Selective postmortem arterial angiography of head and neck using digital x-ray or computed tomography: A practical and rapid method to identify vascular injuries

Identification of vascular injuries is crucial for complete postmortem evaluation and understanding of trauma deaths by the Medical Examiner. Some vascular injuries are difficult to evaluate due to challenging anatomic locations, especially in the head and neck. Documenting injuries of the facial and vertebral arteries is challenging and necessitates time-consuming dissections that can create artifacts and disfigurement. In busy medical examiner offices with a significant number of traumatic injuries, finding a creative solution to employ reliable postmortem angiography is desirable. At the Office of the Chief Medical Examiner for the State of Maryland (OCME), we created and effectively implemented a selective angiography procedure using traditional indwelling Foley catheters and water-soluble barium swallow contrast to evaluate arterial injuries using either digital radiography or computed tomography imaging modalities. This technique and imaging interpretation can be performed by a medical examiner or forensic pathology fellow after basic technical training and basic radiology training. This study outlines the technique, methods, and utilization of the procedure and describes the findings of six deaths due to vascular lesions from different injury mechanisms and disease processes and describes the ease of implementation on a broader scale in busy Medical Examiner's offices.

Forensic Radiology: A Primer

RATIONALE AND OBJECTIVE

Forensic radiology is a relatively unknown subspecialty which is becoming increasingly more important. The field incorporates antemortem and postmortem imaging for the detection and documentation of various pathologies for medicolegal purposes. Postmortem imaging is increasingly used in conjunction with the traditional autopsy in a process called a "virtual" autopsy. Radiography has been a staple of forensic investigations for over a century, first used in 1896. Advanced imaging techniques such as postmortem computed tomography and postmortem magnetic resonance imaging have only recently gained acceptance in the forensic science community. Postmortem computed tomography and postmortem magnetic resonance imaging methods are now widely used in some parts of the world, while other countries including the United States have been slower to adopt these methods into their daily practice. Advanced forensic imaging is increasingly used in the courts where juries have responded positively to such presentation of forensic data. For these reasons, advanced postmortem imaging is becoming a regular part of forensic investigations. The increase in the use of forensic imaging presents a unique opportunity for radiologists to collaborate with pathologists and law enforcement officials. This paper provides an overview of forensic radiology and identifies potential challenges and opportunities.

Utilitarian Aspects of Postmortem Computed Tomography

Computed tomography has been used in clinical medicine for decades, but only recently introduced into the forensic pathology setting. The reasons for the slow adoption of this technology into the autopsy suite are various, including concerns about funding, infrastructural maintenance, training, competency, and scope of utilization. Practical experience in a busy statewide medical examiner department confirmed the utility of this technology as a part of daily practice. The impact of postmortem computed tomography (PMCT) on casework can be stratified into three broad groups: where PMCT 1) supplants invasive autopsy, 2) supplements invasive autopsy, or 3) has limited or no potential for impact on practice. A detailed understanding of the practical uses of this science is important for the practicing forensic pathologist so as to guide decisions about the ways in which PMCT can be implemented within their own institutions and utilized on a daily basis. Dramatic changes in personal and institutional practice trends can be observed once forensic pathologists are comfortable with the evaluation, documentation, and interpretation of PMCT data. Examples of potential paradigm shifts include the performance of only external examination and PMCT instead of invasive autopsy in many cases of motor vehicle fatalities, suicide with violence, and broad categories of death due to natural disease. Over time, the authors believe that the PMCT will become one of the fundamental tools in the forensic pathologist's toolkit.

The Current and Potential Future Role of Postmortem Computed Tomography in Medicolegal Death Investigation

The development of whole body, high resolution postmortem computed tomography (PMCT) with three-dimensional depiction has led some authors to describe the concept of “virtual autopsy” as a noninvasive replacement to conventional autopsy. A realistic appraisal of the capabilities of PMCT suggests its true role is more complex – in some settings such as accidental blunt trauma it has the potential to circumvent conventional autopsy and in others such as severe burns or drowning, PMCT can act as a triage tool to determine if autopsy is required. In many other cases, PMCT has a role of adjunct to conventional autopsy. Despite its myriad potential applications, PMCT remains underutilized in many countries. This paper addresses the background of PMCT, and describes its strengths, weaknesses, and indications. It discusses the economic and logistical challenges to its introduction, and emphasizes the clinical cooperation between diagnostic radiologists and forensic pathologists, and the training initiatives that are necessary for its success.