Lung densitometry in postmortem computed tomography - comparison across different fatal asphyxia groups.

Asphyxia as a cause of death poses a diagnostic challenge in forensic medicine due to both the diversity of underlying mechanisms, and lack of specific markers. Acute emphysema or acute alveolar dilation have long been debated as potential findings in these asphyxia cases. To further explore the supplementary findings in our forensic asphyxia cases, this study applied lung densitometry to pulmonary postmortem computed tomography (PMCT) data. Twenty asphyxia cases (including hanging (n = 9), manual strangulation (n = 4), ligature strangulation (n = 1), smothering (n = 3), and choking (n = 3)) and 21 matched control cases were analysed using lung densitometry parameters - specifically quantification of low attenuation areas (LAA) and the 15th percentile point of lung density (Perc15). Our data revealed statistically significantly higher lung % volume falling within LAA at -950HU (p = 0.04) and - 910HU (p = 0.043) in the asphyxia cases compared to matched controls. The Perc15 values observed were trending towards a lower attenuation corresponding to a lower density in the asphyxia group, although this result was not statistically significant (p = 0.13). A subgroup analysis highlighted potential differences within the asphyxia categories, notably, higher Perc15 values were observed in the choking cases. In conclusion the results from the study support the existing evidence of low pulmonary density as a potential finding in asphyxia cases and demonstrate the potential of applying lung densitometry on pulmonary postmortem computed tomography data.

Visualization of left common carotid artery injury by glass using postmortem virtual angioscopy.

A deceased man in his 50 s was found with his neck over a broken glass door frame, with blood around the body. A non-contrast postmortem computed tomography (PMCT) scan revealed subcutaneous hemorrhage, temporal bone fracture, and cerebral contusion. Also, wounds extending from the anterior to posterior neck and the presence of air in the cervical vessels suggested cervical vascular injury. A virtual angioscopy image reconstructed from PMCT angiography data revealed a ruptured left common carotid artery and allowed accurate measurement of the injury. This case demonstrates the effectiveness of postmortem virtual angioscopy for visualization and evaluation of vascular injuries, providing valuable insights for forensic investigation.

[Between clinical and forensic imaging : Differences, similarities and legal framework]. / Zwischen klinischer und forensischer Bildgebung : Unterschiede, Gemeinsamkeiten und rechtliche Rahmenbedingungen.

Clinical imaging uses a variety of medical imaging techniques to diagnose and monitor diseases, injuries and other health conditions. These include X­ray images, computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. These procedures are used to make accurate diagnoses and plan the best possible treatment for patients. Forensic imaging, in contrast, is used in both living and deceased persons in the context of criminal investigations. Postmortem forensic imaging techniques, such as postmortem CT (PMCT) and postmortem CT angiography (PMCTA), include some of the same procedures used in clinical imaging. An important difference between clinical and forensic imaging is the purpose and context in which the imaging studies are used. In addition, radiological procedures, such as angiography, need to be adapted and modified in the post-mortem setting. From a legal perspective clinical and forensic imaging must strictly adhere to privacy and procedural guidelines. Forensic images often need to be admissible as evidence in court, which places specific requirements on the quality, authenticity and documentation of images. In the case of living individuals, there must be a valid indication and consent from the patient. Consent must also fundamentally be obtained for post-mortem examinations, e.g. from the public prosecutor's office.

Enhancing Forensic Diagnostics: Structured Reporting of Post-Mortem CT versus Autopsy for Laryngohyoid Complex Fractures in Strangulation.

BACKGROUND: The purpose of this study was to establish a standardized structured workflow to compare findings from high-resolution, optimized reconstructions from post-mortem computed tomography (pmCT) with autopsy results in the detection of fractures of the laryngohyoid complex in strangulation victims. METHOD: Forty-two strangulation cases were selected, and pmCT scans of the laryngohyoid complex were obtained. Both pmCT scans and autopsy reports were analyzed using a structured template and compared using Cohen's kappa coefficient (κ) and the McNemar test. The study also compared the prevalence of ossa sesamoidea and non-fusion of the major and minor horns of the hyoid bone between both diagnostic methods. RESULTS: The detection of fractures showed a very good correlation between autopsy and pmCT results (κ = 0.905), with the McNemar test showing no statistically significant difference between the two methods. PmCT identified 28 sesamoid bones, 45 non-fusions of the major horns, and 47 non-fusions of the minor horns of the hyoid bone, compared to four, six, and zero, respectively, identified by autopsy (p < 0.0001). CONCLUSIONS: Autopsy and pmCT findings correlate well and can be used in a complementary manner. PmCT is superior to autopsy in identifying dislocations and detecting anatomical variations in the laryngohyoid complex, which can lead to misinterpretations during autopsy. Therefore, we do not advocate replacing autopsy with pmCT but propose using a structured workflow, including our standardized reporting template, for evaluating lesions in the laryngohyoid complex.

Diagnostic accuracy of post-mortem computed tomography for fractures of the hyoid-larynx complex.

Post-mortem computed tomography (PMCT) is routinely used at many forensic institutions to guide the following autopsy and is especially useful for diagnosing fractures. This systematic review aims to investigate the sensitivity and specificity of a PMCT scan in fracture diagnosis of the hyoid-larynx complex (HLC) compared to traditional autopsy in cases involving traumatic neck injuries. We searched PubMed, SCOPUS and Web of Science and included papers with cases n ≥ 3 published between January 2000 and April 2023 reporting on PMCT and autopsy findings of fractures of the HLC. The search provided 259 results of which 10 were included. Overall sensitivity and specificity were 0.70 [0.59; 0.79] and 0.92 [0.80; 0.97] for hyoid bone fractures and 0.80 [0.62; 0.91] and 0.76 [0.63; 0.85] for the thyroid cartilage. The results show great variation, and a large range between studies. These results indicate that PMCT cannot replace autopsy in cases with HLC fractures. Future larger prospective studies are needed, examining fracture details, scan protocols and different slice thicknesses using uniform reporting.

Asbestos exposure determined 357 days after death through autopsy: a report of a multidisciplinary approach.

Asbestosis is an interstitial lung disease caused by the inhalation of asbestos fibers and poses a significant risk to individuals working in construction, shipping, mining, and related industries. In a forensic context, postmortem investigations are crucial for accurate diagnosis, for which the gold standard is the histopathological examination. This case report describes the autopsy and related investigations conducted on an 84-year-old man, nearly one year (357 days) after his death. After a post-mortem CT scan, an autoptic investigation was performed, followed by histopathological, immunohistochemical, and scanning electron microscopy examinations. The integration of the evidence from these examinations with previously available personal and clinical information conclusively confirmed the diagnosis of asbestosis. We demonstrated the efficacy and reliability of our diagnostic protocol in detecting asbestosis and asbestos fibers and excluding mesothelioma even in decomposed tissues. According to our findings autopsy remains the diagnostic gold standard in cases of suspected asbestosis within a forensic context, even 1 year after death, therefore it is always highly recommended, even in cases where the body has decomposed.

Realistic three-dimensional imaging of injuries in forensic medicine - Survey-based method comparison of CRT and VRT.

OBJECTIVE: A comparison between Cinematic Rendering Technique (CRT) and Volume Rendering Technique (VRT) in cases with postmortem CT-angiography (PMCTA) was carried out. METHODS: For different injuries seen in PMCTA, a VRT and a CRT image of exactly the same pathological section was generated. Two questionnaires were created, one with CRT and one with VRT reconstructions, with the same questions per 3D-image. The questionnaires were sent to forensic pathologists, lawyers and police officers. In total eleven different injuries had to be analyzed. RESULTS: In total 109 questionnaires were answered fully. Of these returnees, 36 stated that they were forensic pathologists. Seventy-three people were assigned to the group of medical laypersons, in the study this group consists mainly of police officers, judges and lawyers. Between the two software programs CRT and VRT that were compared, no significant difference could be identified in any of the participating groups with regard to the assessment of the life-threatening nature of the injury images shown. When asked about the comprehensibility of pathology, there was a significant difference in favour of CRT. This advantage was apparent to named medical laypersons and to forensic pathologists. CONCLUSIONS: The study showed a positive trend that CRT may be more understandable than VRT. Not only the medical laypersons, but also the forensic physicians found CRT to be beneficial.

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.

Automated detection of fatal cerebral haemorrhage in postmortem CT data.

During the last years, the detection of different causes of death based on postmortem imaging findings became more and more relevant. Especially postmortem computed tomography (PMCT) as a non-invasive, relatively cheap, and fast technique is progressively used as an important imaging tool for supporting autopsies. Additionally, previous works showed that deep learning applications yielded robust results for in vivo medical imaging interpretation. In this work, we propose a pipeline to identify fatal cerebral haemorrhage on three-dimensional PMCT data. We retrospectively selected 81 PMCT cases from the database of our institute, whereby 36 cases suffered from a fatal cerebral haemorrhage as confirmed by autopsy. The remaining 45 cases were considered as neurologically healthy. Based on these datasets, six machine learning classifiers (k-nearest neighbour, Gaussian naive Bayes, logistic regression, decision tree, linear discriminant analysis, and support vector machine) were executed and two deep learning models, namely a convolutional neural network (CNN) and a densely connected convolutional network (DenseNet), were trained. For all algorithms, 80% of the data was randomly selected for training and 20% for validation purposes and a five-fold cross-validation was executed. The best-performing classification algorithm for fatal cerebral haemorrhage was the artificial neural network CNN, which resulted in an accuracy of 0.94 for all folds. In the future, artificial neural network algorithms may be applied by forensic pathologists as a helpful computer-assisted diagnostics tool supporting PMCT-based evaluation of cause of death.

Two medicolegal autopsy cases of multinodular and vacuolating neuronal tumor revealed by postmortem MRI.

The multinodular and vacuolating neuronal tumor (MVNT) is a recently recognized brain lesion. MVNT has a characteristic appearance in MRI images and is potentially epileptogenic. To the best of our knowledge, no report has yet described this pathological entity in the forensic medicine literature. We present two medicolegal autopsy cases where postmortem MRI (PMMR) was useful to detect this lesion. Case 1: a man in his 30s, with about a 7-year history of intractable epilepsy and known MVNT died suddenly. Although MVNT was not detected in the initial morphological evaluation during autopsy, PMMR of the formalin-fixed brain revealed the lesion in the left frontal lobe. Histopathology confirmed it as a MVNT. Case 2: a man in his 20s hanged himself to death. PMMR prior to autopsy revealed MVNT in his brain, and the diagnosis was confirmed by a detailed histopathological evaluation. In both cases, postmortem CT was not useful for evaluation. The cases suggested that MVNT can cause sudden, unexpected epileptic death, and pre- or post-autopsy PMMR may be useful to detect it.

Fourteen Deaths from Suspected Heparin Overdose in an Italian Primary-Level Hospital.

Healthcare-related homicidal cases are not novel within the medical-legal landscape, but investigations are often made difficult with the scarcity of material evidence related to the crime. For this reason, it is necessary to carefully analyze the clinical documentation and employ ancillary forensic resources such as radiology, histopathology, and toxicology. In the presented scenario, the observation of 14 deaths from abnormal bleeding in a First-Level Italian Hospital revealed the administration of massive doses of heparin by a nurse. On behalf of the Judicial Authority, a multidisciplinary medical team investigated the case through the following steps: a thorough review of the clinical documentation, exhumation of the bodies belonging to the deceased patients, performing PMCT and autopsy, and collecting tissue samples for histopathological, immunohistochemical, and toxicological investigations. All the analyzed cases have been characterized by the observation of fatal hemorrhagic episodes not explained with the clinical conditions of the patients, confirmed using autopsy observations and the histological demonstration of the vitality of the lesions. However, due to the limited availability of biological material for the toxicological analysis, the indirect evidence from hematological analyses in hospitalized patients was crucial in demonstrating heparin overdose and its link to the recorded deaths. The present scenario demonstrates the fundamental importance of a multidisciplinary approach to cases of judicial interest related to the healthcare context. Therefore, the illustrated methodologies can be interpreted as an operational framework for similar future cases.

Analysis of various radiological age-assessment methods in children, adolescents and young adults regarding the differences between the sexes and sides of the body - A comparative review.

A total of 76 articles published within the last twenty years, indexed in the PubMed and ResearchGate databases, were reviewed in order to compare medical imaging-based methods of age estimation of children, adolescents and young adults. The evaluated studies were analyzed for any statistically significant differences between the sexes and sides of the body, sample sizes, and population age. Irrespective of the evaluation method, there were some studies that showed a statistically significant differences in ossification stages between the male and female groups. Most of the studies whose authors conducted a statistical analysis demonstrated no significant differences between the left and right side of the body.

Survival and analysis of prognostic factors for primary malignant cardiac tumors based on the SEER database.

PURPOSE: The purpose of this study was to use the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the survival rate of primary malignant cardiac tumors (PMCTs), assess the risk factors affecting survival, and calculate the number of PMCT cases in recent years. METHODS: SEER 22 registries were used to calculate the number of cases PMCT. Data on age, sex, race, marital status, tumor size, the American Joint Committee on Cancer (AJCC) stage, lymph node involvement, metastasis, treatment, and survival were collected to analyze the survival and prognostic factors of SEER 17 registries. Using the Kaplan-Meier estimation method, a survival curve was obtained according to the influencing factors, and a multivariable Cox regression model was established. RESULTS: In recent years, the average annual number of PMCT cases was 20.56 ± 7.12, significantly higher than the average before 2004 (P = 0.015; 95% CI 1.14-8.98). The 1-, 3-, and 5-year survival rates were 45.6%, 18.8%, and 11.2%, respectively. Multivariate analysis revealed that age (risk ratio [HR], 2.047; 95% CI 1.381-3.034), AJCC stage III (HR, 1.786; 95% CI 1.123-2.839), AJCC staging with distant metastasis (HR, 2.666; 95% CI 1.509-4.709), no chemotherapy (HR, 2.011; 95% CI 1.561-2.590), and tumor size larger than 99 mm (HR, 1.766; 95% CI 1.132-2.756) were independent risk factors for poor prognosis. Only age over 76 years and distant metastasis were independent risk factors for prognosis in the chemotherapy group. CONCLUSION: In recent years, the annual number of patients with PMCT has increased significantly. Due to developments in chemotherapy, we should re-evaluate the traditional tumor staging and prognostic risk indicators to improve clinical applications.

Lateralized hypostasis of the head on post mortem CT (PMCT) scanning of decomposed bodies-a marker for terminal position.

Post-mortem CT (PMCT) scanning was performed on the bodies of two decomposed adult males who had died of natural causes. The bodies both showed changes of marked decomposition with a prominent swelling of tissues on one side of the head compared to the other. A review of police statements confirmed that this matched the positions of the bodies when they were found. Thus, post-mortem hypostasis of putrefactive fluids correlated in both cases with the positions that the bodies had been in when first located. This may be a simple way of identifying or confirming the positions of decomposed bodies after death. It may also assist in indicating whether a body has been moved after putrefactive fluid hypostasis has developed.

Suspension-associated dislocation of the jaw in hanging.

Hanging is a common type of death, and the role of the medical investigation of such deaths by a forensic pathologist not only requires the determination of the cause of death but providing information to assist in the determination of the manner of death. The forensic pathologist should be well versed in the spectrum of injuries known to be associated with neck compression, to document injuries known to be associated with hanging, but also to identify those that are inconsistent with self-inflicted hanging or that may suggest the involvement of a third party in the death. Comprehensive identification and correct interpretation of external and internal injury are crucial for the appropriate degree of police and coroner/medical examiner investigation. We present two cases of deaths believed to be caused by self-inflicted hanging that were observed to have unexpected unilateral dislocation of the temporomandibular joint identified on routine post-mortem computed tomography, without any evidence of involvement of a third party. This injury was unexplained and had not been previously observed at our Forensic Institute nor was it identified after a review of the published biomedical research literature. Issues regarding the cause of this abnormality, possible mechanisms, and the medicolegal significance of this finding will be discussed.

Marine mimicry is afoot.

It is a relatively common occurrence for forensic pathologists and anthropologists to be presented with what are believed to be human remains as part of their day-to-day practice. Despite this, the literature pertaining to such challenges is not extensive, and much knowledge of this is largely based on experience. As such, we present a case of what appeared to be a severed foot located on a beach, which examination revealed was a marine animal known as a sea squirt (ascidian). While marine scientists have been aware of such mimicry, to our knowledge, this has not been previously described in the forensic pathology literature. The external examination and post-mortem CT scan revealed the nonhuman nature of the remains, and an imminent police investigation was prevented, saving time and resources. Nonhuman remains may include animals and inorganic objects, and their discovery may invoke anxiety in the finder. A timely forensic pathology or anthropology examination will assist in alleviating such concern. Forensic pathologists and anthropologists should be prepared to face a variety of presented remains and objects.

Usefulness of virtual reassembly of the skull and spine in cases of fragmentation due to high-energy trauma: A feasibility study.

With the widespread use of postmortem computed tomography (PMCT) beside forensic autopsies for investigation of causes of death, three-dimensional (3D) reconstruction and fusion imaging using PMCT data are now becoming common. In the present study, the applicability of virtual reassembly from PMCT data was investigated in three cases involving fragmentation of the skull or spine due to high-energy trauma, as in such cases it is sometimes difficult to obtain detailed information on fractures using macroscopic observation alone. In the first case, virtual reassembly of the skull provided more information about the fractures than conventional reconstruction with adhesive. In the second case, although the skull was severely fractured and could not be examined macroscopically, virtual reassembly allowed detailed visualization of the fractures. In the last case, virtual reassembly of the spine helped to clarify that the 6th-8th thoracic vertebrae had been run over by a vehicle at the scene. Thus, virtual reassembly was shown to be useful for assessment of injury patterns, and event reconstruction.

Skeletal and dental age estimation via postmortem computed tomography in Polish subadults group.

This article is a retrospective analysis of postmortem computed tomography scans of ossification stages of the anterior and posterior intra-occipital sutures, the anterior arch of the atlas, and the neurocentral junction of the axis. We also analyzed the development of secondary ossification centers in the proximal humeral, femoral, and tibial epiphyses, and the distal femoral and tibial epiphyses. Additionally, the development of primary ossification centers in the wrist and metacarpals, and maxillary and mandibular deciduous tooth maturation. A total of 58 cadavers (35 males, 23 females), whose age ranged from 3rd month of pregnancy to 14 years, were analyzed. The results of this study show that analysis of synchondrosis closure, primary, and secondary ossification center development and deciduous tooth changes are a good tool for age estimation in subadults group (fetuses, newborns, infants, and children). The results of the study in a Polish population are consistent with those reported by other authors.

Acute subdural hematoma caused by rupture of a mycotic aneurysm due to meningitis associated with infectious endocarditis: comparison of autopsy findings with postmortem computed tomography.

Forensic pathologists often encounter cases of acute subdural hematoma (SDH) due to trauma, whereas those attributable to endogenous causes are rare. Here, we report a case of the latter type in a 42-year-old man who was found dead at home after several months of fever and malaise. Postmortem computed tomography (PMCT) and autopsy were undertaken to clarify the cause of death. PMCT images revealed a fatal SDH and a localized hyper-density area in the right parietal lobe; macroscopic and microscopic examinations revealed SDH due to rupture of a mycotic aneurysm (MA) associated with meningitis. The PMCT images also indicated thickening and calcification of the mitral valve, while autopsy demonstrated infective endocarditis (IE). In addition, PMCT demonstrated a low-density area in the spleen, which was shown to be a splenic abscess at autopsy. PMCT also demonstrated tooth cavities. Based on the findings of autopsy, the cause of death was considered to be SDH due to rupture of the MA resulting from meningitis with IE and splenic abscess. Although PMCT was unable to clarify the significance of any individual feature, a retrospective review of the PMCT images might have suggested IE, bacteremia, or ruptured MA leading to SDH. This case suggests that, instead of interpreting individual features demonstrated on PMCT images, integrated interpretation of overall PMCT findings might provide clues for identifying causes of death, despite the fact that PMCT lacks diagnostic accuracy for infectious diseases such as IE and meningitis.

How low can we go? CT dose reduction in the assessment of the medial clavicular epiphysis in forensic age estimation: a prospective postmortem CT study.

BACKGROUND: Projection radiography and, more recently, computed tomography (CT) play an important role in forensic age estimation. Both in terms of general criminal responsibility and government regulations concerning refugee care, it is important to differentiate correctly between youths and adults. A disadvantage of age estimation in CT is the ionizing radiation exposure. PURPOSE: To investigate how far the CT dose can be reduced without losing diagnostic confidence in assessing the different stages of ossification of the medial clavicle. MATERIAL AND METHODS: We prospectively scanned 25 postmortem cases with a fixed parameters protocol (FPP) and a care dose modulation protocol (CDMP) for different scan parameters. Two radiologists assessed the diagnostic image quality using a 5-point Likert scale. Inter-reader agreement was evaluated with Cohen's kappa. Differences in doses between FPP and CDMP were assessed with the one-tailed t-test. RESULTS: The best combination of diagnostic image quality and lowest radiation dose was obtained using a CDMP with 100 kV and 40 mAs and an FPP with 100 kV and 30 mAs. Doses for 120 kV were significantly higher (one-tailed P < 0.001). The diagnostic image quality for 80 kV was insufficient overall. DISCUSSION: Our results confirm that CT imaging at 100 kV allows a sufficient image quality that is diagnostic for age estimation in the ossification of the medial clavicle.