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Hansen JP, Larsen ST, Jacobsen C. Diagnostic accuracy of post-mortem computed tomography for fractures of the hyoid-larynx complex. Int J Legal Med 2024:10.1007/s00414-024-03293-1. [PMID: 39014249 DOI: 10.1007/s00414-024-03293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 07/09/2024] [Indexed: 07/18/2024]
Abstract
Post-mortem computed tomography (PMCT) is routinely used at many forensic institutions to guide the following autopsy and is especially useful for diagnosing fractures. This systematic review aims to investigate the sensitivity and specificity of a PMCT scan in fracture diagnosis of the hyoid-larynx complex (HLC) compared to traditional autopsy in cases involving traumatic neck injuries. We searched PubMed, SCOPUS and Web of Science and included papers with cases n ≥ 3 published between January 2000 and April 2023 reporting on PMCT and autopsy findings of fractures of the HLC. The search provided 259 results of which 10 were included. Overall sensitivity and specificity were 0.70 [0.59; 0.79] and 0.92 [0.80; 0.97] for hyoid bone fractures and 0.80 [0.62; 0.91] and 0.76 [0.63; 0.85] for the thyroid cartilage. The results show great variation, and a large range between studies. These results indicate that PMCT cannot replace autopsy in cases with HLC fractures. Future larger prospective studies are needed, examining fracture details, scan protocols and different slice thicknesses using uniform reporting.
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Affiliation(s)
- Josephine Ploug Hansen
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Frederik V's Vej 11, Copenhagen, 2100, Denmark
| | - Sara Tangmose Larsen
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Frederik V's Vej 11, Copenhagen, 2100, Denmark.
| | - Christina Jacobsen
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Frederik V's Vej 11, Copenhagen, 2100, Denmark
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Zirn A, Scheurer E, Lenz C. Automated detection of fatal cerebral haemorrhage in postmortem CT data. Int J Legal Med 2024; 138:1391-1399. [PMID: 38329584 PMCID: PMC11164783 DOI: 10.1007/s00414-024-03183-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/01/2024] [Indexed: 02/09/2024]
Abstract
During the last years, the detection of different causes of death based on postmortem imaging findings became more and more relevant. Especially postmortem computed tomography (PMCT) as a non-invasive, relatively cheap, and fast technique is progressively used as an important imaging tool for supporting autopsies. Additionally, previous works showed that deep learning applications yielded robust results for in vivo medical imaging interpretation. In this work, we propose a pipeline to identify fatal cerebral haemorrhage on three-dimensional PMCT data. We retrospectively selected 81 PMCT cases from the database of our institute, whereby 36 cases suffered from a fatal cerebral haemorrhage as confirmed by autopsy. The remaining 45 cases were considered as neurologically healthy. Based on these datasets, six machine learning classifiers (k-nearest neighbour, Gaussian naive Bayes, logistic regression, decision tree, linear discriminant analysis, and support vector machine) were executed and two deep learning models, namely a convolutional neural network (CNN) and a densely connected convolutional network (DenseNet), were trained. For all algorithms, 80% of the data was randomly selected for training and 20% for validation purposes and a five-fold cross-validation was executed. The best-performing classification algorithm for fatal cerebral haemorrhage was the artificial neural network CNN, which resulted in an accuracy of 0.94 for all folds. In the future, artificial neural network algorithms may be applied by forensic pathologists as a helpful computer-assisted diagnostics tool supporting PMCT-based evaluation of cause of death.
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Affiliation(s)
- Andrea Zirn
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056, Basel, Switzerland
- Institute of Forensic Medicine, Health Department Basel-Stadt, Basel, Switzerland
| | - Eva Scheurer
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056, Basel, Switzerland
- Institute of Forensic Medicine, Health Department Basel-Stadt, Basel, Switzerland
| | - Claudia Lenz
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056, Basel, Switzerland.
- Institute of Forensic Medicine, Health Department Basel-Stadt, Basel, Switzerland.
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Shakargy JD, Gendler S, Talmy T, Shushan G, Radomislensky I, Tsur AM, Almog O, Avital G, Benov A, Gelikas S. Blast Injury Patterns Among Israel Defense Forces Fatalities. Mil Med 2023; 188:e1788-e1794. [PMID: 36205252 DOI: 10.1093/milmed/usac280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/03/2022] [Accepted: 09/09/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The incidence of blast injuries on the battlefield has risen over the last several decades. In order to improve prevention and treatment, it is essential to understand the severity and bodily distribution of these injuries. This study aims to characterize blast injury patterns among IDF fatalities. MATERIALS AND METHODS This is a descriptive, retrospective study on postmortem reports of military-blast fatalities between the years 1982 and 2021. Body regions injured according to the Abbreviated Injury Scale (AIS) were described. The frequency of body region injury combinations was mapped, and the correlation between injured body regions was calculated using Pearson's coefficient. Analysis of a subgroup with a postmortem computed tomography (CT-PM) or autopsy was performed, describing severe (AIS ≥ 3) injury patterns. RESULTS Overall, 222 fatalities suffered from blast injury, with most injuries affecting the upper and lower extremities (63.7% and 66.5%, respectively), followed by the head (57.1%) and the thorax (56.6%). The median number of injured body regions was 4 (interquartile range, 2-5). The most frequent injury combinations were the upper and lower extremities (51%), the upper extremities and the thorax (45%), and the lower extremities and the thorax (41%). In all, 47/222 (21.2%) fatalities had a documented autopsy or CT-PM report. Among the fatalities with CT-PM or autopsy, the head (63.8%) and the thorax (57.4%) were most frequently severely injured (AIS ≥ 3). CONCLUSIONS Among blast fatalities in the military setting, the extremities were most commonly injured. However, data suggest that the head and thorax are more likely to sustain severe blast injuries resulting in mortality. Blast injuries in this cohort were characterized by concomitant involvement of several regions. Development of protective gear to minimize the multisystem injuries inflicted by blast injuries is warranted and should be focused on distinct types and anatomical distribution of severe blast injuries as reported in this study. LEVEL OF EVIDENCE Level III, Retrospective analysis.
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Affiliation(s)
- Josef Daniel Shakargy
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Sami Gendler
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Tomer Talmy
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 91120, Israel
| | - Guy Shushan
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Ground forces Technology Unit, Tel-Hashomer, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Irina Radomislensky
- The Israel National Center for Trauma & Emergency Medicine Research, Gertner Institute of Epidemiology and Health Policy Research, Tel Aviv 5262000, Israel
| | - Avishai M Tsur
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Sheba Medical Center Hospital-Tel-Hashomer, Ramat Gan 5262000, Israel
| | - Ofer Almog
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 91120, Israel
| | - Guy Avital
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Division of Anesthesia, Intensive Care & Pain Management, Tel-Aviv Sourasky Medical Center, Tel-Aviv 6423906, Israel
| | - Avi Benov
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
| | - Shaul Gelikas
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Sheba Medical Center Hospital-Tel-Hashomer, Ramat Gan 5262000, Israel
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Vicentin-Junior CA, Vieira RB, Damascena NP, Silva MC, Santiago BM, Cunha E, Issa JPM, Martins-Filho PR, Machado CEP. Differences in ballistic findings between autopsy and post-mortem computed tomography in the head and neck region of gunshot victims: a comprehensive synthesis for forensic decision-making. EXCLI JOURNAL 2023; 22:600-603. [PMID: 37662711 PMCID: PMC10471839 DOI: 10.17179/excli2023-6256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/03/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Carlos Antonio Vicentin-Junior
- Graduate Program in Pathology, Ribeirão Preto Medical School, University of São Paulo, USP, Ribeirão Preto, Brazil
- Investigative Pathology Laboratory, Federal University of Sergipe, Sergipe, Brazil
| | - Raíssa Bastos Vieira
- Graduate Program in Pathology, Ribeirão Preto Medical School, University of São Paulo, USP, Ribeirão Preto, Brazil
- Investigative Pathology Laboratory, Federal University of Sergipe, Sergipe, Brazil
| | - Nicole Prata Damascena
- Investigative Pathology Laboratory, Federal University of Sergipe, Sergipe, Brazil
- Graduate Program in Health Sciences, Federal University of Sergipe, Sergipe, Brazil
| | - Melina Calmon Silva
- National Center for the Dissemination of Forensic Sciences, Brazilian Federal Police, Distrito Federal, Brazil
| | | | - Eugénia Cunha
- Centre for Functional Ecology, Laboratory of Forensic Anthropology, University of Coimbra, Portugal
- National Institute of Legal Medicine and Forensic Sciences, Lisbon, Portugal
| | - João Paulo Mardegan Issa
- Graduate Program in Pathology, Ribeirão Preto Medical School, University of São Paulo, USP, Ribeirão Preto, Brazil
| | - Paulo Ricardo Martins-Filho
- Investigative Pathology Laboratory, Federal University of Sergipe, Sergipe, Brazil
- Graduate Program in Health Sciences, Federal University of Sergipe, Sergipe, Brazil
| | - Carlos Eduardo Palhares Machado
- Graduate Program in Pathology, Ribeirão Preto Medical School, University of São Paulo, USP, Ribeirão Preto, Brazil
- National Center for the Dissemination of Forensic Sciences, Brazilian Federal Police, Distrito Federal, Brazil
- National Institute of Criminalistics, Brazilian Federal Police, Distrito Federal, Brazil
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Ong HN, Chen IH, Hsieh YH, Hsu CH, Weng TI, Chang CC. Comparison of fatal traumatic medico-legal cases with postmortem computed tomography and autopsy: A pilot study in Taiwan. J Formos Med Assoc 2023; 122:351-354. [PMID: 36253239 DOI: 10.1016/j.jfma.2022.09.015] [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: 06/30/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
In order to determine the performance of postmortem computed tomography (PMCT) in identifying traumatic-relevant macroscopic findings in medico-legal cases, this retrospective observational pilot study involving nine trauma casualties who had received PMCT prior to autopsy. The comparison of these findings in six anatomical regions as dictated in Injury Severity Score (ISS) were performed. 104 traumatic-relevant findings were identified with achievement of 51% congruent findings. PMCT and autopsy had additionally found 22 and 29 findings respectively. PMCT had highest sensitivity for extremity injury (81.82%), followed by chest (73.91%), head, neck and face (71.43%), and abdomino-pelvic area (50%). It had excellent detection rate in abnormal air collection, fracture, foreign body localization, internal ballistic and intracranial pathology. However, the solid organ and vascular injuries as well as integumentary lesions were the major drawback. In conclusion, incorporation of PMCT to autopsy in medico-legal investigation helps to preserve the most abundant traumatic-relevant injuries compared to either modality.
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Affiliation(s)
- Hooi-Nee Ong
- Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan, University College of Medicine, Taipei, Taiwan; Department and Graduate Institute of Forensic Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Hung Chen
- Department of Forensic Pathology, Institute of Forensic Medicine, Ministry of Justice, New Taipei City, Taiwan
| | - Yu-Hsuan Hsieh
- Department and Graduate Institute of Forensic Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Cho-Hsien Hsu
- Department of Forensic Pathology, Institute of Forensic Medicine, Ministry of Justice, New Taipei City, Taiwan
| | - Te-I Weng
- Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan, University College of Medicine, Taipei, Taiwan; Department and Graduate Institute of Forensic Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Chin-Chen Chang
- Department and Graduate Institute of Forensic Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Medical Imaging, National Taiwan University Hospital and National Taiwan, University College of Medicine, Taipei, Taiwan.
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Bryce AJ, Dandrieux JR, Lenard Z, Chen Y, Milne ME. Veterinary forensic radiology–Development of a cost-effective and easily performed post mortem computed tomographic angiography protocol. FORENSIC IMAGING 2022. [DOI: 10.1016/j.fri.2022.200528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lyness JR, Collins AJ, Rutty JE, Rutty GN. Comparison of findings identified at traditional invasive autopsy and postmortem computed tomography in suicidal hangings. Int J Legal Med 2022; 136:1865-1881. [PMID: 35960370 PMCID: PMC9576641 DOI: 10.1007/s00414-022-02874-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/03/2022] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
| | | | - Jane E Rutty
- The Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | - Guy N Rutty
- East Midlands Forensic Pathology Unit, University of Leicester, Leicester, UK
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Henningsen MJ, Larsen ST, Jacobsen C, Villa C. Sensitivity and specificity of post-mortem computed tomography in skull fracture detection-a systematic review and meta-analysis. Int J Legal Med 2022; 136:1363-1377. [PMID: 35286468 DOI: 10.1007/s00414-022-02803-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/16/2022] [Indexed: 11/29/2022]
Abstract
Post-mortem computed tomography (PMCT) has been increasingly used as routine examination in forensic pathology. No recent review of the growing number of papers on the ability of PMCT to detect skull fracture exists, and original papers report sensitivities from 0.85 to 1.00. This systematic review (PROSPERO: CRD42021233264) aims to provide a meta-analysis of sensitivity and specificity of PMCT in skull fracture detection. We searched PubMed, MEDLINE and Embase for papers published between January 2000 and August 2021 reporting raw numbers, sensitivity and specificity or Abbreviated Injury Score for PMCT compared to autopsy. Papers without both PMCT and autopsy, no separate reporting of the neuro-cranium, exclusively on children, sharp trauma, gunshot or natural death as well as case reports and reviews were excluded. Two authors independently performed inclusion, bias assessment and data extraction. QUADAS-2 was used for bias assessment and a random effects models used for meta-analysis. From 4.284 hits, 18 studies were eligible and 13 included in the meta-analysis for a total of 1538 cases. All deceased were scanned on multi-slice scanners with comparable parameters. Images were evaluated by radiologists or pathologists. Intra- and inter-observer analyses were rarely reported. In summary, sensitivity of PMCT for detection of fractures in the skull base was 0.87 [0.80; 0.92] with specificity 0.96 [0.90; 0.98], and sensitivity for the vault was 0.89 [0.80; 0.94] with specificity 0.96 [0.91; 0.98]. The mixed samples are a limitation of the review.
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Affiliation(s)
- Mikkel Jon Henningsen
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Frederik V's vej 11, 2100, Copenhagen, Denmark.
| | - Sara Tangmose Larsen
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Frederik V's vej 11, 2100, Copenhagen, Denmark
| | - Christina Jacobsen
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Frederik V's vej 11, 2100, Copenhagen, Denmark
| | - Chiara Villa
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Frederik V's vej 11, 2100, Copenhagen, Denmark
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Takahashi Y, Hayakawa A, Sano R, Fukuda H, Kubo R, Tokue H, Okawa T, Kawamura M, Kominato Y. Usefulness of a tissue optical clearing technique for forensic autopsy. J Forensic Sci 2022; 67:1124-1131. [PMID: 35088897 DOI: 10.1111/1556-4029.14995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/23/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022]
Abstract
Forensic pathologists are required to investigate lethal trauma or disease at autopsy. In addition to massive contusions of various organs, a number of small features with potentially fatal implications also need to be sought. Since such lesions may need microscopic examinations for detailed evaluation, it is important to select suitable anatomic locations for tissue sampling. For practical screening of small lesions, we have developed a tissue optical clearing (TOC) technique for forensic autopsy. The technique involves clearing with a non-toxic organic solvent, ethyl cinnamate, which renders excised organs transparent, while hemorrhages or blood-containing vessels remain opaque. Using this technique, tiny hemorrhages in the spinal cord were able to be identified by gross examination, allowing proper selection of locations for tissue sampling. Subsequent histopathological evaluation was successfully performed with no apparent artifacts related with the TOC procedure. In addition, a combination of TOC and targeted CT angiography allowed feasible examination of the arterial occlusive lesion in the superior mesenteric artery, and when combined with micro-CT scanning it was useful for evaluating the lumen of the coronary artery with stent implantation. The results obtained so far indicated that TOC could complement routine forensic autopsy procedures when detailed evaluation of small lesions is required.
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Affiliation(s)
- Yoichiro Takahashi
- Department of Legal Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
| | - Akira Hayakawa
- Department of Legal Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
| | - Rie Sano
- Department of Legal Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
| | - Haruki Fukuda
- Department of Legal Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
| | - Rieko Kubo
- Department of Legal Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
| | - Hiroyuki Tokue
- Department of Diagnostic Radiology & Nuclear Medicine, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Takafumi Okawa
- Department of Legal Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
| | - Miki Kawamura
- Department of Legal Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
| | - Yoshihiko Kominato
- Department of Legal Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
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Henningsen MJ, Harving ML, Jacobsen C, Villa C. Fractures of the neuro-cranium: sensitivity and specificity of post-mortem computed tomography compared with autopsy. Int J Legal Med 2022; 136:1379-1389. [PMID: 35084533 DOI: 10.1007/s00414-022-02779-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/17/2022] [Indexed: 01/22/2023]
Abstract
Post-mortem computed tomography (PMCT) is a routine tool in many forensic pathology departments as it is fast and non-destructive and allows less gruesome visualization than photographs, and the images are indefinitely storable. Several studies investigated congruence between PMCT and autopsy for skull fracture but registered only the presence or absence of fracture systems. The objective of this study was to determine location-specific sensitivity and specificity of PMCT for individual fracture lines in blunt force head trauma. Accurate 3D models based on PMCT data with all fracture lines visible are important for future studies on fractures, applying finite element analysis (FEA). We retrospectively sampled adult cases from 2013 to 2019 with skull fracture mentioned in the autopsy report. PMCT was on a Siemens 64-slice scanner and autopsy according to international guidelines. The location and direction of all fracture lines at autopsy and at de novo interpretation of scans were registered and compared. Ninety-nine cases with 4809 individual findings were included. Age ranged from 18 to 100 years. The overall sensitivity was 0.58, and specificity was 0.91. For individual locations, sensitivity ranged from 0.24 to 0.85, and specificity ranged from 0.73 to 1.00. Intra-observer agreement was 0.74, and inter-observer agreement ranged from 0.43 to 0.58. In conclusion, PMCT is suited for detection of fracture systems, but not for detection of all individual fracture lines. Our results differed from the existing literature due to the methodological choices of registering individual fracture lines. Future studies utilising FEA must supplement PMCT with autopsy data.
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Affiliation(s)
- Mikkel Jon Henningsen
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Copenhagen, Denmark.
| | | | - Christina Jacobsen
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Copenhagen, Denmark
| | - Chiara Villa
- Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Copenhagen, Denmark
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11
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Shchegolev AI, Tumanova UN, Savva OV. [Postmortem assessment of cerebral edema]. Arkh Patol 2022; 84:74-80. [PMID: 36469722 DOI: 10.17116/patol20228406174] [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] [Indexed: 06/17/2023]
Abstract
An analysis of literature data on the methods of post-mortem assessment of cerebral edema is presented. Based on the mechanisms of development, two main types of cerebral edema are distinguished: cytotoxic (intracellular) and vasogenic (extracellular). To determine cerebral edema, a number of methods are used, both direct and indirect, invasive and non-invasive assessment. Direct methods for assessing cerebral edema are based on determining the amount of water in its tissue. Indirect methods include morphological and radiation studies. Traditionally, the most evidence-based criteria for the diagnosis of cerebral edema are macroscopic and microscopic changes determined at autopsy. Methods are also indicated for determining the content of water in brain tissue by comparing the mass of wet and dry brain, as well as estimating the specific density of brain tissue.
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Affiliation(s)
- A I Shchegolev
- National Medical Research Center for Obstetrics, Gynecology and Perinatology named after academician V.I. Kulakov, Moscow, Russia
| | - U N Tumanova
- National Medical Research Center for Obstetrics, Gynecology and Perinatology named after academician V.I. Kulakov, Moscow, Russia
| | - O V Savva
- National Medical Research Center for Obstetrics, Gynecology and Perinatology named after academician V.I. Kulakov, Moscow, Russia
- Bureau of Forensic Medicine named after D.I. Mastbaum, Ryazan, Russia
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12
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Hammarlebiod S, Farrugia A, Bierry G, Raul JS, Willaume T. Thermal bone injuries: postmortem computed tomography findings in 25 cases. Int J Legal Med 2021; 136:219-227. [PMID: 34570270 DOI: 10.1007/s00414-021-02708-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/13/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Fire death investigations attempt to determine whether a subject was alive or dead before the fire started. Therefore, it is essential to assess if the bone damage is traumatic or the result of exposure to heat. This observational study aims to expose the specific CT semiology of thermal bone lesions to allow the forensic radiologist to identify and distinguish them from traumatic lesions that would have preceded death. MATERIALS AND METHODS We retrospectively reviewed the CT findings of 25 bodies with thermal bone lesions for which a postmortem computed tomography (PMCT) was performed prior to an autopsy. Imaging findings were correlated to the autopsy data to identify the specific features of thermal bone lesions. RESULTS Specific signs of thermal injuries to bone were identified on PMCT on all deceased cases. Thermal damages predominated in areas directly exposed to flames (rib cage, distal extremities) with less soft tissue coverage ("soft tissue shielding"). The mottled appearance of bone marrow was a constant sign of burned bones. Heat fractures such as trans-diploic fractures of flat bones and beveled ("flute-mouthpiece") fractures of extremities seemed specifically related to thermal mechanism. In addition, we provided a better description of superficial cortical fissures of flat bones ("ancient Chinese porcelain") and observed a "stair step" fracture of a long bone until now undescribed in radiological literature. CONCLUSION Thermal bone lesions have specific CT findings, different on several points from traumatic injuries. Their knowledge is essential for radiologists and forensic physicians to provide an accurate report of injury and conclusions.
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Affiliation(s)
- Sarah Hammarlebiod
- Department of Radiology, University Hospital of Strasbourg, 1 Avenue Molière, 67200, Strasbourg, France
| | - Audrey Farrugia
- Institute of Legal Medicine, Hospital of Strasbourg, University of Strasbourg, 11, rue Humann, 67085, Strasbourg cedex, France.
| | - Guillaume Bierry
- Department of Radiology, University Hospital of Strasbourg, 1 Avenue Molière, 67200, Strasbourg, France
| | - Jean-Sébastien Raul
- Institute of Legal Medicine, Hospital of Strasbourg, University of Strasbourg, 11, rue Humann, 67085, Strasbourg cedex, France
| | - Thibault Willaume
- Department of Radiology, University Hospital of Strasbourg, 1 Avenue Molière, 67200, Strasbourg, France
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Hlahla MI, Selatole MJ. Could ante-mortem computed tomography be useful in forensic pathology of traumatic intracranial haemorrhage? Afr J Lab Med 2021; 10:1040. [PMID: 34395198 PMCID: PMC8335788 DOI: 10.4102/ajlm.v10i1.1040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 02/25/2021] [Indexed: 11/21/2022] Open
Abstract
Background Imaging techniques have proven valuable in forensic pathology practice, with computed tomography being preferred for forensic use. In the era of virtual autopsy and a low- to middle-income, resource-constrained country, a question arises as to whether ante-mortem computed tomography (ACT) could be cost-effective by reducing the number of invasive autopsies performed. Objective The objective of this study was to assess the usefulness of ACT in forensic pathology by examining discrepancy rates between ACT scans and autopsy findings in cases of deceased individuals with traumatic intracranial haemorrhages and assess factors associated with discrepancies. Methods Eighty-five cases of ACT and autopsy reports from 01 January 2014 to 31 December 2016 from the Polokwane Forensic Pathology Laboratory, South Africa, were analysed retrospectively. Using Cohen’s kappa statistics, measures of agreement and resultant discrepancy rates were determined. Also, the discrepancy patterns for each identified factor was also analysed. Results The discrepancy rate between ACT and autopsy detection of haemorrhage was 24.71% while diagnostic categorisation of haemorrhage was 55.3%. Classification discrepancy was most observed in subarachnoid haemorrhages and least observed in extradural haemorrhages. A markedly reduced level of consciousness, hospital stay beyond two weeks and three or fewer years of doctors’ experience contributed to classification discrepancies. Conclusion Ante-mortem computed tomography should be used only as an adjunct to autopsy findings. However, the low discrepancy rate seen for extradural haemorrhages implies that ACT may be useful in the forensic diagnosis of extradural haemorrhages.
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Affiliation(s)
- Mmachuene I Hlahla
- Department of Forensic Pathology, Faculty of Health Sciences, University of Limpopo, Polokwane, South Africa
| | - Moshibudi J Selatole
- Department of Forensic Pathology, Faculty of Health Sciences, University of Limpopo, Polokwane, South Africa
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14
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Head and Brain Postmortem Computed Tomography-Autopsy Correlation in Hospital Deaths. Am J Forensic Med Pathol 2021; 41:163-175. [PMID: 32618580 DOI: 10.1097/paf.0000000000000538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of postmortem computed tomography (PMCT) to support autopsy pathology has increased in recent decades. To some extent, PMCT has also been contemplated as a potential alternative to conventional postmortem examination. The purpose of this study was to investigate the ability of PMCT to detect specific pathologic findings in the head and brain in natural hospital deaths.We examined postmortem CT images and autopsy data from 31 subjects who died at SUNY (State University of New York) Upstate University Hospital between 2013 and 2018. Each subject underwent a noncontrast PMCT and a traditional autopsy. A neuroradiologist analyzed PMCT images for head and brain abnormalities. The autopsies were performed by pathologists who were aware of the radiology results.In our series, PMCT was able to detect the majority of the significant space-occupying lesions, although it was not always reliable in ascertaining their nature. Postmortem computed tomography revealed findings usually challenging to detect at autopsy. Unfortunately, there were also situations in which PMCT was misleading, showing changes that were difficult to interpret, or that could be related to postmortem events. Therefore, we conclude PMCT should be used as an adjunct rather than a substitute to autopsy.
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15
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Clinical Relevance of Unexpected Findings of Post-Mortem Computed Tomography in Hospitalized Patients: An Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17207572. [PMID: 33081003 PMCID: PMC7589901 DOI: 10.3390/ijerph17207572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/06/2020] [Accepted: 10/14/2020] [Indexed: 01/20/2023]
Abstract
Background and objective: The current literature describing the use of minimally invasive autopsy in clinical care is mainly focused on the cause of death. However, the identification of unexpected findings is equally important for the evaluation and improvement of daily clinical care. The purpose of this study was to analyze unexpected post-mortem computed tomography (PMCT) findings of hospitalized patients and assess their clinical relevance. Materials and methods: This observational study included patients admitted to the internal medicine ward. Consent for PMCT and autopsy was requested from the next of kin. Decedents were included when consent for at least PMCT was obtained. Consent for autopsy was not obtained for all decedents. All findings reported by PMCT were coded with an International Classification of Diseases (ICD) code. Unexpected findings were identified and subsequently categorized for their clinical relevance by the Goldman classification. Goldman class I and III were considered clinically relevant. Additionally, correlation with autopsy results and ante-mortem imaging was performed. Results: In total, 120 decedents were included and evaluated for unexpected findings on PMCT. Of them, 57 decedents also underwent an autopsy. A total of 1020 findings were identified; 111 correlated with the cause of death (10.9%), 508 were previously reported (49.8%), 99 were interpreted as post-mortem changes (9.7%), and 302 were classified as unexpected findings (29.6%). After correlation with autopsy (in 57 decedents), 24 clinically relevant unexpected findings remained. These findings were reported in 18 of 57 decedents (32%). Interestingly, 25% of all unexpected findings were not reported by autopsy. Conclusion: Many unexpected findings are reported by PMCT in hospitalized patients, a substantial portion of which is clinically relevant. Additionally, PMCT is able to identify pathology and injuries not reported by conventional autopsy. A combination of PMCT and autopsy can thus be considered a more comprehensive and complete post-mortem examination.
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Wijetunga C, O'Donnell C, So TY, Varma D, Cameron P, Burke M, Bassed R, Smith K, Beck B. Injury Detection in Traumatic Death: Postmortem Computed Tomography vs. Open Autopsy. FORENSIC IMAGING 2020. [DOI: 10.1016/j.jofri.2019.100349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Significance of intracranial gas on post-mortem computed tomography in traumatic cases in the context of medico-legal opinions. Forensic Sci Med Pathol 2020; 16:3-11. [PMID: 31463781 PMCID: PMC7069893 DOI: 10.1007/s12024-019-00162-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2019] [Indexed: 11/24/2022]
Abstract
The detection of intracranial gas (ICG) in people who died due to trauma became possible once postmortem computed tomography (PMCT) became available in addition to traditional post-mortem examinations. The aim of this study was to determine the importance of ICG in the context of medico-legal opinions. We assessed 159 cases of trauma-induced death. Cadavers with pronounced signs of decomposition, open skull fractures, and after neurosurgical operations were excluded. Both PMCT findings and data from autopsy reports were analyzed. ICG was found in 38.99% (n = 62) of the cadavers, 96.77% (n = 60) of which presented with pneumocephalus (PNC) and 40.23% (n = 25) with intravascular gas (IVG). There was a strong correlation between ICG and skull fractures/brain injuries, as well as chest injuries, especially lung injuries. In 13 cases, ICG presented without skull fractures; three of these cases died as a result of stab and incised wounds to the neck and chest. The mean time between trauma and death was significantly longer in the non-ICG group than the ICG group at 2.94 days (0–48 days) and 0.01 day (0–1 day), respectively (p < 0.0001). The presence of ICG is a result of severe neck and chest injuries, including stab and incised wounds. The victims die in a very short amount of time after suffering trauma resulting in ICG. The ability to demonstrate ICG on PMCT scans can be of significance in forming medico-legal opinions.
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18
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Comparison between postmortem computed tomography and autopsy in the detection of traumatic head injuries. J Neuroradiol 2020; 47:5-12. [DOI: 10.1016/j.neurad.2019.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/08/2019] [Accepted: 03/08/2019] [Indexed: 01/28/2023]
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19
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Transverse process fractures of the thoracic vertebrae-the significance of this injury in the context of medicolegal opinions on high-energy trauma cases. Int J Legal Med 2019; 134:1431-1440. [PMID: 31529273 PMCID: PMC7295837 DOI: 10.1007/s00414-019-02161-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 09/09/2019] [Indexed: 11/26/2022]
Abstract
Thoracic transverse process fractures (TTPFs) are injuries that go unnoticed during traditional autopsies, as demonstrated by a lack of medicolegal publications regarding TTPFs. However, postmortem computed tomography (PMCT) has made detection of this type of injury easy. Thus, the goal of our study was to analyze the significance of TTPFs in the context of medicolegal opinions. Forensic autopsy reports and PMCT scans of 116 people who had died from high-energy trauma were analyzed. TTPFs were found in 34.48% (n = 40) of the total test group. The highest proportions of TTPFs were found in drivers (50%, n = 8) and in victims of falls from heights (41%, n = 14). Among seven car passengers, only one victim had suffered TTPFs. In comparison with persons without TTPFs, persons with TTPFs demonstrated more severe general injuries, especially to the chest and abdomen, and more often (in 90% of cases) died at the scene of injury (all these differences were statistically significant; p < 0.0001). Pedestrian TTPFs were present only in victims struck from their front or back. TTPFs in victims of falls were found only in those cases in which the height of the fall was at least 9 m. The presence of TTPFs indicates that the application of a very strong force leads to injuries that, in most cases, result in death at the scene of the event. Detecting TTPFs provides additional information about the mechanism of trauma, especially in pedestrians, drivers, passengers, and victims of falls from heights.
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Pal R, Bhattacharya A. Modelling Protein Synthesis as A Biomarker in Fragile X Syndrome Patient-Derived Cells. Brain Sci 2019; 9:E59. [PMID: 30862080 PMCID: PMC6468675 DOI: 10.3390/brainsci9030059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/27/2019] [Accepted: 03/06/2019] [Indexed: 12/26/2022] Open
Abstract
The most conserved molecular phenotype of Fragile X Syndrome (FXS) is aberrant protein synthesis. This has been validated in a variety of experimental model systems from zebrafish to rats, patient-derived lymphoblasts and fibroblasts. With the advent of personalized medicine paradigms, patient-derived cells and their derivatives are gaining more translational importance, not only to model disease in a dish, but also for biomarker discovery. Here we review past and current practices of measuring protein synthesis in FXS, studies in patient derived cells and the inherent challenges in measuring protein synthesis in them to offer usable avenues of modeling this important metabolic metric for further biomarker development.
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Affiliation(s)
- Rakhi Pal
- Centre for Brain Development and Repair, Institute for Stem Cell Biology and Regenerative Medicine, GKVK Post, Bellary Road, Bengaluru 560065, India.
| | - Aditi Bhattacharya
- Centre for Brain Development and Repair, Institute for Stem Cell Biology and Regenerative Medicine, GKVK Post, Bellary Road, Bengaluru 560065, India.
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21
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Symmetrical Apophyses on the Posterior Margins of the Thyroid Cartilage: A Previously Undescribed Anatomical Variation With Potential Forensic Implications. Am J Forensic Med Pathol 2019; 40:84-88. [PMID: 30531210 DOI: 10.1097/paf.0000000000000452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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22
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Gascho D, Heimer J, Tappero C, Schaerli S. 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. Forensic Sci Med Pathol 2019; 15:84-92. [PMID: 30627977 DOI: 10.1007/s12024-018-0070-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2018] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Dominic Gascho
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, 8057, Zurich, Switzerland.
| | - Jakob Heimer
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, 8057, Zurich, Switzerland
| | - Carlo Tappero
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, 8057, Zurich, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, Freiburgstrasse, 3010, Bern, Switzerland
| | - Sarah Schaerli
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, 8057, Zurich, Switzerland
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Kildyushov EM, Egorova EV. [A multitrauma: diagnostic capabilities of computer tomography in forensic medical practice]. Sud Med Ekspert 2019; 62:27-31. [PMID: 31825329 DOI: 10.17116/sudmed20196206127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
For the last thirty years, many scientific publications have been devoted to diagnostic capabilities of postmortem computer tomography (CT). Nevertheless, up to the present day, the expediency of the substitution of a traditional postmortem dissection with a postmortem CT is still not proved. Foreign countries develop methods improving visualization in case of postmortem CT, study the correlation between the time of death and artefacts encountered in the further CT of cadavers. The authors have performed a comparative analysis of the results of intravitam X-ray examinations and data of postmortem dissections basing on the data of the professional literature and authors' own research. Diagnostic capabilities of CT in case of multitrauma have been determined.
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Affiliation(s)
- E M Kildyushov
- Department of Forensic Medicine, Faculty of General Medicine, Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Moscow, Russia, 117997
| | - E V Egorova
- Department of Forensic Medicine, Faculty of General Medicine, Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Moscow, Russia, 117997
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Chatzaraki V, Heimer J, Thali M, Dally A, Schweitzer W. Role of PMCT as a triage tool between external inspection and full autopsy – Case series and review. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.jofri.2018.10.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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