Modern post-mortem imaging: an update on recent developments

Forensic radiography: The perspectives and experiences of qualified radiographers in Ghana

BACKGROUND

Despite the benefits of forensic radiography (FR), its practice is in its infancy in Ghana. Radiographers, knowingly or unknowingly undertake forensic imaging despite a lack of guidelines, protocols and proper training in Ghana. This study aimed to explore Ghanaian radiographers' perceptions of FR and identify their experiences.

METHODS

A cross-sectional study design with an online survey was employed. Study participants included consecutively sampled qualified radiographers practising in Ghana. Data were descriptively and inferentially analysed. The significance for inferential analysis was set at p < 0.05. The key ideas from the narrative response to open-ended questions were presented as frequencies on a bar graph representing the frequency of each response.

RESULTS

Completed responses were received from 124 qualified radiographers. Participants demonstrated a fair knowledge of FR (overall mean score (oms) = 3.95). Most participants (75% n=93) believed FR was within their professional scope of practice though the majority (57.2% n=71) believed they lacked formal training in FR. FR was perceived to be challenging among participants (ms= 3.52). Participants agreed on the provision of guidelines for FR practice by Ghanaian radiography stakeholders (oms= 4.23). Participants' experiences revealed diverse roles in investigations and emotional/psychological reflections. Regarding cadaveric FR, most participants (59.7% n=74) expressed willingness to undertake. Specifically, male participants were 4 times more likely to report willingness than females (odd ratio (OR)= 4.147).

DISCUSSION

Ghanaian radiographers demonstrated fair knowledge of FR despite a lack of awareness regarding cross-sectional techniques in FR. They presented a multitude of positive and negative perspectives regarding FR. Training in FR and guidelines are imperative to transform future practices in Ghana. The study highlighted reluctance and willingness among radiographers to perform cadaveric FR, emphasising the need for emotional preparedness.

CONCLUSION

This study offers insight into the perspectives of Ghanaian radiographers on FR, which would be helpful for future developments regarding its practice.

Forensic significance of VOCs profiling in decayed ante- and post-mortem injuries by GC×GC-TOF/MS

Accurately identifying and differentiating the types of injuries in decomposed corpses is a major challenge in forensic identification. Forensic investigations involving decomposed cadavers pose challenges in determining the cause of death. Traditional methods often lack conclusive evidence. However, the implementation of advanced analytical techniques, such as comprehensive two-dimensional gas chromatography coupled with time-of-flight mass spectrometry (GC × GC-TOF/MS), shows promise in overcoming these limitations, but the potential in this area remains limited. Therefore, this study aims to bridge this gap by exploring the potential of GC × GC-TOF/MS in the analysis of volatile organic compounds (VOCs) changes within decaying ante- and post-mortem injuries.The research emphasizes the forensic significance of VOCs changes in decomposed cadavers. We used GC × GC-TOF/MS analysis to identify the specific volatile compounds in putrefied corpse tissue samples from mice. The GC × GC-TOF/MS analysis results showed that under winter conditions, PC1 explained 57.16% of the variance, and PC2 explained 25.23% of the variance; while under summer conditions, PC1 explained 71.89% of the variance, and PC2 explained 24.49% of the variance. This demonstrates the potential of GC × GC-TOF/MS in identifying specific VOCs present in tissue samples that can serve as potential biomarkers for distinguishing between antemortem and postmortem injury. GC × GC-TOF/MS analysis revealed distinct VOC patterns in both conditions. Comprehensive use of GC × GC-TOF/MS analysis enhances accuracy in identifying and characterizing ante- and post-mortem injuries in decomposed cadavers. This study can significantly contribute to the field of forensic medicine and improve the accuracy of forensic investigations.

Subject-specific finite element head models for skull fracture evaluation-a new tool in forensic pathology

Post-mortem computed tomography (PMCT) enables the creation of subject-specific 3D head models suitable for quantitative analysis such as finite element analysis (FEA). FEA of proposed traumatic events is an objective and repeatable numerical method for assessing whether an event could cause a skull fracture such as seen at autopsy. FEA of blunt force skull fracture in adults with subject-specific 3D models in forensic pathology remains uninvestigated. This study aimed to assess the feasibility of FEA for skull fracture analysis in routine forensic pathology. Five cases with blunt force skull fracture and sufficient information on the kinematics of the traumatic event to enable numerical reconstruction were chosen. Subject-specific finite element (FE) head models were constructed by mesh morphing based on PMCT 3D models and A Detailed and Personalizable Head Model with Axons for Injury Prediction (ADAPT) FE model. Morphing was successful in maintaining subject-specific 3D geometry and quality of the FE mesh in all cases. In three cases, the simulated fracture patterns were comparable in location and pattern to the fractures seen at autopsy/PMCT. In one case, the simulated fracture was in the parietal bone whereas the fracture seen at autopsy/PMCT was in the occipital bone. In another case, the simulated fracture was a spider-web fracture in the frontal bone, whereas a much smaller fracture was seen at autopsy/PMCT; however, the fracture in the early time steps of the simulation was comparable to autopsy/PMCT. FEA might be feasible in forensic pathology in cases with a single blunt force impact and well-described event circumstances.

Congenital heart diseases (CHDs) and forensic investigations: Searching for the cause of death

Congenital Heart Diseases (CHDs) are a group of structural abnormalities or defects of the heart that are present at birth. CHDs could be connected to sudden death (SD), defined by the WHO (World Health Organization) as "death occurring within 24 h after the onset of the symptoms" in an apparently "healthy" subject. These conditions can range from relatively mild defects to severe, life-threatening anomalies. The prevalence of CHDs varies across populations, but they affect millions of individuals worldwide. This article aims to discuss the post-mortem investigation of death related to CHDs, exploring the forensic approach, current methodologies, challenges, and potential advancements in this challenging field. A further goal of this article is to provide a guide for understanding these complex diseases, highlighting the pivotal role of autopsy, histopathology, and genetic investigations in defining the cause of death, and providing evidence about the translational use of autopsy reports. Forensic investigations play a crucial role in understanding the complexities of CHDs and determining the cause of death accurately. Through collaboration between medical professionals and forensic experts, meticulous examinations, and analysis of evidence, valuable insights can be gained. These insights not only provide closure to the families affected but also contribute to the prevention of future tragedies.

Hyoid Bone Fracture Pattern Assessment in the Forensic Field: The Importance of Post Mortem Radiological Imaging

Post mortem hyoid bone fracture findings may be attributable to various factors, including both the onset of acute mechanical asphyxia as it happens in manual strangulation and in charred corpses. In forensic practice, the discovery of corpses burned after death to hide their real cause of death is not uncommon: in these cases, the diagnostic challenge is even greater, as the action of flames is capable of both masking previously generated lesions and/or generating new ones, as occurs for hyoid bone fractures. The case concerns a 76-year-old man found charred in his bedroom. Almost complete body charring made it impossible to evaluate any external damage. Post mortem computed tomography (PMCT) was performed, and an evident bilateral fracture of the greater horn of the hyoid bone was detected. Although the absence of typical charring signs had steered the diagnosis towards post mortem exposure to flames, PMCT proved to be very useful in increasing the accuracy in correctly determining the cause of death. In particular, making use of Maximum Intensity Projection (MIP) hyoid bone reconstructions, it was possible to measure the medial dislocation angle of the fracture fragments and then to establish the applied direction of force, which acted in a lateral-medial way. A manual strangulation diagnosis was confirmed. The increasing importance of performing post mortem radiological exams as a corollary for conventional autopsy has been further confirmed.

A consistent methodology for forensic photogrammetry scanning of human remains using a single handheld DSLR camera

Due to increasingly capable algorithms and more available processing power, photogrammetry is becoming a simple, cheap, and accurate alternative to 3D optical surface scanning. With adequate application, it can be a swift documentation technique for reconstructing the geometry and body surface of deceased persons in autopsies or other forensic medical examinations. Sufficiently easy and swift 3D documentation techniques may allow 3D imaging technologies to become part of the daily routine of any forensic medical examiner or other medical personnel. This paper presents a consistent and systematic photographing methodology (as an alternative to automated or intuitive methods) for photogrammetry scanning of human remains. Although it requires manual photography, the methods presented in this paper offer a swift and easy way to capture an accurate 3D model of human remains under almost any conditions. Four different photographing procedures were tested on four subjects: (i) a systematic circular technique with 100 photos, (ii) a systematic circular technique with 50 photos, (iii) a technique loosely mimicking cameras mounted on a postmortem CT device with 98 photos, and (iv) a technique mimicking cameras mounted on a postmortem CT device with 49 photos. Measurement accuracy was tested with the aid of six adhesive control points placed at approximately the same locations on each subject. Five different distances defined by these control points were measured and compared to the measurements taken by hand. 3D photogrammetry meshes created using these techniques were also compared with point clouds acquired using a 3D laser scanner. We found that a carefully composed, tested, and systematic photographing procedure significantly improved the quality of the photogrammetry models. In terms of relative difference compared to the hand measurements, both Techniques 1 and 2 produced close results, with an average relative difference of 0.160% and 0.197% and a maximum relative difference of 0.481% and 0.481%, respectively, while models reconstructed from images taken using Techniques 3 and 4 seemed to be much less accurate, with an average relative difference of 0.398% and 0.391% and a maximum relative difference as high as 1.233% and 1.139%, respectively. This study highlights the importance of a scientifically tested methodology for obtaining high-quality 3D models in forensic applications.

Key points

Close-range photogrammetry is an easy, fast, and cheap way to acquire 3D models of human remains of forensic importance.A carefully composed, tested, and systematic photographing procedure has a key role and can greatly increase the quality of photogrammetry models.A photogrammetry-based 3D-digitalization technique could be developed and adopted as part of the daily routine during autopsies.Photogrammetry-based 3D models are much quicker to acquire, look more photorealistic, and are almost as accurate as certain laser scanner-based models.

A Virtual, 3D Multimodal Approach to Victim and Crime Scene Reconstruction

In the last two decades, forensic pathology and crime scene investigations have seen a rapid increase in examination tools due to the implementation of several imaging techniques, e.g., CT and MR scanning, surface scanning and photogrammetry. These tools encompass relatively simple visualization tools to powerful instruments for performing virtual 3D crime scene reconstructions. A multi-modality and multiscale approach to a crime scene, where 3D models of victims and the crime scene are combined, offers several advantages. A permanent documentation of all evidence in a single 3D environment can be used during the investigation phases (e.g., for testing hypotheses) or during the court procedures (e.g., to visualize the scene and the victim in a more intuitive manner). Advanced computational approaches to understand what might have happened during a crime can also be applied by, e.g., performing a virtual animation of the victim in the actual context, which can provide important information about possible dynamics during the event. Here, we present an overview of the different techniques and modalities used in forensic pathology in conjunction with crime scene investigations. Based on our experiences, the advantages and challenges of an image-based multi-modality approach will be discussed, including how their use may introduce new visualization modalities in court, e.g., virtual reality (VR) and 3D printing. Finally, considerations about future directions in research will be mentioned.

Application of postmortem imaging modalities in cases of sudden death due to cardiovascular diseases-current achievements and limitations from a pathology perspective : Endorsed by the Association for European Cardiovascular Pathology and by the International Society of Forensic Radiology and Imaging

Postmortem imaging (PMI) is increasingly used in postmortem practice and is considered a potential alternative to a conventional autopsy, particularly in case of sudden cardiac deaths (SCD). In 2017, the Association for European Cardiovascular Pathology (AECVP) published guidelines on how to perform an autopsy in such cases, which is still considered the gold standard, but the diagnostic value of PMI herein was not analyzed in detail. At present, significant progress has been made in the PMI diagnosis of acute ischemic heart disease, the most important cause of SCD, while the introduction of postmortem CT angiography (PMCTA) has improved the visualization of several parameters of coronary artery pathology that can support a diagnosis of SCD. Postmortem magnetic resonance (PMMR) allows the detection of acute myocardial injury-related edema. However, PMI has limitations when compared to clinical imaging, which severely impacts the postmortem diagnosis of myocardial injuries (ischemic versus non-ischemic), the age-dating of coronary occlusion (acute versus old), other potentially SCD-related cardiac lesions (e.g., the distinctive morphologies of cardiomyopathies), aortic diseases underlying dissection or rupture, or pulmonary embolism. In these instances, PMI cannot replace a histopathological examination for a final diagnosis. Emerging minimally invasive techniques at PMI such as image-guided biopsies of the myocardium or the aorta, provide promising results that warrant further investigations. The rapid developments in the field of postmortem imaging imply that the diagnosis of sudden death due to cardiovascular diseases will soon require detailed knowledge of both postmortem radiology and of pathology.

Knowledge and attitudes of Polish prosecutors and general Polish population in regard to post-mortem computed tomography in 2019

Post-mortem computer tomography (PMCT) is an imaging technique that is gaining popularity both worldwide and in Poland. It provides certain benefits in death investigation that a conventional autopsy is not able to, however, it has significant limitations. As PMCT and post-mortem computed angiography (PMCTA) continue to develop in this country, it is critical to become aware what people know and think about these imaging techniques, especially the prosecutors who officially order such examinations to be performed. In 2019, two concurrent surveys were administered to Polish prosecutors and general Polish population, respectively, regarding their current knowledge and opinions on PMCT. The results were collected both online and on paper, and then subjected to analysis. In total, 92 prosecutors and 227 non-prosecutors responded to the survey. The present authors observed that while prosecutors were more likely to have heard of this examination than the general public, their knowledge was often inadequate or incorrect. Conventional autopsy was still held as the gold standard in death investigation. However, a good popular sentiment towards PMCT was shown, and a desire to learn more about it - not just among prosecutors, but among the general public as well. The present authors' recommendation is that more courses and training should be organised for Polish prosecutors to compensate this knowledge gap.

Application of postmortem MRI for identification of medulla oblongata contusion as a cause of death: a case report

Whiplash injury is common in traffic accidents, and severe whiplash is characterized by cervical spinal cord injuries with cervical dislocation or fracture, that can be diagnosed by postmortem computed tomography (PMCT), postmortem magnetic resonance (PMMR), or conventional autopsy. However, for cervical spinal cord injury without fracture and dislocation, PMMR can be more informative because it provides higher resolution of soft tissues. We report the case of a 29-year-old male who died immediately following a traffic accident, in which the vehicle hit an obstacle at a high speed, causing deformation of the bumper and severe damage of the vehicle body. PMCT indicated no significant injuries or diseases related to death, but PMMR showed patchy abnormal signals in the medulla oblongata, and the lower edge of the cerebellar tonsil was herniated out of the foramen magnum. The subsequent pathological and histological results confirmed that death was caused by medulla oblongata contusion combined with cerebellar tonsillar herniation. Our description of this case of a rare but fatal whiplash injury in which there was no fracture or dislocation provides a better understanding of the potentially fatal consequences of cervical spinal cord whiplash injury without fracture or dislocation and of the underlying lethal mechanisms. Compared with PMCT, PMMR provides important diagnostic information in forensic practice for the identification of soft tissue injuries, and is therefore an important imaging modality for diagnosis of whiplash injury when there is no fracture or dislocation.

The Practicality of Post-mortem Imaging in Prenatal, Perinatal, and Pediatric Cases

The essential role of the autopsy is seen in its contributions to medical care, scientific research, and family counseling. Major contributions are also noted in forensic pathology as a means to determine cause-of-death for legal and medical experts. However, autopsy acceptance rates are quite low due to an array of reasons including delayed burials, faith, and moral burdening. Thus, non-invasive post-mortem imaging strategies are becoming increasingly popular. The objective of this literature review is to evaluate the strengths and weaknesses of numerous post-mortem imaging modalities and consider their benefits over the traditional autopsy. The need for expertise in image interpretation for pediatric and perinatal cases is also discussed. A variety of publications, totaling 32 pieces, were selected from available literature on the basis of relevance. These articles studied various perinatal and pediatric post-mortem imaging strategies and their applications in clinical practice. Key strategies include post-mortem MRI, post-mortem CT, fetal post-mortem sonography, post-mortem computed tomographic angiography, and three-dimensional surface scanning. There is a general consensus that no standard model for post-mortem imaging currently exists in the United States and European countries. Amongst the imaging modems studied, post-mortem MRI has been acknowledged to show the greatest promise in diagnostic accuracy for fetal age groups. Most studies demonstrated that post-mortem CT had limited use for autopsy. Post-mortem imaging strategies for autopsy have high potential given their minimal invasiveness and increasing popularity. Furthermore, it is vital to crafting a global standard procedure for post-mortem imaging for prenatal, perinatal, and pediatric cases to better understand the cause of death, decomposition factors, and effects in-utero, and to provide an alternative to traditional autopsy.

Forensic imaging: a powerful tool in modern forensic investigation

Forensic imaging is a non-invasive examination process during the forensic investigation. It is mainly used in forensic pathology as an adjunct to the traditional autopsy. In the past two decades, forensic imaging has been vigorously developed by forensic experts from computed tomography (CT) to multiple augmented techniques through CT and magnetic resonance imaging (MRI). The application field of forensic imaging has also been broadened as its advantages are recognised by more forensic practitioners. In addition to the forensic pathology, this technique has been used in other forensic disciplines, including forensic anthropology, forensic odontology, forensic ballistics and wildlife forensics, etc. This article reviews the development of forensic imaging as the practice and research development in different forensic disciplines based on the relevant literature analysis.

The big puzzle: A critical review of virtual re-association methods for fragmented human remains in a DVI context'

During a Disaster Victims Identification (DVI) mission, international protocols rely on interdisciplinary work, especially between specialists from forensic imaging and anthropology. In case of air crashes or explosions, DVI units may face thousands of fragmented human remains (FHRs). The physical re-association of FHRs and the identification process is very complex and challenging, and relies upon expensive and destructive DNA analysis. A virtual re-association (VRA) of these fragments, using Multidetector Computed Tomography (MDCT), could be a helpful tool in forensic anthropology analysis, as it could assist in reducing the number of DNA samples. However, there is no standardized protocol for including such an approach into a DVI procedure. The aim of this study was to summarize and analyze existing techniques through a systematic review and to develop a protocol for virtual re-association of FHRs, adapted to the DVI context. A keyword-based literature search was conducted, focusing on the VRA methods using MDCT imaging and 3D surface scan methodology. Reviews and primary articles, published between 2005 and 2020 in the fields of forensic anthropology, paleoanthropology, archeology, and fracture reduction surgery were sorted out. A total of 45 publications were selected and analyzed based on their content and relevance. The results show that research on the re-association of FHRs increased significantly during the last five years. Seven steps regarding the MDCT-based method for the virtual re-association of FHRs could be identified: acquisition of 3D-images, segmentation of the MDCT-data, post-processing and surface generation, identification of intact and fracture surfaces, identification and registration of matching fragments, and validation of the re-association. The literature is surprisingly sparse regarding the FHRs re-association as a forensic tool, and mainly consists in case reports, whereas validated methods were presented in archeology and surgery publications. However, we were able to adapt the MDCT-based approach for the virtual re-association of the FHRs and propose an innovative protocol for DVI missions. This protocol includes the needed details, from the acquisition of MDCT imaging to the virtual re-association of 3D models and its validation. Each step has to be fully tested, adapted and validated in future studies.

Thermal bone injuries: postmortem computed tomography findings in 25 cases

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.

3Tesla post-mortem MRI quantification of anatomical brain structures

Quantitative post-mortem magnetic resonance imaging (PMMR) allows for measurement of T1 and T2 relaxation times and proton density (PD) of brain tissue. Quantitative PMMR values may be used for advanced post-mortem neuro-imaging diagnostics such as computer aided diagnosis. So far, the quantitative T1, T2 and PD post-mortem values of regular anatomical brain structures were unknown for a 3 Tesla PMMR application. The goal of this basic research study was to evaluate the quantitative values of post-mortem brain structures for a 3 T post-mortem magnetic resonance application with regard to various corpse temperatures. In 50 forensic cases, a quantitative PMMR brain sequence was applied prior to autopsy. Measurements of T1 (in ms), T2 (in ms), and PD (in %) values of cerebrum (Group 1: frontal grey matter, frontal white matter, thalamus, caudate nucleus, globus pallidus, putamen, internal capsule) brainstem and cerebellum (Group 2: cerebral peduncle, substantia nigra, red nucleus, pons, middle cerebellar peduncle, cerebellar hemisphere, medulla oblongata) were conducted in synthetically calculated axial PMMR brain images. Assessed quantitative values were corrected for corpse temperature. Temperature dependence was observed mainly for T1 values. ANOVA testing resulted in significant differences of quantitative values between the investigated anatomical brain structures in both groups. It can be concluded that temperature corrected 3 Tesla PMMR T1, T2 and PD values are feasible for characterization and discrimination of regular anatomical brain structures. This may provide a base for future advanced diagnostics of forensically relevant brain lesions and pathology.

Pictorial review of the postmortem computed tomography in neonaticide cases

Neonaticide is defined by the deliberate killing or homicide of a child within 24 h of its birth. In this context, three fundamental questions are generally asked of the forensic pathologist: what is the cause of death of the neonate? Was the child viable (i.e., what is the gestational age of the neonate)? Finally, was the neonate stillborn or liveborn?Postmortem imaging can help answer these questions by conducting (1) a complete lesional analysis of the body and the placenta, (2) an estimation of the gestational age by measuring the lengths of the diaphyseal long bones, and (3) an analysis of the aeration of the lungs and intestines. Using the details of 18 cases, we illustrate aspects of neonaticide cases in postmortem computed tomography (PMCT), offering detailed examples of notable postmortem changes and abnormalities, especially in the analysis of the pulmonary parenchyma. This article presents a useful iconography for the radiologist confronted with this rare yet complex forensic situation.

A comparison on the detection accuracy of ante mortem computed tomography vs. autopsy for the diagnosis of pelvic ring injury in legal medicine

A detailed knowledge on the exact morphology of pelvic injuries provided crucial information in understanding the mechanisms of injury and has influence on the natural course and subsequent mortality. However, forensic medical literature investigating pelvic fractures in detail is scarce to date. This case series aims to compare the accuracy in detecting pelvic injuries using autopsy and ante mortem computed tomography (CT). Nineteen deceased patients with CT scans of pelvic fractures were included retrospectively. Pelvic injuries were independently assessed by a board-certified radiologist (R) and a board-certified trauma surgeon (T), both using the ante mortem CT scans, and by a board-certified forensic pathologist using autopsy (A) results without knowledge of the CT scan findings. No patient had died causatively from a pelvic fracture. Most injuries of the pelvis were present in the pubic rami (16/18) and sacral bone (13/18), followed by the sacroiliac joint (9/18) and iliac bone fractures (8/18). Ilium fractures (A:100%;R:67%;T:67%) and injuries of the sacroiliac joint (A:83%;R:50%;T:42%) were best detected via autopsy. The diagnosis of sacral fractures (A:19%;R:94%;T:88%) and fractures of the pubic rami (A:67%;R:96%;T:96%) were most often missed in autopsy. The results show deficits in the assessment of the pelvic injury for both CT and autopsy. Autopsy was superior in detecting injuries of the sacroiliac joint, but inferior in detecting sacral and pubic bone fractures. For an encompassing evaluation of ligamento-skeletal pelvic injuries, the complementary use of both CT and autopsy is recommended.

Comparison of conventional autopsy with post-mortem magnetic resonance, computed tomography in determining the cause of unexplained death

Conventional autopsy is the gold standard for identifying unexplained death but due to declines in referrals, there is an emerging role for post-mortem imaging. We evaluated whether post-mortem magnetic resonance (PMMR) and computed tomography (PMCT) are inferior to conventional autopsy. Deceased individuals ≥ 2 years old with unexplained death referred for coronial investigation between October 2014 to December 2016 underwent PMCT and PMMR prior to conventional autopsy. Images were reported separately and then compared to the autopsy findings by independent and blinded investigators. Outcomes included the accuracy of imaging modalities to identify an organ system cause of death and other significant abnormalities. Sixty-nine individuals underwent post-mortem scanning and autopsy (50 males; 73%) with a median age of 61 years (IQR 50-73) and median time from death to imaging of 2 days (IQR 2-3). With autopsy, 48 (70%) had an organ system cause of death and were included in assessing primary outcome while the remaining 21 (30%) were only included in assessing secondary outcome; 12 (17%) had a non-structural cause and 9 (13%) had no identifiable cause. PMMR and PMCT identified the cause of death in 58% (28/48) of cases; 50% (24/48) for PMMR and 35% (17/48) for PMCT. The sensitivity and specificity were 57% and 57% for PMMR and 38% and 73% for PMCT. Both PMMR and PMCT identified 61% (57/94) of other significant abnormalities. Post-mortem imaging is inferior to autopsy but when reported by experienced clinicians, PMMR provides important information for cardiac and neurological deaths while PMCT is beneficial for neurological, traumatic and gastrointestinal deaths.

Oleic Acid (OA), A Potential Dual Contrast Agent for Postmortem MR Angiography (PMMRA): A Pilot Study

Choosing proper perfusates as contrast agents is an important aspect for postmortem magnetic resonance angiography (PMMRA). However, in this emerging field, the number of suitable kinds of liquid is still very limited. The objective of this research is to compare MR images of oleic acid (OA) with paraffin oil (PO) in vitro and in ex situ animal hearts, in order to evaluate the feasibility to use OA as a novel contrast agent for PMMRA. In vitro, OA, PO and water (control) were introduced into three tubes separately and T₁weighted-spin echo (T₁w-SE) and T₂w-SE images were acquired on a 1.5T MR scanner. In the second experiment, OA and PO were injected into left coronary artery (LCA) and left ventricle (LV) of ex situ bovine hearts and their T₁w-SE, T₂w-SE, T₁w-multipoint Dixon (T₁w-mDixon) and 3DT₂w-mDixon images were acquired. The overall results indicate that OA may have a potential to be used as a dual (T₁ and T₂ based) contrast agent for PMMRA when proper sequence parameters are utilized. However, as the pilot study was based on limited number of animal hearts, more researches using OA in cadavers are needed to validate our findings.

Identifying Fatal Head Injuries on Postmortem Computed Tomography Using Convolutional Neural Network/Deep Learning: A Feasibility Study

Postmortem computed tomography (PMCT) is a relatively recent advancement in forensic pathology practice that has been increasingly used as an ancillary investigation and screening tool. One area of clinical CT imaging that has garnered a lot of research interest recently is the area of "artificial intelligence" (AI), such as in screening and computer-assisted diagnostics. This feasibility study investigated the application of convolutional neural network, a form of deep learning AI, to PMCT head imaging in differentiating fatal head injury from controls. PMCT images of a transverse section of the head at the level of the frontal sinus from 25 cases of fatal head injury were combined with 25 nonhead-injury controls and divided into training and testing datasets. A convolutional neural network was constructed using Keras and was trained against the training data before being assessed against the testing dataset. The results of this study demonstrated an accuracy of between 70% and 92.5%, with difficulties in recognizing subarachnoid hemorrhage and in distinguishing congested vessels and prominent falx from head injury. These results are promising for potential applications as a screening tool or in computer-assisted diagnostics in the future.

The Application of Photogrammetry in the Autopsy Room: A Basic, Practical Workflow

Photogrammetry is a technique that uses two-dimensional photographs taken from different angles and positions to determine three-dimensional coordinates and distances. Becoming familiar with the photography technique for photogrammetry purposes is the first step to obtaining high-quality results. Ten human cadavers were studied to develop this protocol. Appropriate equipment settings, measurements, and suitable ambient conditions were determined. Finally, the protocol was tested on one cadaver wherein a full postmortem examination was conducted, allowing accurate 3D modeling and measurements of the human body. This straightforward, step-by-step workflow will help users become familiar with this technique. A thorough description of the necessary steps is reported, including equipment, environment requirements, body placement, how to take photographs, and the minimum suggested number of photographs. Numerous graphics show the protocol's main steps to help users understand and reproduce the entire process. Photogrammetry allows the permanent recording and storage of photographic evidence of conditions that existed at the time of autopsy and accurate measurements of the body. The 3D model can have a powerful effect in court, where the findings can be accurately depicted without elicitation of strong emotion that may influence the judge or jurors. The primary disadvantage of photogrammetry for forensic pathology is its time-consuming nature. However, the widespread use of the photogrammetry technique in postmortem rooms would allow in-depth testing to detect and fix potential pitfalls, making this technique more reproducible and verifiable, increasing its admissibility in courts.

Early postmortem brain MRI findings in COVID-19 non-survivors

OBJECTIVES

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is considered to have potential neuroinvasiveness that might lead to acute brain disorders or contribute to respiratory distress in patients with coronavirus disease 2019 (COVID-19). This study investigates the occurrence of structural brain abnormalities in non-survivors of COVID-19 in a virtopsy framework.

METHODS

In this prospective, monocentric, case series study, consecutive patients who fulfilled the following inclusion criteria benefited from an early postmortem structural brain MRI: death <24 hours, SARS-CoV-2 detection on nasopharyngeal swab specimen, chest CT scan suggestive of COVID-19, absence of known focal brain lesion, and MRI compatibility.

RESULTS

Among the 62 patients who died of COVID-19 from March 31, 2020, to April 24, 2020, at our institution, 19 decedents fulfilled the inclusion criteria. Parenchymal brain abnormalities were observed in 4 decedents: subcortical microbleeds and macrobleeds (2 decedents), cortico-subcortical edematous changes evocative of posterior reversible encephalopathy syndrome (PRES; 1 decedent), and nonspecific deep white matter changes (1 decedent). Asymmetric olfactory bulbs were found in 4 other decedents without downstream olfactory tract abnormalities. No brainstem MRI signal abnormality was observed.

CONCLUSIONS

Postmortem brain MRI demonstrates hemorrhagic and PRES-related brain lesions in non-survivors of COVID-19. SARS-CoV-2-related olfactory impairment seems to be limited to olfactory bulbs. Brainstem MRI findings do not support a brain-related contribution to respiratory distress in COVID-19.

Erstellung und Etablierung einer wissensbasierten Fallsammlung für forensische Bildgebung – WiFas

Einleitung

Mit der Weiterentwicklung und Verbreitung radiologischer Techniken wie Computertomographie und Magnetresonanztomographie hat in den letzten 2 Jahrzehnten die forensische Bildgebung einen immer größeren Stellenwert eingenommen. Um die damit verbundenen Ergebnisse und daraus gewonnenen Erkenntnisse sowie die in diesem Zusammenhang stehenden radiologischen Daten, welche diese neuen Techniken hervorbringen, allen Mitgliedern der Deutschen Gesellschaft für Rechtsmedizin zugänglich zu machen, wurde die Wissensbasierte Fallsammlung (WiFas) entwickelt.

Material und Methoden

Die Datenbank wurde als Webapplikation entwickelt. Es können externe Dokumente, Bilder und Dateiarchive zu Einzelgutachten in die Datenbank geladen und verwaltet werden. Ein systeminternes Nutzer-Rollen-Konzept verhindert den unautorisierten Systemzugriff durch unbefugte Personen.

Ergebnisse

Es ist eine Datenbank entstanden, die jedem Nutzer einen individuellen Zugang zu zahlreichen rechtsmedizinischen Fällen erlaubt. In der WiFas ist es möglich, sowohl eine Übersicht an Fällen zu erhalten, als auch gezielt nach einzelnen Fallarten zu suchen und Befunde in verschiedenen Dokumenten und Bildmaterial zu vergleichen.

Diskussion

Sowohl die klinische forensische Bildgebung als auch die postmortale Bildgebung sind nicht mit der klinischen Radiologie gleichzusetzen. Oftmals werden seitens der Ermittlungsbehörden rekonstruktive Fragen gestellt, deren Beantwortung nicht nur radiologisches Wissen, sondern auch rechtsmedizinisches Fachwissen fordert. Außerdem sind häufig spezifische Darstellungen der Bilddaten (z. B. dreidimensionale Darstellungen von Befunden) erforderlich. Im gesamten Gebiet der forensischen Bildgebung ist dementsprechend interdisziplinäres radiologisches und rechtsmedizinisches Wissen notwendig. Mit der WiFas wird erstmals eine Plattform angeboten, auf deren Grundlage verschiedenste Informationen aus den Bereichen der Rechtsmedizin und der Radiologie zusammenfließen können.

Secular evolution of femoral morphology from a clinical perspective

INTRODUCTION

Intramedullary nailing is the surgical method of choice for the treatment of proximal femur or femoral shaft fractures. Implant manufacturers aim to design implants fitting for the broadest possible population segment. As complete morphological data sets of long bones are not widely available, anatomical collections of historical dry bone specimens may represent abundant additional sources of morphological three-dimensional (3D) data for implant design, provided they are consistent with present populations. This study aims to investigate secular trends and age-related changes of femoral morphology of the Caucasian population over the past 800 years.

MATERIALS AND METHODS

Computer graphical measurements of 3D-datasets of right and left femora derived from computed tomography (CT) scans, representative of the present Caucasian population, were compared to computer graphical measurements of 3D-datasets of right and left femora derived from CT scans of specimens from a historical medieval European bone collection.

RESULTS

Clinically relevant parameters of historical medieval European femora were found mostly consistent with correlative data of the present Caucasian population. Additionally, for some of the evaluated parameters, particularly anteversion, morphological differences significantly correlated to individual age and sex could be identified, whereas other parameters such as caput-collum-diaphyseal angle or radius of anterior femoral bowing were not correlated to individual age or sex.

CONCLUSION

The findings suggest that more recent historical specimen collections may be a convenient and easily accessible source of new 3D morphological data, as well as to complement existing data, to be used by researchers and manufacturers for the development of intramedullary femoral nails.

Diagnosis of drowning using postmortem computed tomography combined with endoscopic autopsy: A case report

RATIONALE

Postmortem forensic imaging technologies provide a noninvasive/minimally invasive approach for imaging of internal organ structures of the human body to detect injuries, diseases, and other morphologic changes. Currently, postmortem forensic imaging methods have been widely used in determination of the cause of death. However, these methods do not allow histologic examinations. Endoscopic autopsy emerged in the 1990s. Thoracoscopy and laparoscopy are mainly used to examine organs and tissues in the thoracic and abdominal cavity. Target tissues are also sampled for histologic examination. By combining postmortem forensic imaging with endoscopic autopsy, comprehensive examination of the corpse, organs, and sampling for histologic examination can be carried out.

PATIENT CONCERNS

A 34-year-old woman was witnessed jumping into the river, sinking after struggling in the water. The body was found 24 hours later and confirmed with no vital signs. No preexisting medical conditions were known.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

Postmortem computed tomography, target coronary postmortem computed tomography angiography, and endoscopic autopsy were performed before conventional autopsy. Laparoscopic examination was used to examine the abdominal organs. The diaphragm and pericardium were cut open from the abdominal cavity to allow access to the examination of lungs and heart. Tissue samples were collected from various organs for histologic examination, and a diatom test was carried out on lung samples. Postmortem computed tomography revealed fluid in the paranasal sinuses, airways, stomach, and duodenum; emphysema aquosum; and mosaic pattern of the lung parenchyma. Endoscopic examination additionally detected Paltauf spots. The results were consistent with those of conventional autopsy. Histologic examination revealed pulmonary congestion, pulmonary edema, pulmonary emphysema, pulmonary hemorrhage, and congestion in multiple organs such as the liver, spleen, and kidneys. Diatoms were detected in lung tissues, which were identical in morphology to diatoms in water samples collected from the scene. The cause of death was determined as drowning.

CONCLUSION

Combining forensic imaging and endoscopic autopsy for postmortem examination yields a more comprehensive and scientific finding, and the combination is minimally invasive and more acceptable to the family members. This method can be used as an alternative for conventional autopsy under specific circumstances.

Feasibility Study of MRI Muscles Molecular Imaging in Evaluation of Early Post-Mortem Interval

Estimating early postmortem interval (EPI) is a difficult task in daily forensic activity due to limitations of accurate and reliable methods. The aim of the present work is to describe a novel approach in the estimation of EPI based on quantitative magnetic resonance molecular imaging (qMRMI) using a pig phantom since post-mortem degradation of pig meat is similar to that of human muscles. On a pig phantom maintained at 20° degree, using a 1.5 T MRI scanner we performed 10 scans (every 4 hours) monitoring apparent diffusion coefficient (ADC), fractional anisotropy (FA) magnetization transfer ration (MTR), tractography and susceptibility weighted changes in muscles until 36 hours after death. Cooling of the phantom during the experiment was recorded. Histology was also obtained. Pearson’s Test was carried out for time correlation between post-mortem interval and MRI data. We found a significative inverse correlation between ADC, FA, MT values and PMI. Our preliminary data shows that post-mortem qMRMI is a potential powerful tool in accurately determining EPI and is worth of further investigation.

T2 and T2∗ mapping in ex situ porcine myocardium: myocardial intravariability, temporal stability and the effects of complete coronary occlusion

Diagnosis of ischaemia-related sudden cardiac death in the absence of microscopic and macroscopic ischaemic lesions remains a challenge for medical examiners. Medical imaging techniques increasingly provide support in post-mortem examinations by detecting and documenting internal findings prior to autopsy. Previous studies have characterised MR relaxation times to investigate post-mortem signs of myocardial infarction in forensic cohorts. In this prospective study based on an ex situ porcine heart model, we report fundamental findings related to intramyocardial variability and temporal stability of T₂ as well as the effects of permanent coronary occlusion on T₂ and T₂^∗ relaxation in post-mortem myocardium. The ex situ porcine hearts included in this study (n= 19) were examined in two groups (S_s, n= 11 and S_i, n= 8). All magnetic resonance imaging (MRI) examinations were performed ex situ, at room temperature and at 3 T. In the S_s group, T₂ mapping was performed on slaughterhouse porcine hearts at different post-mortem intervals (PMI) between 7 and 26 h. Regarding the intramyocardial variability, no statistically significant differences in T₂ were observed between myocardial segments (p= 0.167). Assessment of temporal stability indicated a weak negative correlation (r=- 0.21) between myocardial T₂ and PMI. In the S_i group, animals underwent ethanol-induced complete occlusion of the left anterior descending artery. T₂ and T₂^∗ mapping were performed within 3 h of death. Differences between the expected ischaemic and remote regions were statistically significant for T₂ (p= 0.007), however not for T₂^∗ (p= 0.062). Our results provide important information for future assessment of the diagnostic potential of quantitative MRI in the post-mortem detection of early acute myocardial infarction.

Postmortem imaging as a complementary tool for the investigation of cardiac death

In the past 2 decades, modern radiological methods, such as multiple detector computed tomography (MDCT), MDCT-angiography, and cardiac magnetic resonance imaging (MRI) were introduced into postmortem practice for investigation of sudden death (SD), including cases of sudden cardiac death (SCD). In forensic cases, the underlying cause of SD is most frequently cardiovascular with coronary atherosclerotic disease as the leading cause. There are many controversies about the role of postmortem imaging in establishing the cause of death and especially the value of minimally invasive autopsy techniques. This paper discusses the state of the art for postmortem radiological evaluation of the heart compared to classical postmortem examination, especially in cases of SCD. In SCD cases, postmortem CT is helpful to estimate the heart size and to visualize haemopericardium and calcified plaques and valves, as well as to identify and locate cardiovascular devices. Angiographic methods are useful to provide a detailed view of the coronary arteries and to analyse them, especially regarding the extent and location of stenosis and obstruction. In postsurgical cases, it allows verification and documentation of the patency of stents and bypass grafts before opening the body. Postmortem MRI is used to investigate soft tissues such as the myocardium, but images are susceptible to postmortem changes and further work is necessary to increase the understanding of these radiological aspects, especially of the ischemic myocardium. In postsurgery cases, the value of postmortem imaging of the heart is reportedly for the diagnostic and documentation purposes. The implementation of new imaging methods into routine postmortem practice is challenging, as it requires not only an investment in equipment but, more importantly, investment in the expertise of interpreting the images. Once those requirements are implemented, however, they bring great advantages in investigating cases of SCD, as they allow documentation of the body, orientation of sampling for further analyses and gathering of other information that cannot be obtained by conventional autopsy such as a complete visualization of the vascular system using postmortem angiography.Key pointsThere are no established guidelines for the interpretation of postmortem imaging examination of the heartAt present, postmortem imaging methods are considered as less accurate than the autopsy for cardiac deathsPostmortem imaging is useful as a complementary tool for cardiac deathsThere is still a need to validate postmortem imaging in cardiac deaths by comparing with autopsy findings.

Toward safer thanatopraxy cares: formaldehyde-releasers use

Human cadavers constitute very useful educational tools to teach anatomy in medical scholarship and related disciplines such as physiology, for example. However, as biological material, human body is subjected to decay. Thanatopraxy cares such as embalming have been developed to slow down and inhibit this decay, but the formula used for the preservation fluids are mainly formaldehyde (FA)-based. Very recently, other formulas were developed in order to replace FA, and to avoid its toxicity leading to important environmental and professional exposure concerns. However, these alternative FA-free fluids are still not validated or commercialized, and their efficiency is still under discussion. In this context, the use of FA-releasing substances, already used in the cosmetics industry, may offer interesting alternatives in order to reduce professional exposures to FA. Simultaneously, the preservation of the body is still guaranteed by FA generated over time from FA-releasers. The aim of this review is to revaluate the use of FA in thanatopraxy cares, to present its benefits and disadvantages, and finally to propose an alternative to reduce FA professional exposure during thanatopraxy cares thanks to FA-releasers use.

Autopsy diagnosis of acupuncture-induced bilateral tension pneumothorax using whole-body postmortem computed tomography: A case report

RATIONALE

Acupuncture, a component of traditional Chinese medicine, is also a well-known form of complementary and alternative medicine. Serious adverse events of acupuncture have been reported, including the acupuncture-related pneumothorax which is a rare but fatal condition sometimes. The pneumothorax was related to needle insertion in the upper back or paraspinal area and the reported victims suffered from either unilateral or bilateral pneumothorax. Postmortem computed tomography has advantages in the detection of pathologic gas and is being considered as a useful visualization tool for diagnosing the cause of death.

PATIENT CONCERNS

A 52-year-old man underwent acupuncture and cupping treatment at an illegal Chinese medicine clinic for neck and back discomfort and was admitted to the hospital with severe gasp and dyspnea about 30 hours later. The patient suddenly became unconscious with heart rate and blood pressure lost and died after cardiopulmonary resuscitation. Diagnosis, interventions and outcomes: Whole-body postmortem computed tomography of the victim revealed collapse of the both lungs and mediastinal compression, which was also confirmed by autopsy. More than 20 pinprick injuries were found on the skin of the upper and lower back in which multiple pinpricks were located on the body surface projection of the lungs. The cause of death was concluded as acute respiratory and circulatory failure due to acupuncture-induced bilateral tension pneumothorax.

LESSONS

Acupuncture-induced tension pneumothorax is rare and should be recognized by forensic pathologists. Postmortem computed tomography can be used to detect and accurately evaluate the severity of pneumothorax before autopsy and can play a supporting role in determining the cause of death.

Post-Mortem Imaging Adjudicated Sudden Death: Causes and Controversies

Sudden cardiac death (SCD) is a catastrophic complication of many cardiac conditions often occurring without warning. In these cases, a post-mortem examination is required to elucidate the cause of death and is regarded as the 'gold standard'. However, in circumstances of certain religious/cultural beliefs and advanced body decomposition an alternative non-invasive approach would be preferred. Although a developing field, post-mortem imaging using computed tomography (pmCT) or magnetic resonance imaging (pmMR) provides a non-invasive and accurate alternative to traditional post-mortem in specific circumstances. In particular, pmMR has an important role in younger decedents while pmCT is more suited to examination of adults with SCD. Despite encouraging results from several preliminary studies, more research is needed to determine the most appropriate role for post-mortem imaging in the clinical algorhythm for investigation of SCD.

Post-mortem computed tomography improves completeness of the trauma registry: a single institution experience

PURPOSE

To describe our institutional experience with post-mortem computed tomography (PMCT) and its impact on decedent injury severity score (ISS) and to assess the adequacy of emergently placed support medical devices.

METHODS

Over a 5-year period, patients who died at or soon after arrival and have physical exam findings inconsistent with death were candidates for inclusion. Whole body CT was performed without contrast with support medical devices left in place. ISS was calculated with and without the PMCT findings. PMCT results were compared to autopsy findings, if performed. The location of support medical devices was documented.

RESULTS

A total of 38 decedents underwent PMCT, including 53.1% males and a mean age of 42.0 years. Pre-PMCT ISS based on physical exam findings alone was 5.2 (range 0-25), including 16 with ISS = 0. Post-PMCT ISS using the additional imaging data was 50.3 (range 21-75), including 15 with ISS = 50 or greater. Nearly half (47.4%) had at least one support medical device that was either malpositioned or suboptimally positioned, including 26.3% with malpositioned airway devices, 10.3% with malpositioned intra-osseous catheters, and 100% with malpositioned decompressive needle thoracotomies.

CONCLUSIONS

PMCT adds value in identifying injuries that otherwise may have gone undetected in lieu of a formal autopsy, thus creating a more complete trauma registry. The identification of malpositioned support lines and tubes allows for educational feedback to the first responders and trainees. Institutions with a low formal autopsy rate for trauma victims may benefit from developing a PMCT program.