNA profiling. Three of the four human skeletal remains that were found were identified as those belonging to men who vanished mysteriously in the nineties. The studies conducted have demonstrated that the victims found were murdered and the murders were attributed to the "Mafia of Gargano". The Mafia of Gargano was officially recognized as a criminal organization dating back to 2009 and their criminal activities included the smuggling of firearms and cigarettes, human trafficking, and smuggling of undocumented immigrants. Murders in which corpses are made to disappear is common practice in criminal activities including that of the Italian Mafia. The "Lupara Bianca" is a colloquial term commonly used in Sicily to refer to concealed murders. To the best of our knowledge, this is the first reported study describing the discovery of one of the locations used extensively by the local Mafia as a "cemetery" for victims of "Lupara Bianca" homicides. Based on evidences collected at the site, an explanation of this homicidal modality will be provided.

Generation of intra-oral-like images from cone beam computed tomography volumes for dental forensic image comparison

Identification of unknown individuals using dental comparison is well established in the forensic setting. The identification technique can be time and resource consuming if many individuals need to be identified at once. Medical CT (MDCT) for dental profiling has had limited success, mostly due to artifact from metal-containing dental restorations and implants.

DESCRIPTION

The authors describe a CBCT reformatting technique that creates images, which closely approximate conventional dental images.

METHOD

Using a i-CAT Platinum CBCT unit and standard issue i-CAT Vision software, a protocol is developed to reproducibly and reliably reformat CBCT volumes. The reformatted images are presented with conventional digital images from the same anatomic area for comparison.

CONCLUSION

The authors conclude that images derived from CBCT volumes following this protocol are similar enough to conventional dental radiographs to allow for dental forensic comparison/identification and that CBCT offers a superior option over MDCT for this purpose.

An autopsy case of otogenic intracranial abscess and meningitis with Bezold's abscess: evaluation of inflammatory bone destruction by postmortem cone-beam CT

The deceased was an unidentified young male found unconscious on a walkway. On autopsy, outer and inner fistulae of the left temporal bone, subcutaneous abscess in the left side of the neck and head, and an intracranial abscess were noted. A portion of the left temporal bone was removed and scanned by cone-beam computed tomography (CT) (normally used for dentistry applications) to evaluate the lesion. The cone-beam CT image revealed roughening of the bone wall and hypolucency of the mastoid air cells, consistent with an inflammatory bone lesion. According to autopsy and imaging findings, the cause of death was diagnosed as intracranial abscess with Bezold's abscess secondary to left mastoiditis as a complication of otitis media. Although determining the histopathology of bone specimens is time-consuming and costly work, we believe that use of cone-beam CT for hard tissue specimens can be useful in forensic practice.

Virtual autopsy using multislice computed tomography in forensic medical diagnosis of drowning

PURPOSE

This study evaluated the usefulness of multidetector computed tomography (MDCT) in the postmortem diagnosis of death by drowning in fresh water by measuring the difference of blood density within the cardiac chambers.

MATERIALS AND METHODS

Twenty-two corpses including six cases of fresh-water drowning (group A) and 16 deaths by other causes (group B), among which were also different forms of mechanical asphyxia other than drowning, underwent MDCT and conventional autopsy. Blood density within the right and left heart chambers, the aorta and the pulmonary trunk was measured and values compared between groups and within each group between heart chambers.

RESULTS

Blood density in all cardiac chambers was lower in group A than in group B. The difference was statistically significant within the left atrium and ventricle and was significantly lower in the left than in the right heart chambers in group A only.

CONCLUSIONS

MDCT, together with conventional autopsy, may contribute to the diagnosis of drowning, by measuring blood density in the heart chambers.

Importance of 3D-CT imaging in single-bullet cranioencephalic gunshot wounds

PURPOSE

The aim of this paper is to demonstrate that computed tomography (CT) and three-dimensional (3D) CT imaging techniques can be useful tools for evaluating gunshot wounds of the skull in forensic medicine. Three purposes can be achieved: (1) identifying and recognising the bullet entrance wound - and exit wound, if present; (2) recognising the bullet's intracranial course by studying damage to bone and brain tissue; (3) suggesting hypotheses as to the dynamics of the event.

MATERIALS AND METHODS

Ten cadavers of people who died of a fatal head injury caused by a single gunshot were imaged with total-body CT prior to conventional autoptic examination. Three-dimensional-CT reconstructions were obtained with the volume-rendering technique, and data were analysed by two independent observers and compared with autopsy results.

RESULTS

In our experience, CT analysis and volumetric reconstruction techniques allowed the identification of the bullet entrance and exit wounds and intracranial trajectory, as well as helping to formulate a hypothesis on the extracranial trajectory to corroborate circumstantial evidence.

CONCLUSIONS

CT imaging techniques are excellent tools for addressing the most important questions of forensic medicine in the case of gunshot wounds of the skull, with results as good as (or sometimes better than) traditional autoptic methods.

Reconstruction and 3D visualisation based on objective real 3D based documentation

Reconstructions based directly upon forensic evidence alone are called primary information. Historically this consists of documentation of findings by verbal protocols, photographs and other visual means. Currently modern imaging techniques such as 3D surface scanning and radiological methods (computer tomography, magnetic resonance imaging) are also applied. Secondary interpretation is based on facts and the examiner's experience. Usually such reconstructive expertises are given in written form, and are often enhanced by sketches. However, narrative interpretations can, especially in complex courses of action, be difficult to present and can be misunderstood. In this report we demonstrate the use of graphic reconstruction of secondary interpretation with supporting pictorial evidence, applying digital visualisation (using 'Poser') or scientific animation (using '3D Studio Max', 'Maya') and present methods of clearly distinguishing between factual documentation and examiners' interpretation based on three cases. The first case involved a pedestrian who was initially struck by a car on a motorway and was then run over by a second car. The second case involved a suicidal gunshot to the head with a rifle, in which the trigger was pushed with a rod. The third case dealt with a collision between two motorcycles. Pictorial reconstruction of the secondary interpretation of these cases has several advantages. The images enable an immediate overview, give rise to enhanced clarity, and compel the examiner to look at all details if he or she is to create a complete image.