Diagnostic value of T1- and T2-weighted 3-Tesla MRI for postmortem detection and age stage classification of myocardial infarction.

The aims of this study are to retrospectively evaluate the diagnostic value of T1- and T2-weighted 3-T magnetic resonance imaging (MRI) for postmortem detection of myocardial infarction (MI) in terms of sensitivity and specificity and to compare the MRI appearance of the infarct area with age stages. Postmortem MRI examinations (n = 88) were retrospectively reviewed for the presence or absence of MI by two raters blinded to the autopsy results. The sensitivity and specificity were calculated using the autopsy results as the gold standard. A third rater, who was not blinded to the autopsy findings, reviewed all cases in which MI was detected at autopsy for MRI appearance (hypointensity, isointensity, hyperintensity) of the infarct area and the surrounding zone. Age stages (peracute, acute, subacute, chronic) were assigned based on the literature and compared with the age stages reported in the autopsy reports. The interrater reliability between the two raters was substantial (κ = 0.78). Sensitivity was 52.94% (both raters). Specificity was 85.19% and 92.59%. In 34 decedents, autopsy identified an MI (peracute: n = 7, acute: n = 25, chronic: n = 2). Of 25 MI classified as acute at autopsy, MRI classified peracute in four cases and subacute in nine cases. In two cases, MRI suggested peracute MI, which was not detected at autopsy. MRI could help to classify the age stage and may indicate the area for sampling for further microscopic examination. However, the low sensitivity requires further additional MRI techniques to increase the diagnostic value.

Noninvasive analysis and identification of an intramuscular fluid collection by postmortem 1H-MRS in a case of a fatal motor vehicle accident.

In a case of a fatal traffic accident, a suspicious finding was identified in the muscular tissue of the left thigh by whole-body postmortem computed tomography. To better interpret the finding, the lower extremities were investigated by magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (1H-MRS). MRI revealed the presence of an evenly distributed intramuscular fluid and 1H-MRS of a volume within the fluid detected concentrations of acetate and lactate. The fluid was assumed to be an extravasation of an intraosseous infusion, erroneously administered to the intermediate vastus of the left thigh during resuscitation, which was later confirmed when access to resuscitation protocols was granted. Further ex situ 1H-MRS investigations of five different infusion fluids showed the possible discrimination of the fluids and further indicated the unknown fluid to be a Ringer's acetate solution. This paper presents the case-based application of postmortem intramuscular 1H-MRS and introduces the possibility of its use to differentiate exo- and endogenic fluids for forensic interpretation. Further research for this method regarding problems in forensic pathology is needed.

Postmortem Magnetic Resonance Imaging and Postmortem Computed Tomography in Ligature and Manual Strangulation.

PURPOSE: The aim of this study was to evaluate magnetic resonance imaging (MRI) findings in cases of fatal manual or ligature strangulation. Verification of strangulation by computed tomography (CT), MRI, and at autopsy as well as its detectability in each modality was assessed. METHODS: We retrospectively analyzed 6 manual and ligature strangulation cases between 2013 and 2019 who all underwent a whole-body CT, head and neck MRI, and an autopsy. Two radiologists examined head and neck imaging data and compared the data to autopsy findings. RESULTS: Magnetic resonance imaging showed a high efficiency in verifying intramuscular hemorrhages, which were confirmed in autopsy. Moreover, in one case without a visible strangulation mark, soft tissue injuries associated with strangulation were detected. Fractures, especially thyroid cartilage fractures, were successfully diagnosed by CT. CONCLUSIONS: As MRI showed a successful detection of soft tissue lesions in relation to strangulation, it can serve as an alternative method or provide additional value to an autopsy. Intramuscular hemorrhages are a common finding in manual and ligature strangulation, providing a useful sign of applied pressure on the neck. However, to evaluate fractures, an additional CT or autopsy is recommended.

Postmortem Computed Tomography and Magnetic Resonance Imaging of an Abdominal Gunshot Wound.

The use of postmortem computed tomography (CT) has been described in many articles concerning gunshot injuries. Postmortem magnetic resonance imaging (MRI) for better assessment of soft tissue injuries has also been mentioned in the literature, albeit much less often. The use of postmortem MRI for abdominal gunshot wounds has not been previously presented in the literature. The present case report describes the findings of an abdominal gunshot wound detected by postmortem CT and MRI, followed by an autopsy. The main imaging findings on CT were a hyperdense ring at the entrance wound, which indicated the muzzle imprint mark, a hyperdense region beneath the skin, which was suggestive of combustion residue, gas cavities surrounding the bullet path, which might be related to the temporary cavity, and a fracture of the 13th rib on the left. Magnetic resonance imaging provided a clear depiction of defects in the muscle tissue and peritoneal fat, as well as an injury to the left kidney and a large volume of blood in the abdominal cavity. Computed tomography combined with MRI provided a descriptive presentation of the intracorporeal trajectory noninvasively. Autopsy confirmed the radiologic findings but additionally revealed further relevant findings, which were not detected radiologically, such as a duodenal perforation. Autopsy also detected subendocardial hemorrhages and shock kidney, which were consistent with severe blood loss.The imaging findings and their interpretations are discussed in this case report, as well as the role of CT and MRI in the assessment of abdominal gunshot wounds compared with autopsy.

The possibility of identifying brain hemorrhage in putrefied bodies with PMCT.

This paper aims to demonstrate that post-mortem CT (PMCT) can locate intracranial hemorrhages, even in decomposed cases. This is of relevance in that post-mortem decomposition is particularly damaging to the brain tissue's consistency, resulting in great difficulties to reliably diagnose and locate intracranial hemorrhages. We searched our case database of the last 11 years to find cases with decomposition of the body, where PMCT and an autopsy had been performed. We identified eleven cases according to these criteria. Postmortem interval ranged from 2 days to 2 weeks, and post-mortem radiological alteration index (RAI) was at or above 49. Eight out of eleven cases showed an intraparenchymal hemorrhage whereas the hemorrhage was extra-axial in the remaining three cases. Autopsy validated the presence of intracranial hemorrhage in all eleven cases, but location could not be confirmed due to liquid state of the brain. PMCT identified and localized intracranial hemorrhages in decomposed bodies, and in all of these cases, autopsy validated their presence. The actual cause of the hemorrhage (e.g. tumor, metastasis, vascular malformation, hypertensive hemorrhage) remained obscure. From this case series, it can be concluded that PMCT may add relevant information pertaining to localization of intracranial hemorrhages in decomposed bodies.

The added value of postmortem magnetic resonance imaging in cases of hanging compared to postmortem computed tomography and autopsy.

The purpose of this study was to evaluate the added value of postmortem magnetic resonance imaging (MRI) compared to postmortem computed tomography (CT) and autopsy in cases of fatal hanging. In addition, the study analyzed the strengths of each examination method regarding typical injuries in these cases. We investigated a cohort of 25 decedents who underwent CT, MRI and autopsy. Two radiologists assessed all MR images of the head and neck as well as the corresponding CT images. The results were compared to autopsy findings by retrospectively analyzing the autopsy reports. Postmortem MRI revealed intramuscular hemorrhages in a large number of cases, however, autopsy did not confirm all of the detected hemorrhages. CT and autopsy detected fractures in several cases, whereas MRI showed a fracture in just one single case. Other previously described vital signs and relevant findings, such as fracture-related gas bubbles, soft tissue emphysema or pneumomediastinum, were observed in only a few individual cases. MRI provided added diagnostic value in the detection of soft tissue injuries and lymph node swelling in fatal hangings. As an adjunct to autopsy, postmortem MRI may reveal additional hemorrhages, which might be missed at autopsy. Since standard MRI demonstrated low sensitivity for the detection of fractures, an additional imaging modality or autopsy is required to overcome this limitation.

Noninvasive 7 tesla MRI of fatal craniocerebral gunshots - a glance into the future of radiologic wound ballistics.

Compared to computed tomography (CT), magnetic resonance imaging (MRI) provides superior visualization of the soft tissue. Recently, the first 7 Tesla (7 T) MRI scanner was approved for clinical use, which will facilitate access to these ultra-high-field MRI scanners for noninvasive examinations and scientific studies on decedents. 7 T MRI has the potential to provide a higher signal-to-noise ratio (SNR), a characteristic that can be directly exploited to improve image quality and invest in attempts to increase resolution. Therefore, evaluating the diagnostic potential of 7 T MRI for forensic purposes, such as assessments of fatal gunshot wounds, was deemed essential. In this article, we present radiologic findings obtained for craniocerebral gunshot wounds in three decedents. The decedents were submitted to MRI examinations using a 7 T MRI scanner that has been approved for clinical use and a clinical 3 T MRI scanner for comparison. We focused on detecting tiny injuries beyond the wound tract caused by temporary cavitation, such as microbleeds. Additionally, 7 T T2-weighted MRI highlighted a dark (hypo intense) zone beyond the permanent wound tract, which was attributed to increased amounts of paramagnetic blood components in damaged tissue. Microbleeds were also detected adjacent to the wound tract in the white matter on 7 T MRI. Based on the findings of radiologic assessments, the advantages and disadvantages of postmortem 7 T MRI compared to 3 T MRI are discussed with regard to investigations of craniocerebral gunshot wounds as well as the potential role of 7 T MRI in the future of forensic science.

Synergy of CT and MRI in detecting trajectories of lodged bullets in decedents and potential hazards concerning the heating and movement of bullets during MRI.

The purpose of this study was to assess the value of magnetic resonance imaging (MRI) in addition to computed tomography (CT) in gunshot wound cases with bullets or pellets lodged inside the head. In this context, the potential heating and movement of the lodged bullets were additionally investigated using animal models. Eleven forensic cases of penetrating gunshot wounds underwent CT and MRI. The data of each imaging modality were reviewed according to the following relevant characteristics: bony lesion at the entrance, intracranial bone fragments, intracranial metal fragments, gunshot residues, the wound channel and the severity of metal artifacts. Four-point Likert scales were used for the assessment. The heating of projectiles and their magnetic field interactions with the static magnetic field were assessed using animal models. MRI presented major advantages in cases with transversal trajectories and non-ferromagnetic bullets compared to CT. In general, MRI enabled a clear visualization of the wound channel and gunshot-related soft tissue injuries. An image fusion of CT and MRI datasets demonstrated the individual strengths of both modalities. Radio frequency (RF)-induced heating due to bullets lodged inside the brain tissue was invalidated. The likelihood of ferromagnetic projectile migration inside brain tissue is low. MRI of decedents with a bullet lodged inside their heads is viable and provides a valuable supplement to CT. The in situ, noninvasive depiction of the wound channel and gunshot-related soft tissue injuries on MRI can contribute to the knowledge of wound ballistics.

Value of 3T craniocervical magnetic resonance imaging following nonfatal strangulation.

OBJECTIVE: The aims of this study were (1) to provide an overview of craniocervical magnetic resonance imaging (MR) findings following nonfatal strangulation (NFS), (2) to detect the time dependency of the presence of these findings, and (3) to explore the additional value of MR with regard to the forensic interpretation of NFS. METHODOLOGY: All 633 victims of manual strangulation between October 2011 and March 2018 were examined, including the case history and external findings. Following written consent, 114 cases were included in the study. The duration between the event, clinical forensic examination, and MR was noted. Radiologic images were reviewed by a clinical and a forensic radiologist. RESULTS: The case group consisted of 90 women and 24 men with a mean age of 32.5 years. Delimitable external findings were present in 93% (N = 106) of cases. MR yielded a positive finding in 43% of cases (N = 49). There was no significant difference in the mean time interval between examinations between MR-positive and MR-negative cases. Perilaryngeal fluid accumulation was associated with difficulty swallowing and victims put in a chokehold. All cerebral MR were unremarkable, except for one patient with edema of the corpus callosum. CONCLUSIONS: The role of craniocervical MR following NFS is currently limited, particularly with regard to the forensic interpretation of NFS. MR may reveal internal injury in victims who report subjective symptoms of airway compression and in those who were placed in a chokehold. The presence of MR findings is not dependent on immediate examinations following the assault. KEY POINTS: • Magnetic resonance imaging does not currently provide additional value for the estimation of the severity of nonfatal manual strangulation. • Magnetic resonance imaging of the neck may reveal internal injury in cases without external findings, particularly in victims placed in a chokehold and with symptoms of airway compression. • The incidence of carotid artery dissections and laryngeal fractures is low in victims of nonfatal manual strangulation.

Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy - a systematic review.

Several articles have described the use of postmortem computed tomography (CT) and postmortem magnetic resonance imaging (MRI) in forensic medicine. Although access to CT scanners and, particularly, access to MRI scanners, is still limited for several institutes, both modalities are being applied with increasing frequency in the forensic setting. Certainly, postmortem imaging can provide crucial information prior to autopsy, and this method has even been considered a replacement to autopsy in selected cases by some forensic institutes. However, the role of postmortem imaging has to be assessed individually according to various injury categories and causes of death. Therefore, this systematic review focuses on the role of postmortem CT and MRI in cases of hanging and ligature and manual strangulation. We assessed the most common and relevant findings on CT and MRI in cases of strangulation and compared the detectability of these findings among CT, MRI and autopsy. According to the available literature, mainly fractures of the hyoid bone or thyroid cartilage were investigated using postmortem CT. Compared to autopsy, CT demonstrated equivalent results concerning the detection of these fractures. A currently described "gas bubble sign" may even facilitate the detection of laryngeal fractures on CT. Regarding the detection of hemorrhages in the soft tissue of the neck, postmortem MRI is more suitable for the detection of this "vital sign" in strangulation. Compared to autopsy, postmortem MRI is almost equally accurate for the detection of hemorrhages in the neck. Another "vital sign", gas within the soft tissue in hanging, which is hardly detectable by conventional autopsy, can be clearly depicted by CT and MRI. The number of cases of manual and ligature strangulation that were investigated by means of postmortem CT and MRI is much smaller than the number of cases of hanging that were investigated by CT and MRI. Likewise, judicial hanging and the hangman's fracture on postmortem imaging were described in only a few cases. Based on the results of this systematic review, we discuss the additional value of CT and MRI in fatal strangulation compared to autopsy, and we reflect on where the literature is currently lacking.

Death by hanging: a retrospective case-control investigation of the intervertebral disc vacuum phenomenon on PMCT.

During hanging gravitational forces affect the spine. Intervertebral vacuum phenomenon (VP) implies that gas accumulations in the discs are caused by degeneration of the spine and trauma. It was hypothesized that VP detected on postmortem computed tomography (PMCT) has a higher incidence in hanging deaths, which can be correlated to age, degenerative spinal changes and type of hanging (complete-incomplete). Secondly, it was investigated whether the presence of Simon's bleedings is related to hanging type and VP on PMCT. A retrospective hanging case-control study of 72 cases was conducted. PMCT data were evaluated by two observers for the presence of VP and its localization within the thoracic and lumbar discs, and for any degenerative changes of the spine. Autopsy protocols were assessed for the presence of Simon's bleedings during autopsy. VP did not statistically differ among hanging and control cases but it was statistically correlated to complete hanging, increasing age and degenerative spinal changes. Centrally located VP within the discs was correlated to hanging, especially complete hanging, and younger ages, contrary to control cases that showed gas at the disc periphery. Simon's bleedings were correlated with complete hanging and centrally located VP. Centrally located VP within the discs increases the probability for complete hanging, while increasing age and degenerative changes reduce this probability. Intervertebral VP is multifactorial radiological entity. The presence of centrally located VP can indicate that hanging could be considered as an alternative mechanism of death and that great forces and loads may have affected the spine perimortem, especially with decreasing age and when Simon's bleedings are present.

Computed tomography guided navigation assisted percutaneous ablation of osteoid osteoma in a 7-year-old patient: the low dose approach.

Osteoid osteoma (OO) is a benign tumour that can cause severe pain and functional limitation to children and young adults; the treatment of choice is image-guided ablation. Due to the very small size of the lesion, detection and accurate needle placement may be challenging. Computed tomography (CT) offers very detailed imaging of the skeleton and is the modality of choice for the detection of small OO and for ablation guidance. Nevertheless, CT-guided positioning of the ablation applicator is linked to significant radiation exposure, particularly for the paediatric population. This case describes the successful use of a novel CT-based navigation system that offers the possibility of accurate ablation with only minimal radiation exposure in a paediatric patient.

7-T MRI for brain virtual autopsy: a proof of concept in comparison to 3-T MRI and CT.

The detection and assessment of cerebral lesions and traumatic brain injuries are of particular interest in forensic investigations in order to differentiate between natural and traumatic deaths and to reconstruct the course of events in case of traumatic deaths. For this purpose, computed tomography (CT) and magnetic resonance imaging (MRI) are applied to supplement autopsy (traumatic death) or to supplant autopsy (natural deaths). This approach is termed "virtual autopsy." The value of this approach increases as more microlesions and traumatic brain injuries are detected and assessed. Focusing on these findings, this article describes the examination of two decedents using CT, 3-T, and 7-T MRI. The main question asked was whether there is a benefit in using 7-T over 3-T MRI. To answer this question, the 3-T and 7-T images were graded regarding the detectability and the assessability of coup/contrecoup injuries and microlesions using 3-point Likert scales. While CT missed these findings, they were detectable on 3-T and 7-T MRI. However, the 3-T images appeared blurry in direct comparison with the 7-T images; thus, the detectability and assessability of small findings were hampered on 3-T MRI. The potential benefit of 7-T over 3-T MRI is discussed.

Rapid death following undiagnosed stercoral perforation in a chronic opioid user.

A case of rapid demise following an undiagnosed stercoral perforation is reported. A 57-year-old woman on chronic opioid replacement therapy presented with constipation and abdominal pain to the hospital. Following an unremarkable abdominal radiograph and admission for laxation and pain therapy, she was found dead only 18 h later. To exclude medical malpractice, a postmortem investigation was ordered. Postmortem computed tomography and autopsy revealed fatal fecal peritonitis based on a stercoral perforation of the rectosigmoid, which had been undiagnosed. This report highlights the need for early cross-sectional imaging and contributes to the data collection concerning this ever-growing, vulnerable group of patients undergoing opioid replacement.

Visualization and material-based differentiation of lodged projectiles by extended CT scale and the dual-energy index.

Computed tomography (CT) scans of gunshot wounds and their high sensitivity in detecting osseous lesions has often been reported in the literature. However, studies concerning in situ examinations of lodged projectiles with CT to determine the ammunition used are lacking. Projectile visualizations are hampered in standard CT due to the presence of metal artifacts and the limited range of Hounsfield units (HU). The use of special reconstruction algorithms can overcome these limitations. For instance, using extended CT scale (ECTS) reconstruction supports detailed visualizations of metallic objects. In addition to projectile visualizations, X-ray attenuation measurements (CT numbers) of metallic objects can be used to differentiate materials in CT. This study uses real forensic cases to demonstrate that-depending on the degree of deformation-a detailed visualization of lodged projectiles using ECTS can provide useful information regarding the ammunition used and allows accurate caliber measurements. Independent from the degree of deformation, the in situ classification of bullets, even fragmented bullets, according to their metallic components is feasible by dual-energy index (DEI) calculations. The assessment of a lodged projectile with CT images provides useful information on the case; thus, a close examination of lodged projectiles or bullet fragments should be a part of the overall radiological examination for cases of penetrating gunshot wounds.

In situ identification of Action 4, SECA and QD-PEP bullets from special police ammunitions by computed tomography.

INTRODUCTION: Special deformation bullets were developed for police forces to achieve a defined penetration depth (avoiding over-penetration) and a controlled energy transfer (avoiding collateral damage). This article focuses on Action 4, SECA and QD-PEP bullets. These 9 mm bullets were specially designed for controlled deformation. The characteristic slight mushrooming with a front cross-section of approximately 11.5 mm after entering a ballistic simulant was verified in ballistic tests. To achieve such slight mushrooming, the projectile's core is hollowed. The purpose of this study was to investigate the feasibility of visualising the hollowed cores of Action 4, SECA and QD-PEP bullets using a standard clinical computed tomography (CT) scanner for non-invasive identification of these special bullets from police ammunitions. METHODS: First, undeformed specimens were scanned to reveal the shape of the hollowed core of each type of special bullet. Second, Action 4, SECA and QD-PEP bullets were fired towards animal cadaver models to visualise their hollow core after deformation inside biological tissue. Third, two reviewers were tasked with identifying special bullets from police ammunition (Action 4 bullets: n = 3) among 10 CT examinations of humans with lodged projectiles who were selected by the supervisor of the study. RESULTS: The CT scans of the undeformed specimens revealed the special design of the bullets' metal core. All special bullets from police ammunitions that were fired towards an animal cadaver model demonstrated the characteristic slight mushrooming. In accordance with the CT scans of the undeformed bullets, visualisation of the individual internal cavities of the special bullets allowed the Action 4, SECA and QD-PEP bullets to be clearly distinguished. With regard to the real forensic cases, both reviewers clearly identified each of the three Action 4 bullets among all other lodged projectiles. CONCLUSIONS: This study demonstrates the feasibility of identifying Action 4, SECA and QD-PEP bullets from special police ammunitions by CT. The individual shapes of the cavity inside the bullets were clearly visible on CT. In situ identification of these bullets can aid in the assessment of injuries, and since these bullets are fabricated from non-ferromagnetic metals, their clear identification allows for magnetic resonance imaging (MRI) without the risk of bullet movement inside the body due to the magnetic pull of the MRI unit. Furthermore, this approach could be of great interest to forensic investigators if patients who received gunshot wounds underwent non-operative treatments and the projectile remains in the body. Since the use of CT is also increasing for medico-legal post-mortem examinations, the identification of lodged projectiles is of interest for a virtual autopsy or 'Virtopsy'.