Postmortem computed tomography findings in suicide victims

Self-harm, suicide and brain death: the role of the radiologist

Suicide is a leading cause of death worldwide and takes many forms, which include hanging, jumping from a height, sharp force trauma, ingestion/poisoning, drowning, and firearm injuries. Self-harm and suicide are associated with particular injuries and patterns of injury. Many of these patterns are apparent on imaging. Self-harm or suicidal intent may be overlooked initially in such cases, particularly when the patient is unconscious or uncooperative. Correct identification of these findings by the radiologist will allow a patient's management to be tailored accordingly and may prevent future suicide attempts. The initial role of the radiologists in these cases is to identify life-threatening injuries that require urgent medical attention. The radiologist can add value by drawing attention to associated injuries, which may have been missed on initial clinical assessment. In many cases of self-harm and suicide, imaging is more reliable than clinical assessment. The radiologist may be able to provide important prognostic information that allows clinicians to manage expectations and plan appropriately. Furthermore, some imaging studies will provide essential forensic information. Unfortunately, many cases of attempted suicide will end in brain death. The radiologist may have a role in these cases in identifying evidence of hypoxic-ischaemic brain injury, confirming a diagnosis of brain death through judicious use of ancillary tests and, finally, in donor screening for organ transplantation. A review is presented to illustrate the imaging features of self-harm, suicide, and brain death, and to highlight the important role of the radiologist in these cases.

USA Suicides Compared to Other Western Countries in the 21st Century: Is there a Relationship with Gun Ownership?

OBJECTIVES

Causes of suicide are complex indicating a nation's psycho-socio-economic well-being hence this population-based study explores whether USA suicides worsened compared to nineteen Other Western Countries (OWC) being possibly related to gun ownership in the 21st Century.

METHODS

Total suicide data are drawn from the latest WHO Age-Standardised-Death-Rates per million (pm) controlled for age, sex, and population, along with suicides in the five age- bands 15-34 years to 75 + years. National gun ownership data from the international Small Arms Survey. Chi-square tests any significant difference between American and OWC suicides during the century. Spearman Rank Order correlations are used to determine comparability of suicides and gun ownership per thousand person rates over the period 2000-15.

RESULTS

USA had the highest gun ownership, treble the rate of the next highest country. American Total suicides rose 27%, significantly more than eight other countries (p < 0.05). The USA had significantly worse suicide outcomes for Older (75+) people than three OWC; eleven for Mature Adults 55-74; eight for Adults 34-54 and for ten countries for Young Adults 15-34. Young Adult suicides numbered 12,438, 6,702 gun-related in 2015, exceeding recent USA military losses. Only Young Adult suicides positively correlated with gun ownership (<0.025).

CONCLUSIONS

The key finding is whilst most countries reduced suicides American rates rose substantially this century, raising questions about US society. Importantly the easy access to firearms in the USA makes Young Adult suicide more likely when facing psycho-social stress. This study exposes the vulnerability of distressed young American adults in a permissive gun culture, with its sequel, life-long grieving parents.HighlightsDuring 21st Century USA suicides rose substantially more than other Western nations.Only USA suicides rose >20% amongst Total suicides and in those aged 15-to-74years.USA Young Adult suicides 150,099 in 21st century, 12,438 in 2015, 6,702 were gun-related.

Cartilage Tissue in Forensic Science—State of the Art and Future Research Directions

Cartilage tissue performs many functions in the human body. The diseases and injuries affecting it are prevalent due to its slow regeneration rate. However, cartilage tissue is exceptionally important for its auspicious use in forensic medicine due to its slow postmortem degradation rate. The presented review summarizes the latest research on cartilage tissues and their current and potential applications in forensic science. It also describes the most important studies on using cartilage and its microscopic and macroscopic analyses to estimate the deceased age and determine postmortem interval (PMI) values and the crime weapon. Additionally, the review describes attempts to isolate DNA from cartilage tissue for individual identification. The review also mentions recent, less abundant studies on the cartilage in forensic toxicology and genetics. It points out further directions and prospects for research development on cartilage tissue and its promising use in forensic medicine

Comparison of findings identified at traditional invasive autopsy and postmortem computed tomography in suicidal hangings

Cases of suicidal hanging are a common death referred for medico-legal autopsy throughout the world. Although some advocate using postmortem computed tomography (PMCT) without traditional invasive autopsy (TIA) to investigate such deaths, others reject this approach. There is currently limited evidence to guide practice. In this context, the TIA reports and PMCT images of 50 cases of suspected suicidal hanging during an 11-month period were reviewed. The reviewers were blinded to the findings of the other modality. A Cohen’s Kappa coefficient (K) was calculated to assess agreement between TIA and PMCT across a range of pertinent findings. This analysis demonstrated perfect agreement for identification of a ligature (K = 1.00) and a strong level of agreement for identification of a ligature suspension point (K = 0.832) but only a minimal level of agreement for overall ligature mark (K = 0.223). PMCT demonstrated a weak level of agreement for fractures of hyoid bone (K = 0.555) and thyroid cartilage (K = 0.538). Three probable fractures not identified at TIA were identified on PMCT. TIA was shown to be superior in the identification of intramuscular and laryngeal fracture–related haemorrhage/bruising whereas PMCT was superior to TIA in identifying body gas deposition. There was overall good correlation between the natural disease and trauma identified elsewhere in the body during the TIA and PMCT. The study demonstrates that PMCT can assist the investigation of suspected suicidal hangings. However, the accuracy of many findings is limited, and if it is used as an alternative to the TIA, potentially pertinent findings, such as fractures of the laryngeal cartilages, could be missed.

Incidence and factor analysis of laryngohyoid fractures in hanging individuals-computed tomography study

OBJECTIVES

Although laryngohyoid fracture indicates the applied neck pressure and is an important finding in hanging individuals, the reported rate varies widely and its true incidence remains controversial. We used computed tomography (CT) studies to investigate the incidence of laryngohyoid fracture in hanging individuals and identify factors contributing to such fractures.

METHODS

Considered for inclusion in this study were 107 attempted or successful hanging individuals subjected to CT studies between 2005 and 2019. After excluding 19 whose images were inadequate for evaluation, 88 subjects were included. Body suspension was complete in 20, partial in 49, and unknown in 19; 54 (61.4%) individuals died. Two radiologists performed image analysis and recorded the presence and site of laryngohyoid fractures. Multiple logistic regression analysis was used for factor analysis of laryngohyoid fractures; it included the gender, the age (< or ≧ 40 years), the type of suspension (complete or incomplete), and the outcome (death or survival).

RESULTS

Of the 88 subjects, 35 (39.8%) presented with laryngohyoid fractures on CT images; the superior horn of the thyroid cartilage was fractured in 32 (91.4%) of the 35. Age was the only factor significantly related to laryngohyoid fracture (odds ratio = 2.85, 95% confidence interval = 1.08-7.52).

CONCLUSIONS

In hanging individuals, the incidence of laryngohyoid fracture on CT images was 39.8%. The superior horn of the thyroid cartilage was the most frequent fracture site.

KEY POINTS

• The incidence of laryngohyoid fracture on CT images of hanging individuals was almost 40%; the superior horn of the thyroid cartilage was the most frequent fracture site. • In older hanging individuals, attention must be paid to laryngohyoid fractures on CT images.

Unusual attempted suicide or covered attempted homicide? A neck stabbing case report and review of literature

A medico-legal consult is frequently required in a clinical context in order to assess the eventual compatibility of specific wounds with a self- or hetero-infliction. Accordingly, the case of a 52-year-old man with a single, penetrating stab wound of the neck, reported as self-inflicted, is here presented. The forensic aspects, taken into account in order to determine the self- or hetero-infliction nature of the wound, are further discussed and compared to cases described in the literature.

Post-mortem computed tomography for forensic applications: A systematic review of gunshot deaths

The first reported application of computed tomography (CT) to the field of forensic medicine was in 1977 for the study of gunshot injuries to the head. Since then, CT scanning has shown increased uses within the field of forensic practice. In this study a systematic literature search was carried out by consulting 17 electronic scientific databases. This systematic review considers studies published to date concerning the use of post-mortem CT (PMCT) in gunshot injury cases; this review shows variability between the PMCT and autopsy examination findings. Furthermore we identify the technical differences between the selected studies, emphasizing the specific findings obtainable with PMCT, in order to support forensic research towards shared and validated practices, whose results are used as evidence in the courtroom.

An analysis of reports concerning overdose evaluated by abdominal computed tomography

Recently, there have been a number of reports concerning the utility of abdominal computed tomography (CT) for diagnosing overdose (OD). We herein report the summary and results of an analysis of these reports to assess the significance of CT for patients with OD. Searches of Ichushi (Japana Centra Revuo Medicine) and PubMed were carried out to identify articles from 1983 to 2019 using the key words "poisoning" and "abdominal computed tomography". Forty-eight cases across 15 articles were defined as subjects in this report. The average age of subjects was 46 years old, and there were 28 women. Forty-five of the 48 subjects (93.8%) had positive findings of residual drugs on CT. The finding of a high-density fluid level in the stomach was the most frequent (60.4%), followed by ill-defined high-density material in the stomach (12.5%) and high-density tablets in the stomach (10.4%). One prospective study suggested the merits of decontamination for patients with positive findings on CT even if more than 60 min had elapsed since the ingestion of drugs. Computed tomography could aid in the diagnosis of OD in comatose patients who cannot talk or who present without any other evidence of OD. In addition, a recent study revealed the merits of decontamination for patients with positive findings on the CT even if more than 60 min had elapsed since the ingestion of drugs.

Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy - a systematic review

Several articles have described the use of postmortem computed tomography (CT) and postmortem magnetic resonance imaging (MRI) in forensic medicine. Although access to CT scanners and, particularly, access to MRI scanners, is still limited for several institutes, both modalities are being applied with increasing frequency in the forensic setting. Certainly, postmortem imaging can provide crucial information prior to autopsy, and this method has even been considered a replacement to autopsy in selected cases by some forensic institutes. However, the role of postmortem imaging has to be assessed individually according to various injury categories and causes of death. Therefore, this systematic review focuses on the role of postmortem CT and MRI in cases of hanging and ligature and manual strangulation. We assessed the most common and relevant findings on CT and MRI in cases of strangulation and compared the detectability of these findings among CT, MRI and autopsy. According to the available literature, mainly fractures of the hyoid bone or thyroid cartilage were investigated using postmortem CT. Compared to autopsy, CT demonstrated equivalent results concerning the detection of these fractures. A currently described "gas bubble sign" may even facilitate the detection of laryngeal fractures on CT. Regarding the detection of hemorrhages in the soft tissue of the neck, postmortem MRI is more suitable for the detection of this "vital sign" in strangulation. Compared to autopsy, postmortem MRI is almost equally accurate for the detection of hemorrhages in the neck. Another "vital sign", gas within the soft tissue in hanging, which is hardly detectable by conventional autopsy, can be clearly depicted by CT and MRI. The number of cases of manual and ligature strangulation that were investigated by means of postmortem CT and MRI is much smaller than the number of cases of hanging that were investigated by CT and MRI. Likewise, judicial hanging and the hangman's fracture on postmortem imaging were described in only a few cases. Based on the results of this systematic review, we discuss the additional value of CT and MRI in fatal strangulation compared to autopsy, and we reflect on where the literature is currently lacking.

Virtual reconstruction of paranasal sinuses from CT data: A feasibility study for forensic application

PURPOSE

The purpose of this study was to report the feasibility of computed modelization and reconstitution of the paranasal sinuses, before and after trauma, from CT data.

MATERIALS AND METHODS

We modeled and reconstructed the paranasal sinuses of two patients (A and B), before and after trauma, using two different softwares (3DSlicer^® and Blender^®). Both patients had different numbers and locations of fractures. The 3DSlicer^® software was used to create a 3D model from CT data. We then imported the 3D data into the Blender^® software, to reconstruct and compare the dimensions of the paranasal sinuses before and after trauma.

RESULTS

The 3 fragments of patient A and the 7 fragments of patient B could be repositioned in the pre-traumatic configuration. Distance measurements proved to be similar between pre- and post-traumatic 3D volumes.

CONCLUSION

After simple trauma, bone facial anatomy reconstruction is manually feasible. The whole procedure could benefit from automatization through machine learning. However, this feasibility must be confirmed on more severely fractured paranasal sinuses, to consider an application in forensic identification.

Diagnostic value of unenhanced postmortem computed tomography in the detection of traumatic abdominal injuries

OBJECTIVE

To determine the diagnostic capabilities of unenhanced postmortem computed tomography (UPMCT) in detecting traumatic abdominal injuries.

MATERIAL AND METHODS

Cases of traumatic death with both UPMCT and classical autopsy were collected retrospectively from our institution "virtopsy" database in a period of 5 years. Cadavers with gunshot injuries were excluded. Sensitivity, specificity, accuracy, negative (NPV) and positive (PPV) predictive values of PMCT globally and for hemoperitoneum, liver, spleen, pancreas and kidney injuries individually were estimated using the autopsy report as gold standard.

RESULTS

Seventy-one cadavers were included. UPMCT had a sensitivity of 80% and a specificity 94%, with an accuracy of 83%, a PPV of 98% and a NPV of 59% for the diagnosis of traumatic abdominal injuries. The highest sensitivity was obtained for the detection of hepatic injuries (71%) and the lowest for pancreatic injuries (12%). UPMCT had a specificity of 100% for the detection of hemoperitoneum. A NPV of 98% was found for the detection of perihepatic hematomas.

CONCLUSION

The low sensitivity and low NPV do not support the use of UPMCT as an alternative to conventional autopsy to diagnose and/or rule out traumatic abdominal injuries. Nevertheless, UPMCT remains a helpful tool as it helps detect hemoperitoneum and virtually exclude presence of perihepatic hematomas.