A computational approach to estimate postmortem interval using postmortem computed tomography of multiple tissues based on animal experiments.

The estimation of postmortem interval (PMI) is a complex and challenging problem in forensic medicine. In recent years, many studies have begun to use machine learning methods to estimate PMI. However, research combining postmortem computed tomography (PMCT) with machine learning models for PMI estimation is still in early stages. This study aims to establish a multi-tissue machine learning model for PMI estimation using PMCT data from various tissues. We collected PMCT data of seven tissues, including brain, eyeballs, myocardium, liver, kidneys, erector spinae, and quadriceps femoris from 10 rabbits after death. CT images were taken every 12 h until 192 h after death, and HU values were extracted from the CT images of each tissue as a dataset. Support vector machine, random forest, and K-nearest neighbors were performed to establish PMI estimation models, and after adjusting the parameters of each model, they were used as first-level classification to build a stacking model to further improve the PMI estimation accuracy. The accuracy and generalized area under the receiver operating characteristic curve of the multi-tissue stacking model were able to reach 93% and 0.96, respectively. Results indicated that PMCT detection could be used to obtain postmortem change of different tissue densities, and the stacking model demonstrated strong predictive and generalization abilities. This approach provides new research methods and ideas for the study of PMI estimation.

Biocultural and social determinants of ill health and early mortality in a New Mexican paediatric autopsy sample.

RESULTS: Hispanic children have higher odds of growth stunting than non-Hispanic White children. Native American children die younger and have higher odds of respiratory diseases and porous lesions than Hispanic and non-Hispanic Whites. Rural/urban location does not significantly impact age at death, but housing type does. Individuals who lived in trailers/mobile homes had earlier ages at death. When intersections between housing type and housing location are considered, children who were poor and from impoverished areas lived longer than those who were poor from relatively well-off areas. CONCLUSIONS: Children's health is shaped by factors outside their control. The children included in this study embodied experiences of social and ELS and did not survive to adulthood. They provide the most sobering example of the harm that social factors (structural racism/discrimination, socioeconomic, and political structures) can inflict.

Validity of postmortem computed tomography for use in forensic odontology identification casework.

Forensic Odontology (FO) identification compares antemortem (AM) and postmortem (PM) dental datasets and is widely accepted as a primary identifier. Traditionally, a PM dental examination is undertaken in the same manner as a dental examination conducted for a living patient. Recently, the increased forensic application of computed tomography (CT) offers an alternative source of PM data. While charting from PMCT is widely accepted as less accurate, the impact on reconciliation is unknown. This study aims to determine if reconciliation outcome differs when PM dental data is collected from PMCT, compared with conventional PM examination. PMCT data was reviewed for 21 cases previously completed using conventional PM dental examination. Operators blinded to original identification outcomes charted from CT images before comparing to AM data to form an opinion regarding identity. Opinions formed were compared with original identification outcomes. Differences in PM dental charting between the two methods and the evidentiary value of AM and PM datasets were assessed to determine driving factors of differences in identification outcome. Compared to conventional PM dental examination, PMCT examination resulted in similar or less certain identification outcomes. Discrepancies in outcome were driven by the quality of AM and PM datasets rather than inaccuracies in charting from PMCT. Based on the results of this study, both conventional and PMCT methods of PM dental examination can reach similar identification outcomes. However, operators remained more certain in establishing identity when conducting conventional PM dental examinations especially when AM data was lacking.

Enhanced autopsy triage (EA-Triage) in drug-related deaths: integrating quick toxicological analysis and postmortem computed tomography.

The objective was to assess the diagnostic accuracy of an enhanced autopsy triage (EA-Triage) setup consisting of postmortem computed tomography (PMCT), simulated quick toxicological analysis (sQTA), external examination, and case information in determining cause of death (COD) in persons with past or current use of illegal drugs (drug-related deaths). Information on drug-related deaths selected for medico-legal autopsy in 2020-2021 at the Department of Forensic Medicine, Aarhus University, Denmark, was analyzed retrospectively. The included cases underwent conventional autopsy, PMCT, and systematic toxicological analysis. A board-certified forensic pathologist, who was blinded to the internal examination and COD from the medico-legal autopsy, determined COD based on the EA-Triage setup. 154 cases with a median age of 40.6 years (range 17-70 years, 82% males) were included. The COD determined by medico-legal autopsy and that determined by EA-Triage matched in 113 cases (73%), including those with an unknown COD. EA-Triage and medico-legal autopsy determined unknown COD in 45 (29%) and 5 cases (3%), respectively. Excluding cases with an unknown COD, EA-Triage predicted COD in 109 cases (71%); of those, 72 (66%) had no unexplained case circumstances or suspicion of a criminal act. In these 72 cases, the CODs determined by EA-Triage and medico-legal autopsy matched in 71 cases (99%), and the sensitivity and specificity for detecting lethal intoxication were 100% and 90%, respectively. EA-Triage showed strong diagnostic accuracy for determining COD in drug-related deaths. This method may be suitable for enhancing preautopsy triage and guiding police investigations at an early stage.

Age estimation by evaluating median palatine suture closure using postmortem CT.

This study sought to develop an age-estimation formula to evaluate the extent of median palatine suture (MP) closure using postmortem computed tomographic (PMCT) images. The PMCT images of 634 Japanese subjects (mean age, 54.5 years; standard deviation [SD], 23.2 years) with known age and sex were examined. The degree of suture closure of the MP, anterior median palatine suture (AMP), and posterior median palatine suture (PMP) was measured and scored (suture closure score, SCS), and a single linear regression analysis was conducted with age at death. On the analysis, SCS of MP, AMP, and PMP showed a significant correlation with age (p < 0.001). The correlation coefficient of MP was higher (0.760, male; 0.803, female; and 0.779, total) than that of AMP (0.726, male; 0.745, female; and 0.735, total) or PMP (0.457, male; 0.630, female; and 0.549, total). The regression formula and standard error of estimation (SEE) of MP were calculated as Age = 100.95 × SCS + 20.51 (SEE 14.87 years) for male subjects, Age = 91.93 × SCS + 26.65 (SEE 14.12 years) for female subjects, and Age = 95.17 × SCS + 24.09 (SEE 14.59 years) for the total, respectively. In addition, another 50 Japanese subjects were randomly selected to validate the age-estimation formula. In this validation, the actual age of 36 subjects (72%) was within the estimated age ± SEE. This study showed that the age estimation formula using PMCT images of MPs was potentially useful for estimating the age of unidentified corpses.

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.

Comparison of fatal traumatic medico-legal cases with postmortem computed tomography and autopsy: A pilot study in Taiwan.

In order to determine the performance of postmortem computed tomography (PMCT) in identifying traumatic-relevant macroscopic findings in medico-legal cases, this retrospective observational pilot study involving nine trauma casualties who had received PMCT prior to autopsy. The comparison of these findings in six anatomical regions as dictated in Injury Severity Score (ISS) were performed. 104 traumatic-relevant findings were identified with achievement of 51% congruent findings. PMCT and autopsy had additionally found 22 and 29 findings respectively. PMCT had highest sensitivity for extremity injury (81.82%), followed by chest (73.91%), head, neck and face (71.43%), and abdomino-pelvic area (50%). It had excellent detection rate in abnormal air collection, fracture, foreign body localization, internal ballistic and intracranial pathology. However, the solid organ and vascular injuries as well as integumentary lesions were the major drawback. In conclusion, incorporation of PMCT to autopsy in medico-legal investigation helps to preserve the most abundant traumatic-relevant injuries compared to either modality.

Classification of rib fracture types from postmortem computed tomography images using deep learning.

Human or time resources can sometimes fall short in medical image diagnostics, and analyzing images in full detail can be a challenging task. With recent advances in artificial intelligence, an increasing number of systems have been developed to assist clinicians in their work. In this study, the objective was to train a model that can distinguish between various fracture types on different levels of hierarchical taxonomy and detect them on 2D-image representations of volumetric postmortem computed tomography (PMCT) data. We used a deep learning model based on the ResNet50 architecture that was pretrained on ImageNet data, and we used transfer learning to fine-tune it to our specific task. We trained our model to distinguish between "displaced," "nondisplaced," "ad latus," "ad longitudinem cum contractione," and "ad longitudinem cum distractione" fractures. Radiographs with no fractures were correctly predicted in 95-99% of cases. Nondisplaced fractures were correctly predicted in 80-86% of cases. Displaced fractures of the "ad latus" type were correctly predicted in 17-18% of cases. The other two displaced types of fractures, "ad longitudinem cum contractione" and "ad longitudinem cum distractione," were correctly predicted in 70-75% and 64-75% of cases, respectively. The model achieved the best performance when the level of hierarchical taxonomy was high, while it had more difficulties when the level of hierarchical taxonomy was lower. Overall, deep learning techniques constitute a reliable solution for forensic pathologists and medical practitioners seeking to reduce workload.

Postmortem computed tomography assessment of skeletal and dental age in Polish children, adolescents, and young adults.

This paper presents a retrospective analysis of postmortem computed tomography (PMCT) scans of secondary ossification centers in the medial clavicular epiphysis, iliac crest apophysis, proximal humeral epiphysis, distal femoral epiphysis, proximal tibial epiphysis, and distal tibial epiphysis. At the same time, we analyzed PMCT scans of the maxillary and mandibular incisors, canines, premolars, and molars. We assessed 203 corpses, whose age ranged from 2 to 30 years, including 156 males and 47 females. The purpose of our study was to compare the processes of secondary ossification center fusion and permanent tooth maturation. Our research hypothesis was that certain stages of skeletal and dental maturation occur along consistent timelines that can be related to the chronological age. Secondary ossification center fusion was evaluated based on Kreitner and also McKern and Steward's classifications. The process of permanent tooth maturation was evaluated with Demirjian's method. Spearman's correlation coefficients (Rho) were positive in all analyses, which indicates that epiphyseal fusion progresses with age. The strongest relationship between the age and the stages of ossification was observed in the proximal tibial epiphysis (p < 0.001; Rho = 0.93) in females and in the medial clavicular epiphysis (p < 0.001; Rho = 0.77) in males. Studies show the importance of concomitant analysis of skeletal and dental maturation with a subsequent comparison of the results to achieve a greater precision in age estimation. A comparison of the results obtained in the study population of Polish children, adolescents, and young adults with the results of other studies in populations of similar ages showed a number of similarities in the time windows of dental and skeletal maturation. These similarities may help in age estimation.

Application of Targeted Coronary Angiography in the Diagnosis of Sudden Cardiac Death.

OBJECTIVES: To diagnose coronary artery stenosis by using the postmortem computed tomography angiography (PMCTA), and to explore the diagnostic value of PMCTA in sudden cardiac death. METHODS: Six death cases were selected, and the contrast medium iohexol was injected under high pressure through femoral artery approach with 5F pigtail catheter to obtain coronary image data and then the data was analyzed. The results of targeted coronary imaging and coronary artery calcium score (CaS) were compared with the results of conventional autopsy and histopathological examination. RESULTS: The autopsy and histopathological examination of cases with coronary artery stenosis obtained similar results in targeted coronary angiography, with a diagnostic concordance rate of 83.3%. Targeted coronary angiography could effectively show coronary artery diseases, and the CaS was consistent with the results of conventional autopsy and histopathological examination. CONCLUSIONS: Targeted coronary angiography can be used as an effective auxiliary method for conventional autopsy in cases of sudden cardiac death.

Effects of blood loss on organ attenuation on postmortem CT and organ weight at autopsy.

BACKGROUND: Cases of external hemorrhage are difficult to recognize on postmortem computed tomography (PMCT). PURPOSE: To investigate the effects of blood loss on CT attenuation of the spleen, liver, kidneys, and lungs on PMCT and to assess the relationship between blood loss and organ weight. METHODS: A total of 125 cases with blood loss were sex- and age-matched to 125 control cases without blood loss. Individual organ attenuation was measured on transverse CT images. Organ weights of the liver, spleen, kidneys, and lung were extracted from the autopsy protocols. RESULTS: Organ weight was significantly lower in cases with blood loss (lung 30%, spleen 28%, kidneys 14%, liver 18%) than in controls. CT attenuation of the lungs was significantly lower (30%) in cases with blood loss than in controls. CT attenuation of the spleen and kidneys did not significantly differ between cases and controls. CT attenuation of the liver was significantly higher (25%) in cases with blood loss than in controls. CONCLUSION: Blood loss decreases organ weight and CT attenuation of the lungs but appears to have no significant effect on CT attenuation of the spleen and kidneys. The increased liver attenuation in cases with blood loss compared to controls was an unexpected finding and remains challenging to explain. One probable interpretation refers to different levels of hepatic glycogen; however, further work is warranted to substantiate this hypothesis.

Postmortem computed tomography differentiation between intraperitoneal decomposition gas and pneumoperitoneum.

PURPOSE: The aim of this study is to investigate the ability of postmortem computed tomography (PMCT) to distinguish intraperitoneal decomposition gas from pneumoperitoneum due to intestinal perforation. METHODS: This retrospective study investigated the factors affecting intraperitoneal gas in two groups of 14 decedents as detected by postmortem CT performed in the Department of Legal Medicine of Hamburg University. The first group died with a cause of death associated with intestinal perforation, and the second group with other different natural causes of death. These factors include postmortem interval, gas volume, gas distribution, radiology alteration index (RAI), and pneumoperitoneum-associated pathology. RESULTS: The findings of this study showed the appearance of specific gas distribution patterns and a significant increase in gas volumes in the cases of intestinal perforation. Moreover, postmortem interval and the pneumoperitoneum-associated pathology could help distinguish postmortem-generated gas from pneumoperitoneum. CONCLUSION: Based on the findings of this study, we propose that these findings can improve the proper detection of intestinal perforation cases in the future.

Comparison of findings identified at traditional invasive autopsy and postmortem computed tomography in suicidal hangings.

Cases of suicidal hanging are a common death referred for medico-legal autopsy throughout the world. Although some advocate using postmortem computed tomography (PMCT) without traditional invasive autopsy (TIA) to investigate such deaths, others reject this approach. There is currently limited evidence to guide practice. In this context, the TIA reports and PMCT images of 50 cases of suspected suicidal hanging during an 11-month period were reviewed. The reviewers were blinded to the findings of the other modality. A Cohen's Kappa coefficient (K) was calculated to assess agreement between TIA and PMCT across a range of pertinent findings. This analysis demonstrated perfect agreement for identification of a ligature (K = 1.00) and a strong level of agreement for identification of a ligature suspension point (K = 0.832) but only a minimal level of agreement for overall ligature mark (K = 0.223). PMCT demonstrated a weak level of agreement for fractures of hyoid bone (K = 0.555) and thyroid cartilage (K = 0.538). Three probable fractures not identified at TIA were identified on PMCT. TIA was shown to be superior in the identification of intramuscular and laryngeal fracture-related haemorrhage/bruising whereas PMCT was superior to TIA in identifying body gas deposition. There was overall good correlation between the natural disease and trauma identified elsewhere in the body during the TIA and PMCT. The study demonstrates that PMCT can assist the investigation of suspected suicidal hangings. However, the accuracy of many findings is limited, and if it is used as an alternative to the TIA, potentially pertinent findings, such as fractures of the laryngeal cartilages, could be missed.

Gunshot wounds to the head: a comparison of postmortem magnetic resonance imaging, computed tomography, and autopsy.

BACKGROUND: Postmortem imaging has become a powerful diagnostic tool in forensics. Postmortem computed tomography (PMCT) is often used currently to complement and sometimes even replace an autopsy. PURPOSE: To compare PMCT, postmortem magnetic resonance imaging (PMMRI), and autopsy findings for gunshot wounds to the head. MATERIAL AND METHODS: Cross-sectional study. We performed a retrospective analysis of 24 cases with gunshot wounds to the head that underwent both PMCT and PMMRI between 2011 and 2018 at the Institute of Forensic Medicine, University of Zurich (Switzerland). RESULTS: Our study confirms that PMCT and, to a slightly lesser degree, PMMRI provide additional information that is valuable when combined with autopsy findings. Air embolism was solely detected in PMCT (67% vs. 0% at autopsy). A retained bullet or projectile and bone fragments were diagnosed more frequently with PMCT (42%, 67%, and 92%) than at autopsy (33%, 42%, and 46%). Soft tissue lesions were more often detected with PMMRI than with PMCT. With regard to autopsy, subdural hemorrhage and ventricular hemorrhage were slightly more frequently diagnosed with PMMRI (63% and 75% vs. 38% and 58% at autopsy). Intracerebral hemorrhage was by far most often diagnosed with PMMRI (92%) compared with both PMCT (38%) and autopsy (14%). CONCLUSION: All three modalities should ideally be considered in cases of craniocerebral gunshot wounds. However, it might be conceivable that depending on the forensic query, PMCT and PMMRI may be an adequate replacement for an autopsy.

Diagnosing Drowning in Postmortem CT Images Using Artificial Intelligence.

Imaging features of the lung in postmortem computed tomography (CT) scans have been reported in drowning cases. However, it is difficult for forensic pathologists with limited experience to distinguish subtle differences in CT images. In this study, artificial intelligence (AI) with deep learning capability was used to diagnose drowning in postmortem CT images, and its performance was evaluated. The samples consisted of high-resolution CT images of the chest of 153 drowned and 160 non-drowned bodies captured by an 8- or 64-row multislice CT system. The images were captured with an image slice thickness of 1.0 mm and spacing of 30 mm, and 28 images were typically captured. A modified AlexNet was used as the AI architecture. The output result was the drowning probability for each component image. To evaluate the performance of the proposed model, the area under the receiver operating characteristic curve (AUC) was analyzed, and the AUC value of 0.95 was obtained. This indicates that the proposed AI architecture is a useful and powerful complementary testing approach for diagnosing drowning in postmortem CT images. Notably, the accuracy was 81% (62/77) for cases in which resuscitation was performed, and 92% (216/236) for cases in which resuscitation was not attempted. Therefore, the proposed AI method should not be used to diagnose the cause of death when aggressive cardiopulmonary resuscitation was performed. Additionally, because honeycomb lungs are likely to exhibit different morphologies, emphysema cases should also be treated with caution when the proposed AI method is used to diagnose drowning.

Diagnostic Accuracy of Liver Damage Based on Postmortem Computed Tomography Findings in High-Energy Trauma.

The liver is an organ that is frequently injured by blunt trauma. In clinical medicine, contrast-enhanced computed tomography (CT) is useful for diagnosing liver damage. However, detection of liver injury is difficult with postmortem CT (PMCT) that does not use contrast media. This study aims to identify findings that are useful for diagnosing liver injury with PMCT. This study included 97 high-energy trauma cases that underwent both PMCT without contrast and forensic autopsy between July 2009 and November 2020. PMCT findings in and around the liver in cases of liver injury were collected. The diagnostic accuracy of each finding was calculated. Of 97 cases, 62 had liver injury on autopsy. PMCT detected hepatic surface gas in 31 cases, intrahepatic focal gas in 19 cases, high-density fluid accumulation around the liver in 12 cases, and fracture of a right lower (9th-12th) rib in 48 cases. Abnormal PMCT findings in and around the liver had insufficient diagnostic sensitivity, ranging from 19.4% to 38.7%. By contrast, the finding of a right lower rib fracture was more sensitive for suspected liver injury. Our results indicate that abdominal liver findings (hepatic surface gas, intrahepatic focal gas, and high-density fluid accumulation around the liver) are of limited utility for the diagnosis of liver injury, whereas a right lower rib fracture is a useful indirect finding.

[Postmortem computed tomography of the frozen corpse]. / Posmertnaya komp'yuternaya tomografiya oledenevshego trupa.

The purpose of the work is to identify the possibilities of computed tomography in establishing postmortem changes in the bones of the skeleton and internal organs during in a frozen corpse. The article describes a case from thanatological practice with the performance of a pre-sectional computed tomography of a corpse of a young woman found in a forest in a state of complete freezing. As a result of the study, CT images of frozen internal organs were obtained, which are never found in clinical practice. Significant changes in the CT pattern were revealed due to a decrease in the density of the frozen zones. The use of pre-sectional computed tomography enabled to identify postmortem changes in internal organs formed during freezing of the corpse; the position of the corpse during its glaciation and the uniformity of the freezing process.

Diagnostic accuracy of postmortem computed tomography for bleeding source determination in cases with hemoperitoneum.

AIM: The aim of this retrospective study was to determine the accuracy of postmortem computed tomography and different radiological signs for the determination of the bleeding source in cases with hemoperitoneum confirmed at autopsy. METHODS: Postmortem computed tomography data of consecutive cases with hemoperitoneum confirmed at autopsy were reviewed by two raters, blinded to the autopsy findings. The determination of possible bleeding sources was based on the presence of the sentinel clot sign, blood or sedimented blood surrounding an organ, intraparenchymal abnormal gas distribution, and parenchymal disruption. The bleeding source and the cause of hemoperitoneum (traumatic, surgical, natural, or resuscitation) as reported in the autopsy report were noted. The survival intervals of the deceased were calculated when information about the time of an incident related to death was available in the autopsy reports. RESULTS: Eighty-five cases were included in the study. Postmortem computed tomography showed 79% sensitivity and 92.1% specificity for the detection of the bleeding source. The sentinel clot sign was associated with surgical or natural causes of hemoperitoneum and longer survival intervals. Sedimented blood around the bleeding source was associated with resuscitation. Abnormal gas distribution within organs and combination of multiple radiological signs provided higher sensitivity. CONCLUSION: Postmortem computed tomography provides moderate sensitivity and high specificity for determining the bleeding source in cases with hemoperitoneum. Different PMCT signs are associated with different causes of hemoperitoneum and survival intervals.

A review of visualization techniques of post-mortem computed tomography data for forensic death investigations.

Postmortem computed tomography (PMCT) is a standard image modality used in forensic death investigations. Case- and audience-specific visualizations are vital for identifying relevant findings and communicating them appropriately. Different data types and visualization methods exist in 2D and 3D, and all of these types have specific applications. 2D visualizations are more suited for the radiological assessment of PMCT data because they allow the depiction of subtle details. 3D visualizations are better suited for creating visualizations for medical laypersons, such as state attorneys, because they maintain the anatomical context. Visualizations can be refined by using additional techniques, such as annotation or layering. Specialized methods such as 3D printing and virtual and augmented reality often require data conversion. The resulting data can also be used to combine PMCT data with other 3D data such as crime scene laser scans to create crime scene reconstructions. Knowledge of these techniques is essential for the successful handling of PMCT data in a forensic setting. In this review, we present an overview of current visualization techniques for PMCT.

Evaluation of the mediastinal-thoracic volume ratio on postmortem computed tomography.

OBJECTIVES: The aim of this study was to measure the mediastinal-thoracic volume ratio (CTR_VOL) on PMCT as a more accurate version of traditional CTR, in order to assess the terminal positional relationship between the heart and lungs in the different causes of death with regard to age, gender, BMI, cardiomegaly, and lung expansion. MATERIALS: Two hundred fifty consecutive postmortem cases with pre-autopsy PMCT and full forensic autopsy were retrospectively evaluated. The lungs and the mediastinum were manually segmented on the PMCT data and the correspondent volumes were estimated in situ. CTR_VOL was calculated as the ratio of the mediastinal to the thoracic volume. The volume measurements were repeated by the same rater for the evaluation of the intrarater reliability. Age, gender, body weight and height, heart weight at autopsy, and cause of death were retrieved from the autopsy reports. Presence of lung expansion was radiologically evaluated in situ. RESULTS: CTR_VOL was positively associated with age and BMI but not with gender and was higher for cardiomegaly compared to normal hearts, lower for asphyxiation-related deaths compared to cardiac deaths and intoxications, and lower for cases with lung expansion. The intrarater reliability was excellent for the calculated volumes of both lungs and mediastinum. CONCLUSION: The results of the present study support CTR_VOL as a tool to assess the relationship between the heart and lungs in situ, which differs significantly between the studied cause of death categories.