Female genital injury-which findings have to be considered physiological using colposcopy with and without toluidine blue dye?

This study aimed to assess the validity and efficacy of blue dye in colposcopic assessment of genital injury in pre- and postmenopausal women with and without history of consensual sexual intercourse. Two hundred women were prospectively enrolled and examined colposcopically with and without toluidine blue dye in order to detect and categorize genital lesions (laceration, bruise and abrasion). Examination of genital trauma was accomplished in a standardized way and findings were photo documented. A wide range of influencing factors with a potential impact on prevalence and nature of genital injury was recorded beforehand using a questionnaire. The frequency of diagnostic injury differed substantially depending on the examination technique, ranging from 9% using colposcopic magnification only to 28% with the additional use of toluidine blue dye. A vertical laceration affecting the posterior fourchette was the most frequent lesion detected (17%, n = 32). Menopausal status seems to have significant impact on genital injury prevalence (p = 0.0165), as 42% (16/ 38) of postmenopausal compared to 24% (36/ 151) of premenopausal women had at least one genital lesion. Furthermore, vaginal medication (p = 0.0369), vaginal dryness (p = 0.0228), dyspareunia (p = 0.0234) and low frequency of sexual intercourse (p = 0.0022) were found to significantly correlate with the presence of genital lesions. According to our findings, standardized colposcopy in combination with toluidine blue dye facilitates accurate assessment of genital lesions. Genital trauma situated at another site than the posterior part of the vaginal introitus seems to be uncommon after consensual intercourse.

New bone post-processing tools in forensic imaging: a multi-reader feasibility study to evaluate detection time and diagnostic accuracy in rib fracture assessment.

PURPOSE: The aim of this multi-reader feasibility study was to evaluate new post-processing CT imaging tools in rib fracture assessment of forensic cases by analyzing detection time and diagnostic accuracy. MATERIALS AND METHODS: Thirty autopsy cases (20 with and 10 without rib fractures in autopsy) were randomly selected and included in this study. All cases received a native whole body CT scan prior to the autopsy procedure, which included dissection and careful evaluation of each rib. In addition to standard transverse sections (modality A), CT images were subjected to a reconstruction algorithm to compute axial labelling of the ribs (modality B) as well as "unfolding" visualizations of the rib cage (modality C, "eagle tool"). Three radiologists with different clinical and forensic experience who were blinded to autopsy results evaluated all cases in a random manner of modality and case. RESULTS: Rib fracture assessment of each reader was evaluated compared to autopsy and a CT consensus read as radiologic reference. A detailed evaluation of relevant test parameters revealed a better accordance to the CT consensus read as to the autopsy. Modality C was the significantly quickest rib fracture detection modality despite slightly reduced statistic test parameters compared to modalities A and B. CONCLUSION: Modern CT post-processing software is able to shorten reading time and to increase sensitivity and specificity compared to standard autopsy alone. The eagle tool as an easy to use tool is suited for an initial rib fracture screening prior to autopsy and can therefore be beneficial for forensic pathologists.

Detection and volume estimation of artificial hematomas in the subcutaneous fatty tissue: comparison of different MR sequences at 3.0 T.

In legal medicine, reliable localization and analysis of hematomas in subcutaneous fatty tissue is required for forensic reconstruction. Due to the absence of ionizing radiation, magnetic resonance imaging (MRI) is particularly suited to examining living persons with forensically relevant injuries. However, there is limited experience regarding MRI signal properties of hemorrhage in soft tissue. The aim of this study was to evaluate MR sequences with respect to their ability to show high contrast between hematomas and subcutaneous fatty tissue as well as to reliably determine the volume of artificial hematomas. Porcine tissue models were prepared by injecting blood into the subcutaneous fatty tissue to create artificial hematomas. MR images were acquired at 3T and four blinded observers conducted manual segmentation of the hematomas. To assess segmentability, the agreement of measured volume with the known volume of injected blood was statistically analyzed. A physically motivated normalization taking into account partial volume effect was applied to the data to ensure comparable results among differently sized hematomas. The inversion recovery sequence exhibited the best segmentability rate, whereas the T1T2w turbo spin echo sequence showed the most accurate results regarding volume estimation. Both sequences led to reproducible volume estimations. This study demonstrates that MRI is a promising forensic tool to assess and visualize even very small amounts of blood in soft tissue. The presented results enable the improvement of protocols for detection and volume determination of hemorrhage in forensically relevant cases and also provide fundamental knowledge for future in-vivo examinations.

Contrast of artificial subcutaneous hematomas in MRI over time.

In clinical forensic medicine, hematomas and other externally visible injuries build the basis for the reconstruction of events. However, dating of subcutaneous hematomas based on their external aspect is difficult. Magnetic resonance imaging (MRI) has proven its use in dating intracranial hemorrhage. Thus, the aim was to investigate if MRI can also be used for dating subcutaneous hematomas and to analyze an eventual influence of the hematoma shape. In 20 healthy volunteers (11 females, 9 males, aged 26.9 ± 3.8 years), 4 ml of autologous blood were injected subcutaneously in the thigh. The hematoma was scanned immediately after the injection, after 3 and 24 h and 3, 7, and 14 days using three sequences with different contrast. Data was analyzed by measuring signal intensities of the hematoma, the muscle, and the subcutaneous tissue over time, and the Michelson contrast coefficients between the tissues were calculated. In the analysis, hematoma shape was considered. Signal intensity of blood in the proton density-weighted sequence reached its maximum 3 h after the injection with a subsequent decrease, whereas the signal intensities of muscle and fatty tissue remained constant. The time course of the Michelson coefficient of blood versus muscle decreased exponentially with a change from hyperintensity to hypointensity at 116.9 h, depending on hematoma shape. In the other sequences, either variability was large or contrast coefficients stayed constant over time. The observed change of contrast of blood versus muscle permits a quick estimate of a hematoma's age. The consideration of the hematoma shape is expected to further enhance dating using MRI.

Detection and characterization of traumatic scalp injuries for forensic evaluation using computed tomography.

The purpose of this prospective study was to evaluate the rate of detection and correct classification of traumatic soft tissue injuries of the head using clinical multislice computed tomography (MSCT) compared with an external forensic examination. Thirty-one patients with soft tissue injuries after head trauma and clinically indicated cerebral MSCT scan underwent an external forensic examination with documentation of the morphological appearance and the exact localization of scalp and facial injuries. MSCT data were evaluated by a radiologist blinded to the results of the external examination using axial images as well as multiplanar reconstruction tools. The results of the radiological and forensic report were compared and analyzed. The main finding was that clinical MSCT data of the head detected 55 % of all external lesions and diagnosed the correct morphological type of lesion in 30 %. All lacerations and 44 % of the hematomas were correctly identified in the radiological report, whereas the diagnosis of swellings and abrasions was difficult. MSCT showed a high specificity for all types of soft tissue lesions. Additionally, a substantial number of internal lesions such as fractures or intracerebral bleedings were revealed which were not detected in the external examination. The results demonstrate that the forensic-radiologic evaluation of clinical MSCT data has a good diagnostic performance and is a valuable method to retrospectively supplement external forensic examination in living crime victims. It also might-to a certain extent-be used as the only source in cases where no forensic external examination has taken place within due time.

Forensic Medical Examination After Sexual Violence: Implications Based on Victims' Perceptions.

BACKGROUND/AIM: The objective of this study was to assess the perception of the forensic medical examination (FME) by victims of sexual violence. Based on patient-related outcomes gained in terms of personnel, chronological and spatial parameters, an additional aim was to derive improved examination procedures. PATIENTS AND METHODS: A total of 49 sexually assaulted women were enrolled in this study. After standardized FME by a forensic doctor followed by a gynecologist, women were asked to complete a questionnaire addressing general perception, preferences regarding attending staff's sex, sequence and time frame of the examinations performed. The attending gynecologist also completed a questionnaire addressing demographic and medical parameters of the patient as well as assault-related information. RESULTS: The examination setting in general was evaluated positively. Nevertheless, 52% of examined victims perceived the FME as an additional psychological burden. Overall, 85% of the affected women preferred a female forensic physician and 76% a female gynecologist to perform the examination. When women said they experienced a violation of their privacy during the gynecological examination, a male was more often present (60% vs. 35%, p=0.0866). Regarding the sequence of the examination components, 65% of the victims preferred to start with their medical history followed by the forensic and then the gynecological examination. CONCLUSION: Forensic medical and gynecological examination after sexual assault is an essential procedure, yet it is a potentially further traumatizing experience for the victim. The identified patient preferences should be taken into account in order to diminish further trauma.

Susceptibility induced gray-white matter MRI contrast in the human brain.

MR phase images have shown significantly improved contrast between cortical gray and white matter regions compared to magnitude images obtained with gradient echo sequences. A variety of underlying biophysical mechanisms (including iron, blood, myelin content, macromolecular chemical exchange, and fiber orientation) have been suggested to account for this observation but assessing the individual contribution of these factors is limited in vivo. For a closer investigation of iron and myelin induced susceptibility changes, postmortem MRI of six human corpses (age range at death: 56-80 years) was acquired in situ. Following autopsy, the iron concentrations in the frontal and occipital cortex as well as in white matter regions were chemically determined. The magnetization transfer ratio (MTR) was used as an indirect measure for myelin content. Susceptibility effects were assessed separately by determining R2* relaxation rates and quantitative phase shifts. Contributions of myelin and iron to local variations of the susceptibility were assessed by univariate and multivariate linear regression analysis. Mean iron concentration was lower in the frontal cortex than in frontal white matter (26 ± 6 vs. 45 ± 6 mg/kg wet tissue) while an inverse relation was found in the occipital lobe (cortical gray matter: 41 ± 10 vs. white matter: 34 ± 10mg/kg wet tissue). Multiple regression analysis revealed iron and MTR as independent predictors of the effective transverse relaxation rate R2 but solely MTR was identified as source of MR phase contrast. R2 was correlated with iron concentrations in cortical gray matter only (r=0.42, p<0.05). In conclusion, MR phase contrast between cortical gray and white matter can be mainly attributed to variations in myelin content, but not to iron concentration. Both, myelin and iron impact the effective transverse relaxation rate R2 significantly. Magnitude contrast is limited because it only reflects the extent but not the direction of the susceptibility shift.

Quantitative susceptibility mapping (QSM) as a means to measure brain iron? A post mortem validation study.

Quantitative susceptibility mapping (QSM) is a novel technique which allows determining the bulk magnetic susceptibility distribution of tissue in vivo from gradient echo magnetic resonance phase images. It is commonly assumed that paramagnetic iron is the predominant source of susceptibility variations in gray matter as many studies have reported a reasonable correlation of magnetic susceptibility with brain iron concentrations in vivo. Instead of performing direct comparisons, however, all these studies used the putative iron concentrations reported in the hallmark study by Hallgren and Sourander (1958) for their analysis. Consequently, the extent to which QSM can serve to reliably assess brain iron levels is not yet fully clear. To provide such information we investigated the relation between bulk tissue magnetic susceptibility and brain iron concentration in unfixed (in situ) post mortem brains of 13 subjects using MRI and inductively coupled plasma mass spectrometry. A strong linear correlation between chemically determined iron concentration and bulk magnetic susceptibility was found in gray matter structures (r=0.84, p<0.001), whereas the correlation coefficient was much lower in white matter (r=0.27, p<0.001). The slope of the overall linear correlation was consistent with theoretical considerations of the magnetism of ferritin supporting that most of the iron in the brain is bound to ferritin proteins. In conclusion, iron is the dominant source of magnetic susceptibility in deep gray matter and can be assessed with QSM. In white matter regions the estimation of iron concentrations by QSM is less accurate and more complex because the counteracting contribution from diamagnetic myelinated neuronal fibers confounds the interpretation.

Validation of reference data on wisdom tooth mineralization and eruption for forensic age estimation in living persons.

Estimation of dental age is an important part of forensic age estimation in living persons. As the quality of the values given in population-specific reference studies has a great impact on the estimation, the aim of this study was to validate reference data for wisdom teeth mineralization and eruption of a German population concerning the diagnosis of the age limit of 18 years in persons with known age. Mineralization and eruption was evaluated in 307 orthopantomograms of Central European subjects aged 17.5-18.5 years. Dental age was estimated using reference data and compared to chronological age. Statistical methods were used to analyze the differences and to propose adjusted reference values. Estimation of dental age relying on mineralization resulted in overestimations of 2 years on average in 76% of the males and 82% of the females. Using eruption, all men and 75% of the women were overestimated by up to 7 years. The differences between estimated and chronological age in both men and women were associated with the mineralization and eruption stage, respectively. The higher the stage, the higher was the risk of overestimation. The mineralization stages up to stage E were associated with underestimations. Using the proposed adjusted reference values resulted in more accurate estimations of dental age. Validation of reference values for dental age estimation showed great overestimations resulting in high error rates with numerous persons being younger than the estimated dental age. Adjustments are proposed which reduce differences between estimated dental age and chronological age.

Quantitative MR imaging of brain iron: a postmortem validation study.

PURPOSE: To investigate the relationship between transverse relaxation rates R2 and R2*, the most frequently used surrogate markers for iron in brain tissue, and chemically determined iron concentrations. MATERIALS AND METHODS: This study was approved by the local ethics committee, and informed consent was obtained from each individual's next of kin. Quantitative magnetic resonance (MR) imaging was performed at 3.0 T in seven human postmortem brains in situ (age range at death, 38-81 years). Following brain extraction, iron concentrations were determined with inductively coupled plasma mass spectrometry in prespecified gray and white matter regions and correlated with R2 and R2* by using linear regression analysis. Hemispheric differences were tested with paired t tests. RESULTS: The highest iron concentrations were found in the globus pallidus (mean ± standard deviation, 205 mg/kg wet mass ± 32), followed by the putamen (mean, 153 mg/kg wet mass ± 29), caudate nucleus (mean, 92 mg/kg wet mass ± 15), thalamus (mean, 49 mg/kg wet mass ± 11), and white matter regions. When all tissue samples were considered, transverse relaxation rates showed a strong linear correlation with iron concentration throughout the brain (r² = 0.67 for R2, r² = 0.90 for R2*; P < .001). In white matter structures, only R2* showed a linear correlation with iron concentration. Chemical analysis revealed significantly higher iron concentrations in the left hemisphere than in the right hemisphere, a finding that was not reflected in the relaxation rates. CONCLUSION: Because of their strong linear correlation with iron concentration, both R2 and R2* can be used to measure iron deposition in the brain. Because R2* is more sensitive than R2 to variations in brain iron concentration and can detect differences in white matter, it is the preferred parameter for the assessment of iron concentration in vivo.

Overview of clinical forensic services in various countries of the European Union.

Examination of a person who has been a victim of a physical or sexual assault may be very important for upcoming legal proceedings. In the context of a clinical forensic examination, physical findings are recorded and biological trace material is gathered and secured. Ideally, all forensic findings are documented in a detailed report combined with photographic documentation, which employs a forensic scale to depict the size of the injuries. However, the integrity of such forensic findings depends particularly on two factors. First, the examination needs to be conducted professionally to ensure that the findings are properly admissible as court evidence. Second, the examination should take place as soon as possible because the opportunity to successfully secure biological samples declines rapidly with time. Access to low-threshold clinical forensic examinations is not evenly provided in all member states of the European Union (EU); in some states, they are not available at all. As part of the JUSTeU! (Juridical standards for clinical forensic examinations of victims of violence in Europe) project, the Ludwig Boltzmann Institute for Clinical Forensic Imaging in Graz, Austria created (in cooperation with its international partner consortium) a questionnaire: the purpose was to collect information about support for victims of physical and/or sexual assault in obtaining a low-threshold clinical forensic examination in various countries of the EU. Our paper provides a summary of the responses and an overview of the current situation concerning provided clinical forensic services.

Long-term reaction to bone cement in osteoporotic bone: new bone formation in vertebral bodies after vertebroplasty.

Elderly patients frequently suffer from osteoporotic vertebral fractures resulting in the need of vertebroplasty or kyphoplasty. Nevertheless, no data are available about the long-term consequences of cement injection into osteoporotic bone. Therefore, the aim of the present study was to evaluate the long-term tissue reaction on bone cement injected to osteoporotic bone during vertebroplasty. The thoracic spine of an 80-year-old female was explanted 3.5 years after vertebroplasty with polymethylmethacrylate. The treatment had been performed due to painful osteoporotic compression fractures. Individual vertebral bodies were cut in axial or sagittal sections after embedding. The sections were analysed using contact radiography and staining with toluidine blue. Furthermore, selected samples were evaluated with scanning electron microscopy and micro-compted tomography (in-plane resolution 6 microm). Large amounts of newly formed callus surrounding the injected polymethylmethacrylate were detected with all imaging techniques. The callus formation almost completely filled the spaces between the vertebral endplate, the cancellous bone, and the injected polymethylmethacrylate. In trabecular bone microfractures and osteoclast lacuna were bridged or filled with newly formed bone. Nevertheless, the majority of the callus formation was found in the immediate vicinity of the polymethylmethacrylate without any obvious relationship to trabecular fractures. The results indicate for the first time that, contrary to established knowledge, even in osteoporosis the formation of large amounts of new bone is possible.

Postmortem imaging of blunt chest trauma using CT and MRI: comparison with autopsy.

OBJECTIVE: Postmortem examination of chest trauma is an important domain in forensic medicine, which is today performed using autopsy. Since the implementation of cross-sectional imaging methods in forensic medicine such as computed tomography (CT) and magnetic resonance imaging (MRI), a number of advantages in comparison with autopsy have been described. Within the scope of validation of cross-sectional radiology in forensic medicine, the comparison of findings of postmortem imaging and autopsy in chest trauma was performed. METHODS: This retrospective study includes 24 cases with chest trauma that underwent postmortem CT, MRI, and autopsy. Two board-certified radiologists, blind to the autopsy findings, evaluated the radiologic data independently. Each radiologist interpreted postmortem CT and MRI data together for every case. The comparison of the results of the radiologic assessment with the autopsy and a calculation of interobserver discrepancy was performed. RESULTS: Using combined CT and MRI, between 75% and 100% of the investigated findings, except for hemomediastinum (70%), diaphragmatic ruptures (50%; n=2) and heart injury (38%), were discovered. Although the sensitivity and specificity regarding pneumomediastinum, pneumopericardium, and pericardial effusion were not calculated, as these findings were not mentioned at the autopsy, these findings were clearly seen radiologically. The averaged interobserver concordance was 90%. CONCLUSION: The sensitivity and specificity of our results demonstrate that postmortem CT and MRI are useful diagnostic methods for assessing chest trauma in forensic medicine as a supplement to autopsy. Further radiologic-pathologic case studies are necessary to define the role of postmortem CT and MRI as a single examination modality.

Heart luxation and myocardium rupture in postmortem multislice computed tomography and magnetic resonance imaging.

Postmortem cross-sectional imaging in situ of nontraumatic human heart and of the heart with a penetrating trauma has already been described. In postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) the diagnosis of blunt trauma to the heart was reported to be challenging. We examined a case of fatal vehicle accident with severe heart trauma, which underwent postmortem MSCT and MRI before autopsy. Both radiologic methods showed dislocation of the heart. Based on this finding a rupture of the pericardium was suspected. T2-weighted MRI sequence and MSCT images allowed for diagnosis of myocardium rupture. We conclude that postmortem MSCT and MRI performed in suspicion of blunt trauma to the heart in forensic cases are useful documentation and diagnostic tools.

Knowledge, competencies and attitudes regarding external post-mortem physical examination: A survey among German post-graduate trainees in general practice.

BACKGROUND: The external post-mortem examination (EPME) is an important medical, legal and socio-economic task with far-reaching relevance; however, due to discrepancies between findings from EPMEs and actual cause of death, improvements in accuracy and quality are needed. OBJECTIVES: To investigate knowledge, competencies and attitudes regarding EPME in general practitioner (GP) post-graduate trainees. METHODS: Before four post-graduate training courses on the EPME for general practitioner trainees, organized in 2014 in the German federal state of Baden-Wuerttemberg, a questionnaire on the EPME was distributed by the lecturer, completed by the GP post-graduate trainees and returned to the lecturer. The questionnaire consisted of 19 items related to three main categories: knowledge, competencies and attitudes. RESULTS: Out of 380 GP post-graduate trainees, 128 completed and returned the questionnaire (response rate 33.7%). Less than 18% felt adequately confident in identifying a natural cause of death and less than 5% felt adequately confident in identifying an unnatural cause of death. Only 33% consistently fully uncover the corpse for the EPME. CONCLUSION: We found an important uncertainty in GP post-graduate trainees regarding their EPME knowledge and competencies.

Integrated computer-aided forensic case analysis, presentation, and documentation based on multimodal 3D data.

Three-dimensional (3D) crime scene documentation using 3D scanners and medical imaging modalities like computed tomography (CT) and magnetic resonance imaging (MRI) are increasingly applied in forensic casework. Together with digital photography, these modalities enable comprehensive and non-invasive recording of forensically relevant information regarding injuries/pathologies inside the body and on its surface. Furthermore, it is possible to capture traces and items at crime scenes. Such digitally secured evidence has the potential to similarly increase case understanding by forensic experts and non-experts in court. Unlike photographs and 3D surface models, images from CT and MRI are not self-explanatory. Their interpretation and understanding requires radiological knowledge. Findings in tomography data must not only be revealed, but should also be jointly studied with all the 2D and 3D data available in order to clarify spatial interrelations and to optimally exploit the data at hand. This is technically challenging due to the heterogeneous data representations including volumetric data, polygonal 3D models, and images. This paper presents a novel computer-aided forensic toolbox providing tools to support the analysis, documentation, annotation, and illustration of forensic cases using heterogeneous digital data. Conjoint visualization of data from different modalities in their native form and efficient tools to visually extract and emphasize findings help experts to reveal unrecognized correlations and thereby enhance their case understanding. Moreover, the 3D case illustrations created for case analysis represent an efficient means to convey the insights gained from case analysis to forensic non-experts involved in court proceedings like jurists and laymen. The capability of the presented approach in the context of case analysis, its potential to speed up legal procedures and to ultimately enhance legal certainty is demonstrated by introducing a number of representative forensic cases.

Postmortem angiography: review of former and current methods.

OBJECTIVE: Postmortem investigations are becoming more and more sophisticated. CT and MRI are already being used in pathology and forensic medicine. In this context, the impact of postmortem angiography increases because of the rapid evaluation of organ-specific vascular patterns, vascular alteration under pathologic and physiologic conditions, and tissue changes induced by artificial and unnatural causes. CONCLUSION: In this article, the advantages and disadvantages of former and current techniques and contrast agents are reviewed.

Noninvasive estimation of organ weights by postmortem magnetic resonance imaging and multislice computed tomography.

OBJECTIVE: Computed tomography (CT) and magnetic resonance imaging (MRI) are introduced as an alternative to traditional autopsy. The purpose of this study was to investigate their accuracy in mass estimation of liver and spleen. METHODS: In 44 cases, the weights of spleen and liver were estimated based on MRI and CT data using a volume-analysis software and a postmortem tissue-specific density factor. In a blinded approach, the results were compared with the weights noted at autopsy. RESULTS: Excellent correlation between estimated and real weights (r = 0.997 for MRI, r = 0.997 for CT) was found. Putrefaction gas and venous air embolism led to an overestimation. Venous congestion and drowning caused higher estimated weights. CONCLUSION: Postmortem weights of liver and spleen can accurately be assessed by nondestructive imaging. Multislice CT overcomes the limitation of putrefaction and venous air embolism by the possibility to exclude gas. Congestion seems to be even better assessed.

Postmortem radiology of fatal hemorrhage: measurements of cross-sectional areas of major blood vessels and volumes of aorta and spleen on MDCT and volumes of heart chambers on MRI.

OBJECTIVE: Autopsy determination of fatal hemorrhage as the cause of death is often a difficult diagnosis in forensic medicine. No quantitative system for accurately measuring the blood volume in a corpse has been developed. MATERIALS AND METHODS: This article describes the measurement and evaluation of the cross-sectional areas of major blood vessels, of the diameter of the right pulmonary artery, of the volumes of thoracic aorta and spleen on MDCT, and of the volumes of heart chambers on MRI in 65 autopsy-verified cases of fatal hemorrhage or no fatal hemorrhage. RESULTS: Most cases with a cause of death of "fatal hemorrhage" had collapsed vessels. The finding of a collapsed superior vena cava, main pulmonary artery, or right pulmonary artery was 100% specific for fatal hemorrhage. The mean volumes of the thoracic aorta and of each of the heart chambers and the mean cross-sectional areas of all vessels except the inferior vena cava and abdominal aorta were significantly smaller in fatal hemorrhage than in no fatal hemorrhage. CONCLUSION: For the quantitative differentiation of fatal hemorrhage from other causes of death, we propose a three-step algorithm with measurements of the diameter of the right pulmonary artery, the cross-sectional area of the main pulmonary artery, and the volume of the right atrium (specificity, 100%; sensitivity, 95%). However, this algorithm must be corroborated in a prospective study, which would eliminate the limitations of this study. Quantitative postmortem cross-sectional imaging might become a reliable objective method to assess the question of fatal hemorrhage in forensic medicine.