Exception to the Puppe's rule reloaded and a warning in the interpretation of skull fractures: they run even through recent craniotomy burr holes.

A possible "exception" to Puppe's rule regarding the intersection of skull fractures has been previously addressed due to the observation that skull fractures can pass through old and remodeled craniotomies. In a further case presented herein, however, it was shown that cranial fractures are also able to pass through recent burr holes, a phenomenon never previously described. A 63-year-old man sustained a self-inflicted gunshot wound to the right temple region, with an exit wound in the left temporal region. Twenty-five days prior, the patient had undergone parietal craniotomy for the evacuation of a subdural hematoma secondary to glioblastoma. Among the fracture lines originating from the exit wound, one traversed the craniotomy hole, terminating approximately 1.4 cm beyond its contralateral margin. This illustrates that cranial fractures possess the capability to cross "fresh" burr holes that have not undergone to bone remodeling. Consequently, the evaluation of Puppe's rule should be reconsidered, particularly in cases of gunshot injuries, wherein fractures pass through full-thickness circular lesions (such as entry and exit wounds). The varied scenarios underscore the potential for fractures to "pass through" these burr holes if they have not themselves generated fracture lines, as may be the case with entry holes with circular lesions without fractures.

Preparing for patients with high-consequence infectious diseases: Example of a high-level isolation unit.

INTRODUCTION: Patients with high-consequence infectious diseases (HCID) are rare in Western Europe. However, high-level isolation units (HLIU) must always be prepared for patient admission. Case fatality rates of HCID can be reduced by providing optimal intensive care management. We here describe a single centre's preparation, its embedding in the national context and the challenges we faced during the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic. METHODS: Ten team leaders organize monthly whole day trainings for a team of doctors and nurses from the HLIU focusing on intensive care medicine. Impact and relevance of training are assessed by a questionnaire and a perception survey, respectively. Furthermore, yearly exercises with several partner institutions are performed to cover different real-life scenarios. Exercises are evaluated by internal and external observers. Both training sessions and exercises are accompanied by intense feedback. RESULTS: From May 2017 monthly training sessions were held with a two-month and a seven-month break due to the first and second wave of the SARS-CoV-2 pandemic, respectively. Agreement with the statements of the questionnaire was higher after training compared to before training indicating a positive effect of training sessions on competence. Participants rated joint trainings for nurses and doctors at regular intervals as important. Numerous issues with potential for improvement were identified during post processing of exercises. Action plans for their improvement were drafted and as of now mostly implemented. The network of the permanent working group of competence and treatment centres for HCID (Ständiger Arbeitskreis der Kompetenz- und Behandlungszentren für Krankheiten durch hochpathogene Erreger (STAKOB)) at the Robert Koch-Institute (RKI) was strengthened throughout the SARS-CoV-2 pandemic. DISCUSSION: Adequate preparation for the admission of patients with HCID is challenging. We show that joint regular trainings of doctors and nurses are appreciated and that training sessions may improve perceived skills. We also show that real-life scenario exercises may reveal additional deficits, which cannot be easily disclosed in training sessions. Although the SARS-CoV-2 pandemic interfered with our activities the enhanced cooperation among German HLIU during the pandemic ensured constant readiness for the admission of HCID patients to our or to collaborating HLIU. This is a single centre's experience, which may not be generalized to other centres. However, we believe that our work may address aspects that should be considered when preparing a unit for the admission of patients with HCID. These may then be adapted to the local situations.

Olfactory transmucosal SARS-CoV-2 invasion as a port of central nervous system entry in individuals with COVID-19.

The newly identified severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19, a pandemic respiratory disease. Moreover, thromboembolic events throughout the body, including in the CNS, have been described. Given the neurological symptoms observed in a large majority of individuals with COVID-19, SARS-CoV-2 penetrance of the CNS is likely. By various means, we demonstrate the presence of SARS-CoV-2 RNA and protein in anatomically distinct regions of the nasopharynx and brain. Furthermore, we describe the morphological changes associated with infection such as thromboembolic ischemic infarction of the CNS and present evidence of SARS-CoV-2 neurotropism. SARS-CoV-2 can enter the nervous system by crossing the neural-mucosal interface in olfactory mucosa, exploiting the close vicinity of olfactory mucosal, endothelial and nervous tissue, including delicate olfactory and sensory nerve endings. Subsequently, SARS-CoV-2 appears to follow neuroanatomical structures, penetrating defined neuroanatomical areas including the primary respiratory and cardiovascular control center in the medulla oblongata.

Death scene investigation and autopsy proceedings in identifying the victims of the terror attack on the Breitscheidplatz in Berlin 19th December 2016.

We describe and discuss the forensic mission after the terrorist attack on the Breitscheidplatz in Berlin on 19th December 2016, focusing on co-operation with police authorities, and the injury patterns of the deceased. Even after massive blunt trauma, severe injury patterns are often unrecognizable by visual inspection of the body ("Casper's sign"), which could instill false security among rescuers or, as happened on the Breitscheidplatz, may lead to distress or even trauma in rescue personnel when obviously primarily uninjured patients die suddenly.

Fatal gas embolism in hospital: accident or suicide?

Fatal gas embolism in hospital is usually an iatrogenic complication of invasive diagnostic and therapeutic procedures. Air or gas enters the venous circulation, leading to cardiovascular failure or migrating to the systemic arterial circulation. A 73-year-old man died suddenly in hospital. An allergic reaction was initially suspected because of the presence of soft tissue swelling, but it was noticed that his oxygen tube was attached to the indwelling catheter inserted in the patient's right median cubital vein. Whole-body post-mortem multi-slice computed tomography (pm-MSCT) revealed abundant gas in the subcutaneous fatty tissue, in the heart chambers, in the mediastinum, pericardium, thoracic wall and peritoneum. The external examination revealed massive subcutaneous emphysema with marked palpable cutaneous tension and crepitation on palpation of the entire body's surface. Autopsy found gas bubbles in the heart and throughout the vascular system. Death was attributed to cardiac gas embolism.

Postmortem CT angiography: capabilities and limitations in traumatic and natural causes of death.

Whole-body postmortem computed tomographic (CT) angiography is a promising new development in forensic radiology that has the potential to improve vascular and soft-tissue imaging beyond levels currently achievable with unenhanced postmortem CT. Postmortem access to the vascular system and injection of contrast medium are different from those steps in clinical (antemortem) radiology. Because there is no circulation in a corpse that could transport or dilute a contrast medium, the injection must be performed by using a roller pump to fill the vasculature (arterial and venous) with a mixture of a water-soluble iodized contrast medium and polyethylene glycol. In contrast to a classic autopsy, postmortem CT angiography is a minimally invasive procedure. It allows the diagnosis of vascular lesions without the disruption or destruction of anatomic structures, which could result in a loss of evidence in a criminal investigation. Furthermore, postmortem CT angiography facilitates the display of vascular pathologic conditions in areas that are not typically covered with autopsy alone, such as the craniocervical junction and the small pelvis. Therefore, postmortem CT angiography adds substantial value to the classic forensic autopsy; cross-sectional data can be reevaluated objectively at any time and are fully reproducible as counterexpertise, which is as useful in the fields of forensic medicine and pathology as in clinical research. Familiarity with the capabilities of postmortem CT angiography may help radiologists working with forensic cases improve their diagnostic performance.

Postmortem multislice computed tomography (pmMSCT) imaging of hangman's fracture.

First described in 1965, avulsion of the neural arch from the vertebral body of the axis (C2) as a sequel to violent and rapid hyperextension of the head was termed hangman's fracture because of its similarity to the injury observed after judicial hanging. Since diagnosing such a fracture at autopsy is difficult because of its anatomic position, accurate determination of features of a hangman's fracture in cases of non-judicial hanging has not been systematically elucidated. We performed a prospective autopsy study visualizing hangman's fractures in 32 cases of hanging using postmortem multislice computed tomography (pmMSCT). A hangman's fracture with a fracture of the vertebral arch adjacent to the C2 vertebral body was only detected in one case (3.1 %). In this case a rarely observed longer drop with a lateral knot was used. Although a hangman's fracture was invariably observed bilaterally in previously reported cases, our case revealed a unilateral fracture at the side corresponding to the location of the knot. Out of the three types of hangman's fracture, pmMSCT is especially useful for detecting type 1 (nonangulated, undisplaced C2 with a normal disk at C2/C3). Also, pmMSCT is superior to conventional radiography in diagnosis, especially when the fracture is extending into the transverse foramen. In conclusion, pmMSCT imaging is useful for detecting hangman's fracture in hanging cases. Accumulating more evidence through pmMSCT will allow clarification of the actual incidence and circumstantial findings of hangman's fracture that have been controversially debated for many decades in the forensic community.

Murder-suicide by carbon dioxide (CO2) poisoning: a family case from Berlin, Germany.

This report demonstrates how carbon dioxide (CO(2)) may be a potent weapon in murder-suicide, where the death scene offers virtually no clues as to the lethal modality and the autopsy findings are nonspecific. Four bodies were discovered in an apartment in midsummer 2012 in Berlin, Germany. The bodies were those of a father (a 69-year-old business consultant), his wife (aged 26-years), and two sons (aged 3 and 6 years, respectively). The police found the wife and two sons lying in their beds and the husband in a supine position on the floor with a plastic bag over his head tied loosely around his neck with a rope. A 500 g single-use CO(2) cylinder was standing on the floor. The container was almost empty and according to the label had been sold as a CO(2)-fertilizer for aquarium plants. Two synthetic inhalation face masks and tubing were also found, which tested positive for the DNA of all four deceased family members. It is hypothesized that the husband placed an inhalation mask over the mouths and noses of his wife and children while they were sleeping. Inhalation of pure CO(2) ensured their rapid unconsciousness due to hypercapnia and severe anoxia. The rapid increase in CO(2) concentration would render a victim helpless, with no time to wake and defend themselves, or others. The proximate cause of death in all cases was attributed to CO(2) intoxication, based on the scene findings, the reconstructed sequence of events, the autopsy, and results of toxicological studies.

Different conditions and strategies to utilize forensic radiology in the cities of Melbourne, Australia and Berlin, Germany.

Forensic radiology has become a common modality in many forensic practices around the world. Here, we report and compare the usage patterns in the cities of Melbourne, Australia, and Berlin, Germany, using 16 multislice scanners in two large forensic facilities with both machines integrated in the mortuary. While in Melbourne all bodies receive a full body computed tomography (CT) scan resulting in nearly 5,000 scans per year, the situation differs in Berlin where approximately 250 state prosecutor sanctioned cases are scanned per year. While in Melbourne the CT scanner is an integral element of the process of determining whether further examinations will follow, in contrast in Berlin all cases proceed to autopsy irrespective of the findings from the CT scan. While pathologists in Berlin receive on site training to use the CT scanner by a highly experienced forensic pathologist who has previously been involved in the Virtopsy(®) program in Switzerland, training of pathologists in Melbourne is multifaceted. A radiologist with extensive experience in the forensic environment is employed part time at the institute in Melbourne and provides radiology lectures including topics such as postmortem artifacts, regional anatomy, and neuroradiology. CT is gaining acceptance as a useful modality for presenting information to the courts and juries, as well as providing an easily accessible platform to review cases and initiated research projects.

Proof of live birth using postmortem multislice computed tomography (pmMSCT) in cases of suspected neonaticide: advantages of diagnostic imaging compared to conventional autopsy.

Proof of live birth is of major importance in suspected neonaticide cases. Although not without controversy the lung flotation test is the main method used to asses this in different jurisdictions worldwide. The present study examines the usefulness of postmortem multislice computed tomography (pmMSCT) in the detection of live birth signs. Body scans were conducted on four infants, one was stillborn, another died a day after birth and the other two were classified as neonaticides. The appearance of the lungs, gastrointestinal tract and vascular system of the liver was compared in these cases. Clear differences were discernable between the lungs of the stillborn and the 1 day old infant. The aerated lungs and air in the stomach and duodenum were clearly visible in the latter case while the stillborn infant lacked these signs. The two neonaticide cases demonstrated similarly aerated lung tissue to the 1 day old infant. The hepatic vessels did not show any putrefactive gas changes in any of the cases. The extent of aeration of the peripheral alveoli was easily observable on the pmMSCT, thus making it a useful tool in the possible differentiation between artificially and naturally aerated lungs. During the four autopsies the classic flotation tests were performed and similar positive aeration of the lungs in the two neonaticides was shown. The stillborn's tests, on the other hand were negative for aeration. The results of this study clearly demonstrate the advantages of using pmMSCT before commencing a conventional autopsy in cases of suspected neonaticide.

Can MRI of the neck compete with clinical findings in assessing danger to life for survivors of manual strangulation? A statistical analysis.

OBJECTIVE: The aim of the study was to examine the clinical forensic findings of strangulation according to their ability to differentiate between life-threatening and non-life-threatening strangulation, compare clinical and MRI findings of the neck and discuss a simple score for life-threatening strangulation (SLS). MATERIALS AND METHODS: Forensic pathologists classified a continuous sample of 56 survivors of strangulation into life-threatening cases by clinical history and examination alone. Subjective, objective and radiological signs were evaluated for discriminating the two groups. RESULTS: In 27% of the cases life was in danger. The most significant signs of danger to life were congestive petechial hemorrhage in the face (eyes); hematoma of the neck and loss of consciousness. The radiological score could compete with the clinical scores. CONCLUSION: Clinical forensic findings differ significantly in non-life-threatening and life-threatening manual strangulation. Thanks to MRI a rather objective test for life-threatening strangulation can be added to a SLS.

Is differentiation of frequently encountered foreign bodies in corpses possible by Hounsfield density measurement?

The radiological determination of foreign objects in corpses can be difficult if they are fragmented or deformed. With multislice computed tomography, radiodensities--referred to as Hounsfield units (HU)--can be measured. We examined the possibility of differentiating 21 frequently occurring foreign bodies, such as metals, rocks, and different manmade materials by virtue of their HU values. Gold, steel, and brass showed mean HU values of 30671-30710 (upper measurable limit), mean HU values for steel, silver, copper, and limestone were 20346, 16949, 14033, and 2765, respectively. The group consisting of objects, such as aluminum, tarmac, car front-window glass, and other rocks, displayed mean HU values of 2329-2131 HU. The mean HU value of bottle glass and car side-window glass was 2088, whereas windowpane glass was 493. HU value determination may therefore help in preautopsy differentiation between case-relevant and irrelevant foreign bodies and thus be useful for autopsy planning and extraction of the objects in question.

Virtopsy: postmortem imaging of laryngeal foreign bodies.

CONTEXT: Death from corpora aliena in the larynx is a well-known entity in forensic pathology. The correct diagnosis of this cause of death is difficult without an autopsy, and misdiagnoses by external examination alone are common. OBJECTIVE: To determine the postmortem usefulness of modern imaging techniques in the diagnosis of foreign bodies in the larynx, multislice computed tomography, magnetic resonance imaging, and postmortem full-body computed tomography-angiography were performed. DESIGN: Three decedents with a suspected foreign body in the larynx underwent the 3 different imaging techniques before medicolegal autopsy. RESULTS: Multislice computed tomography has a high diagnostic value in the noninvasive localization of a foreign body and abnormalities in the larynx. The differentiation between neoplasm or soft foreign bodies (eg, food) is possible, but difficult, by unenhanced multislice computed tomography. By magnetic resonance imaging, the discrimination of the soft tissue structures and soft foreign bodies is much easier. In addition to the postmortem multislice computed tomography, the combination with postmortem angiography will increase the diagnostic value. CONCLUSIONS: Postmortem, cross-sectional imaging methods are highly valuable procedures for the noninvasive detection of corpora aliena in the larynx.

Abdominal trauma--sensitivity and specificity of postmortem noncontrast imaging findings compared with autopsy findings.

OBJECTIVE: The aim of the study was to determine the sensitivity and specificity for typical abdominal injuries after major blunt trauma in postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI). MATERIAL: Thirty-four cases of accidental death underwent postmortem pre-autopsy MSCT and MRI. The imaging findings were correlated with the autopsy findings. RESULTS: Sensitivity and specificity for liver injury in computed tomography (CT) alone were 53% and 84%. In MRI, a sensitivity of 58% and a specificity of 46% were found. CT and MRI together (when either one was positive, liver-injury was considered) had a sensitivity of 73% and a specificity of 63%. For major liver lacerations (grades II-VI) a slightly higher sensitivity of 81% and a better specificity of 100% were noted. CT and MRI together showed a sensitivity of 50% for injuries of the spleen, specificity was 89%. CT and MRI together had a sensitivity of only 25% for trauma of the kidney, but a specificity of 100%. CONCLUSION: A lot of cases with small organ injuries (such as superficial liver-laceration) seemed that could not be found by MSCT or by MRI, leading to a rather low sensitivity. Nevertheless, most of the life-threatening liver injuries could be detected, which is essential in forensic pathology.

Life-threatening versus non-life-threatening manual strangulation: are there appropriate criteria for MR imaging of the neck?

The aim of the study was to determine objective radiological signs of danger to life in survivors of manual strangulation and to establish a radiological scoring system for the differentiation between life-threatening and non-life-threatening strangulation by dividing the cross section of the neck into three zones (superficial, middle and deep zone). Forensic pathologists classified 56 survivors of strangulation into life-threatening and non-life-threatening cases by history and clinical examination alone, and two blinded radiologists evaluated the MRIs of the neck. In 15 cases, strangulation was life-threatening (27%), compared with 41 cases in which strangulation was non-life-threatening (73%). The best radiological signs on MRI to differentiate between the two groups were intramuscular haemorrhage/oedema, swelling of platysma and intracutaneous bleeding (all p = 0.02) followed by subcutaneous bleeding (p = 0.034) and haemorrhagic lymph nodes (p = 0.04), all indicating life-threatening strangulation. The radiological scoring system showed a sensitivity and specificity of approximately 70% for life-threatening strangulation, when at least two neck zones were affected. MRI is not only helpful in assessing the severity of strangulation, but is also an excellent documentation tool that is even admissible in court.

Are full or empty beer bottles sturdier and does their fracture-threshold suffice to break the human skull?

Beer bottles are often used in physical disputes. If the bottles break, they may give rise to sharp trauma. However, if the bottles remain intact, they may cause blunt injuries. In order to investigate whether full or empty standard half-litre beer bottles are sturdier and if the necessary breaking energy surpasses the minimum fracture-threshold of the human skull, we tested the fracture properties of such beer bottles in a drop-tower. Full bottles broke at 30 J impact energy, empty bottles at 40 J. These breaking energies surpass the minimum fracture-threshold of the human neurocranium. Beer bottles may therefore fracture the human skull and therefore serve as dangerous instruments in a physical dispute.

Estimation of sex and age of "virtual skeletons"--a feasibility study.

This article presents a feasibility study with the objective of investigating the potential of multi-detector computed tomography (MDCT) to estimate the bone age and sex of deceased persons. To obtain virtual skeletons, the bodies of 22 deceased persons with known age at death were scanned by MDCT using a special protocol that consisted of high-resolution imaging of the skull, shoulder girdle (including the upper half of the humeri), the symphysis pubis and the upper halves of the femora. Bone and soft-tissue reconstructions were performed in two and three dimensions. The resulting data were investigated by three anthropologists with different professional experience. Sex was determined by investigating three-dimensional models of the skull and pelvis. As a basic orientation for the age estimation, the complex method according to Nemeskéri and co-workers was applied. The final estimation was effected using additional parameters like the state of dentition, degeneration of the spine, etc., which where chosen individually by the three observers according to their experience. The results of the study show that the estimation of sex and age is possible by the use of MDCT. Virtual skeletons present an ideal collection for anthropological studies, because they are obtained in a non-invasive way and can be investigated ad infinitum.

Postmortem whole-body CT angiography: evaluation of two contrast media solutions.

OBJECTIVE: The objective of our study was to establish a standardized procedure for postmortem whole-body CT-based angiography with lipophilic and hydrophilic contrast media solutions and to compare the results of these two methods. MATERIALS AND METHODS: Minimally invasive postmortem CT angiography was performed on 10 human cadavers via access to the femoral blood vessels. Separate perfusion of the arterial and venous systems was established with a modified heart-lung machine using a mixture of an oily contrast medium and paraffin (five cases) and a mixture of a water-soluble contrast medium with polyethylene glycol (PEG) 200 in the other five cases. Imaging was executed with an MDCT scanner. RESULTS: The minimally invasive femoral approach to the vascular system provided a good depiction of lesions of the complete vascular system down to the level of the small supplying vessels. Because of the enhancement of well-vascularized tissues, angiography with the PEG-mixed contrast medium allowed the detection of tissue lesions and the depiction of vascular abnormalities such as pulmonary embolisms or ruptures of the vessel wall. CONCLUSION: The angiographic method with a water-soluble contrast medium and PEG as a contrast-agent dissolver showed a clearly superior quality due to the lack of extravasation through the gastrointestinal vascular bed and the enhancement of soft tissues (cerebral cortex, myocardium, and parenchymal abdominal organs). The diagnostic possibilities of these findings in cases of antemortem ischemia of these tissues are not yet fully understood.

Detection of smuggled cocaine in cargo using MDCT.

OBJECTIVE: Smuggling dissolved drugs, especially cocaine, in bottled liquids is an ongoing problem at borders. Common fluoroscopy of packages at the border cannot detect contaminated liquids. The objective of our study was to develop an MDCT screening method to detect cocaine-containing vessels that are hidden between uncontaminated ones in a shipment. MATERIALS AND METHODS: Studies were performed on three wine bottles containing cocaine solutions that were confiscated at the Swiss border. Reference values were obtained by scans of different sorts of commercially available wine and aqueous solutions of dissolved sugar. All bottles were scanned using MDCT, and data evaluation was performed by measuring the mean peak of Hounsfield units. To verify the method, simulated testing was performed. RESULTS: Using measurements of the mean peak of Hounsfield units enables the detection of dissolved cocaine in wine bottles in a noninvasive and rapid fashion. Increasing opacity corresponds well with the concentration of dissolved cocaine. Simulated testing showed that it is possible to distinguish between cocaine-contaminated and uncontaminated wine bottles. CONCLUSION: The described method is an efficacious screening method to detect cocaine-contaminated bottles that are hidden between untreated bottles in cargo. The noninvasive examination of cargo allows a questionable delivery to be tracked without arousing the suspicion of the smugglers.