Added value of postmortem mri in sudden unexpected infant death cases.

We aimed to investigate the potential added value of postmortem MRI (PMMRI) in sudden unexpected infant death (SUID) cases referred to our center between September 2020 and June 2023. Ultimately, 19 SUID cases underwent PMMRI alongside standard autopsy procedures, which included technical examinations such as postmortem CT (PMCT). Four radiologists, two with prior PMMRI experience, provided structured reports following consensus. For each case, the responsible forensic medicine specialist documented the cause of death before and after reviewing the PMMRI report. Additionally, they assessed the overall impact of the PMMRI report and had the opportunity to provide written comments. The results of our study indicate that none of the PMMRI reports altered the prior determined cause of death, which included cases of infection, asphyxia, and sudden infant death syndrome (SIDS). However, we observed a moderate impact in one case and a low impact in 10 cases. The moderate impact arose from the PMMRI report identifying hypoxic-ischemic changes, where histologic examination of the brain was perceived as normal. Conversely, in the 10 cases with a low impact, the PMMRI reports supported the autopsy findings, specifically indicating brain injury and intra-alveolar cellular infiltrates. In conclusion, our study suggests that while PMMRI may not be pivotal in determining the cause of death in SUID cases, it could aid in detecting hypoxic-ischemic changes and reinforcing brain and lung observations. However, distinguishing genuine lung pathology from postmortem changes using PMMRI remains challenging. Further research is warranted to clarify the role of PMMRI in forensic SUID investigations.

Fracture patterns of the hyoid-larynx complex after fatal trauma on the neck: retrospective radiological postmortem analysis of 284 cases.

PURPOSE: Fatal trauma on the neck occurs frequent in forensic cases and often results in fractures of the hyoid-larynx complex. The aim of the present study is to provide an overview of fractures in the hyoid-larynx complex that occur due to fatal trauma on the neck and can be observed by radiological evaluation. METHODS: Radiological images from a forensic radiological database created in -BLINDED- were used for analysis. Hyoid-larynx complexes were explanted in 284 individuals who accordingly to the forensic pathologist allegedly died from fatal trauma on the neck. These explants were imaged with conventional X-rays in eight directions and a CT scan. Radiological images were analyzed for fractures, dislocations, joints, and anatomical variations by a trained analyst and a radiologist. RESULTS: In 281/284 cases, the hyoid bone and, in 252/284 cases, the thyroid cartilage could be assessed. In 56 victims (20%), the hyoid bone was fractured, 55 times in the greater horn, 1 fracture in the body. The calcified superior horn of the thyroid showed a fracture in 101 victims (40%). The calcified cricoid cartilage was fractured in one case. Multiple fractures were found in 31/284 cases (11%). Joints between the greater horn and body of the hyoid were present in 74%. CONCLUSION: Trauma on the neck leads most frequently to fractures of the superior horn of the thyroid cartilage and second most to fractures in the greater horn of the hyoid bone. (Forensic) radiologists should be aware of uncommon fracture locations, anatomical variations, and dislocations in the hyoid-larynx complex.

Massive gas embolisms in diving fatalities visualized by radiology and neuropathology.

Massive vascular gas embolism is a feared and often lethal symptom of decompression illness, resulting from diving accidents. The aim of this case report was to correlate post-mortem computed tomography scan (PMCT) findings with autopsy in cases of massive vascular gas embolism. Two cases of fatal diving accidents were retrospectively selected from a forensic radiological pathological database. The PMCT results were initially shared with the forensic pathologist prior to autopsy, enabling a more accurate overall assessment. Both cases were in retrospect thoroughly studied to compare the PMCT findings with the autopsy results. In general, intra- and extra-vascular gas collections are easily detected on PMCT in all body regions. We focused on abundant intravascular gas collections, mainly in the large brain vessels. General autopsy findings are described in both cases, and in one case we elaborate on specific intracerebral changes found at autopsy. Both cases were diagnosed as pulmonary barotrauma with subsequent vascular gas embolisms. We conclude that PMCT excels in the detection of macroscopic gas collections in the body, whereas microscopic gas collections identified at autopsy aid in the differentiation between decompression sickness and pulmonary barotrauma followed by vascular gas embolism. The presented cases highlight the advantages of using both PMCT and autopsy in the post-mortem evaluation of fatal diving accidents.

The value of post-mortem computed tomography of burned victims in a forensic setting.

OBJECTIVES: Fire deaths are challenging fatalities for forensic pathologists, as the main question of whether death was due to the fire or not needs to be answered. In this retrospective study, we assessed whether post-mortem computed tomography (PMCT) has an added value prior to a forensic autopsy of burned victims. METHODS: From 2008 to 2016, a PMCT was performed in 50 burned corpses prior to a complete forensic autopsy. In retrospect, all 50 PMCT scans were systematically assessed by a forensically experienced radiologist, masked from the autopsy reports. Subsequently, the PMCT findings were compared with the autopsy reports. RESULTS: Heat fractures, contractions and destruction of extremities, subcutaneous emphysema and post-mortem gas collections were easier to detect by PMCT compared to autopsy. Alterations by penetrating and blunt trauma and the presence of foreign bodies were easy to detect by PMCT as well by autopsy. PMCT was, however, not successful in detecting signs of vitality during the fire, detection of superficial thermal injuries and to answer the main question of the forensic autopsy, which is to investigate the cause of death. CONCLUSIONS: PMCT prior to autopsy is a valuable add-on in the post-mortem forensic investigation of burned victims for detection of hidden signs of trauma, gas collections and foreign bodies. However, since PMCT cannot answer the two main questions in forensic examination-determining the cause of death and detecting signs of vitality during the fire-it cannot replace an autopsy. KEY POINTS: • Post-mortem CT (PMCT) in burned victims shows hidden signs of trauma. • Foreign bodies and gas collections can easily be detected. • Cause of death and vitality signs cannot be assessed by PMCT.

Fatalities, Cerebral Hemorrhage, and Severe Cardiovascular Toxicity After Exposure to the New Psychoactive Substance 4-Fluoroamphetamine: A Prospective Cohort Study.

STUDY OBJECTIVE: We study adverse health effects after use of the new psychoactive substance 4-fluoroamphetamine. METHODS: All patients who reported 4-fluoroamphetamine exposure and for whom the Dutch Poisons Information Center was consulted by their physician in 2016 were included in a prospective cohort study. The clinical course was investigated through telephone interviews with the physician and/or patient, using standardized questionnaires. 4-Fluoroamphetamine was analyzed in remaining drug material and biological samples with liquid and gas chromatography-mass spectrometry techniques. RESULTS: We included 45 patients, and follow-up with the physician and/or patient was performed in 33 cases. All patients experienced adverse effects after 4-fluoroamphetamine use. Severe toxicity was reported in 8 patients. In 5 of these patients, 4-fluoroamphetamine exposure was confirmed in biological specimens. Severe toxicity that was reported included 2 fatalities, 4 patients with cerebral hemorrhage (1 fatal), 2 patients with inverted Takotsubo's cardiomyopathy, 1 patient with myocardial infarction, 1 patient with acute heart failure, and an overall high prevalence of pronounced hypertension and tachycardia. CONCLUSION: Since the introduction of 4-fluoroamphetamine to the Dutch drug market in 2007, its use continues to increase, possibly because users perceive it as "ecstasy light" and thus relatively safe. However, the proportion of patients with severe toxicity after 4-fluoroamphetamine use is relatively large in our study population. Therefore, users should be warned about the risks of 4-fluoroamphetamine.

Postmortem radiological case series of acetabular fractures after fatal aviation accidents.

The purpose of this study was to describe radiological fracture patterns of the acetabulum sustained after fatal small aircraft aviation accidents, aiming at facilitating a better understanding of trauma mechanisms in a forensic setting. Postmortem conventional radiographs or CT scans of 29 victims of 20 small aircraft aviation accidents were analyzed for skeletal acetabular trauma. Among the 29 fatalities (27 males and 2 females, median age 55 years (range: 21-76 years)), 20 victims had pelvic fractures (69%), of which 19 victims (66%) had one or more acetabular fractures. Bilateral acetabular fractures occurred in 11 victims. When considering left and right acetabula in each victim as separate entities, 38 of the 58 acetabula included in this case series exhibited one or more fractures. Both the anterior and posterior acetabular columns were fractured in 28 acetabula. Acetabular fractures were frequently encountered in this series of 29 victims of small fatal aircraft accidents. Fractures of the acetabulum occur from ventrally directed impact (i.e. to the knee) or laterally directed impact (i.e. to the greater trochanter of the femur). Radiological descriptions of the fracture patterns can therefore aid in the forensic analysis of the mechanism of trauma in aviation accidents. Postmortem multi-slice CT scan images are preferrable in the assessment of acetabular fractures.

Correction to: Fracture patterns of the hyoid-larynx complex after fatal trauma on the neck: retrospective radiological postmortem analysis of 284 cases.

PURPOSE: Fatal trauma on the neck occurs frequent in forensic cases and often results in fractures of the hyoid-larynx complex. The aim of the present study is to provide an overview of fractures in the hyoid-larynx complex that occur due to fatal trauma on the neck and can be observed by radiological evaluation. METHODS: Radiological images from a forensic radiological database created in the Groene Hart Hospital, Gouda, the Netherlands were used for analysis. Hyoid-larynx complexes were explanted in 284 individuals who accordingly to the forensic pathologist allegedly died from fatal trauma on the neck. These explants were imaged with conventional X-rays in eight directions and a CT scan. Radiological images were analyzed for fractures, dislocations, joints, and anatomical variations by a trained analyst and a radiologist. RESULTS: In 281/284 cases, the hyoid bone and, in 252/284 cases, the thyroid cartilage could be assessed. In 56 victims (20%), the hyoid bone was fractured, 55 times in the greater horn, 1 fracture in the body. The calcified superior horn of the thyroid showed a fracture in 101 victims (40%). The calcified cricoid cartilage was fractured in one case. Multiple fractures were found in 31/284 cases (11%). Joints between the greater horn and body of the hyoid were present in 74%. CONCLUSION: Trauma on the neck leads most frequently to fractures of the superior horn of the thyroid cartilage and second most to fractures in the greater horn of the hyoid bone. (Forensic) radiologists should be aware of uncommon fracture locations, anatomical variations, and dislocations in the hyoid-larynx complex.

Postmortem CT compared to autopsy in children; concordance in a forensic setting.

OBJECTIVES: The aim of this study is to assess the accuracy of postmortem CT (PMCT) in determining the cause of death in children who underwent a forensic autopsy because of a suspected nonnatural death. METHODS: We selected forensic pediatric autopsies at the Netherlands Forensic Institute, whereby the subject underwent PMCT between 1-1-2008 and 31-12-2012. Cause of death was independently scored by a radiologist and a pathologist. Cause of death was classified (1) in categories being natural, unnatural, and unknown; (2) according to the ICD-10; and (3) according to institutional classification. RESULTS: In the study period, 189 pediatric forensic autopsies were performed. Fifteen were excluded because of putrefaction. Of the remaining 174 autopsies, 98 (56%) underwent PMCT. PMCT and autopsy identified the same category in 69/98 cases (70%, kappa 0.49). They identified the same cause of death in 66/98 cases (67%, kappa 0.5) using ICD-10; in 71/98 (72%, kappa 0.62) using a forensic classification. PMCT performed better in unnatural deaths (59-67 % agreement) than in natural deaths (0 % agreement). If no cause of death was detected with autopsy, PMCT failed to identify a cause of death in 98% (39/40). CONCLUSIONS: Pediatric PMCT does identify the majority of unnatural causes of death, but does not identify new diagnoses (true positives) if no cause of death is found during autopsy. Diagnostic accuracy in natural deaths is low. KEY POINTS: • The case mix is an important predictor for the concordance between PMCT and autopsy. • In case of an unnatural death, 72--81% of PMCT results matches autopsy results. • In case of a natural death, 0% of PMCT results matches autopsy results. • If no cause of death is identified with autopsy, 98% of PMCT results concurs.

An open-source, three-dimensional growth model of the mandible.

The available reference data for the mandible and mandibular growth consists primarily of two-dimensional linear or angular measurements. The aim of this study was to create the first open-source, three-dimensional statistical shape model of the mandible that spans the complete growth period. Computed tomography scans of 678 mandibles from children and young adults between 0 and 22 years old were included in the model. The mandibles were segmented using a semi-automatic or automatic (artificial intelligence-based) segmentation method. Point correspondence among the samples was achieved by rigid registration, followed by non-rigid registration of a symmetrical template onto each sample. The registration process was validated with adequate results. Principal component analysis was used to gain insight in the variation within the dataset and to investigate age-related changes and sexual dimorphism. The presented growth model is accessible globally and free-of-charge for scientists, physicians and forensic investigators for any kind of purpose deemed suitable. The versatility of the model opens up new possibilities in the fields of oral and maxillofacial surgery, forensic sciences or biological anthropology. In clinical settings, the model may aid diagnostic decision-making, treatment planning and treatment evaluation.

Prevalence of Pulmonary Bullae and Blebs in Postmortem CT Imaging With Potential Implications for Diving Medicine.

BACKGROUND: Pulmonary bullae and blebs can result in a pneumothorax. Their prevalence in the normal population is currently unknown. Postmortem CT (PMCT) images from a forensic database were used to determine the prevalence of pulmonary bullae/blebs in the normal Dutch adult population and its consequence for diving medicine, as bullae and blebs are often considered a contraindication for diving. METHODS: Forensic PMCT scans of 130 adults were analyzed for the presence of bullae and/or blebs in a cross-section of the Dutch population without pulmonary disorders. The lungs had to be unharmed, expanded, and without signs of illnesses. Normal early-stage postmortem changes in the lungs were accepted. RESULTS: Analysis was performed per decade. Group I (aged 21-30 years) included 26 patients. Blebs were observed in four persons; one exhibited blebs and bullae. Group II (aged 31-40 years) included 28 patients; blebs were observed in nine individuals, one with bullae. Group III (aged 41-50 years) included 27 patients; blebs were noted in nine individuals, bullae in one, and bullae and blebs in four. Group IV (aged 51-60 years) included 28 patients; blebs were noted in seven individuals and two with bullae and blebs. Group V (aged 61-70 years) included 21 patients; blebs were noted in three persons, bullae and blebs in two, and isolated bullae in one. On average, most bullae/blebs were < 10 mm, and none exceeded 20 mm. CONCLUSIONS: By reassessing pulmonary PMCT scans, we found a surprisingly high incidence of small bullae and/or blebs in one-third (33.8%; 95% CI, 25.7-41.9) of the general population without underlying lung disease. This finding can have potential implications for diving medicine.

Variants of the hyoid-larynx complex, with implications for forensic science and consequence for the diagnosis of Eagle's syndrome.

Thorough anatomic knowledge of the hyoid-larynx complex is necessary for forensic radiologists and ear-nose-throat surgeons, given the many anatomic variations that originate in embryology. In forensics the anomalies must be distinguished from fractures because the latter are indicative of violence on the neck. In this manuscript we describe the anatomical variations that can be found in the hyoid-larynx complex and explain their etiology. 284 radiological scans of excised hyoid-larynx complexes were examined with X-ray and CT. Some rare cases from literature and historical collections were added. Two third of the examined hyoid-larynx complexes deviated from the anatomical standard and showed uni- or bilateral ankylosis in the hyoid bone and/or so-called triticeal cartilages. In one fifth of the cases we found striking anatomical variants, mostly derived from the cartilage of the second pharyngeal arch. Anatomical variations of the hyoid-larynx complex can be explained by embryological development. The aberrant hyoid apparatus and the elongated styloid processes (Eagle syndrome) should be considered as one clinical entity with two different expressions as both anomalies are derived from the cartilage of the second pharyngeal arch. Several variants can mimic fractures in this region, so our study is important for radiologists and forensic experts assessing cases of possible violence on the neck.

The development of the human hyoid-larynx complex revisited.

OBJECTIVES/HYPOTHESIS: The hyoid-larynx complex is highly prone to anatomical variation. The etiology of anatomical variants such as Eagle's syndrome and the aberrant hyoid apparatus can be explained from embryonic development. Modern textbooks state that the hyoid bone body develops from the second and third pharyngeal arch cartilages, and that thyroid cartilage derives from the fourth and sixth arch cartilages. This description, however, is incompatible with various anatomical variants, and it is unclear whether it was based on observations in human embryos or on comparative embryology. STUDY DESIGN: 14 human embryos from the Carnegie collection between Carnegie stage 17 and 23 (42-60 days) were selected based on their histological quality. METHODS: Histological sections of the selected embryos were examined. Three-dimensional models were prepared in an interactive format. These anatomical models provide crucial spatial information and facilitate interpretation. RESULTS: We observed a less-complicated development of the hyoid-larynx complex than is currently described in textbooks. The body of the hyoid bone originates from a single growth center, without overt contributions from second and third pharyngeal arch cartilages. The fourth and sixth arch cartilages were not detected in human embryos; the thyroid and cricoid cartilages develop as mesenchymal condensations in the neck region. CONCLUSIONS: Despite new research techniques, theories about hyoid-larynx complex development from the beginning of the 20th century have not been refuted properly and can still be found in modern literature. Based on observations in human embryos, we propose a new and relatively simple description of the development of the hyoid-larynx complex to facilitate better understanding of the etiology of anatomical variants. LEVEL OF EVIDENCE: NA Laryngoscope, 1829-1834, 2018.

Pneumomediastinum and soft tissue emphysema in pediatric hanging.

Postmortem computed tomography (CT) is increasingly being used as a tool in forensic pathology. The exact value of postmortem imaging in detecting specific conditions has not yet been established, but in specific cases, it can be used as a diagnostic tool demonstrating findings that remain undetected during autopsy, as in this case. Pneumomediastinum and soft tissue emphysema were detected with postmortem CT in a 3-year-old girl after hanging. It was not found during autopsy. This radiological finding matches 3 adult cases previously described. It is assumed that in this case, the first reported in a child, hanging was the most likely cause as well. In the adult cases, it was interpreted as a vital sign; the person must have been alive to create a pressure gradient causing rupture of the alveoli. This case demonstrates one of the added values of postmortem imaging, the possibility of demonstrating findings that remain undetected during autopsy.

[Neonaticide: frequently suspected, seldom proven]. / Neonaticide: vaak vermoed, zelden bewezen.

OBJECTIVE: To present an overview of pathological findings on neonaticide in the Netherlands. DESIGN: Retrospective descriptive study. METHOD: We analyzed all autopsy reports on neonates from the Netherlands Forensic Institute for the period 1994-2011. We collected data on gestational age, how the body had been discovered and autopsy results. RESULTS: We included details of 78 victims; 61 (78%) had been born at full term and 17 (22%) prematurely. Half of the victims were girls, 40% were boys and in 10% the state of the body meant that it was not possible to determine the sex. Minimal, moderate and severe putrefaction was observed in 29 bodies (37%), 15 bodies (19%) and 34 bodies (44%), respectively. In the cases with moderate or severe decomposition it was not possible to determine with certainty whether the child had been born alive and, if applicable, the cause of death. Of the remaining 29 cases with minimal decomposition, 1 had been stillborn; a possible cause of death could be determined in 12 cases. CONCLUSION: In the Netherlands 4 to 5 forensic autopsies are performed annually in cases of suspected neonaticide. In most cases decomposition is already too advanced to be able to determine whether there was any sign of life at birth and to establish the cause of death, if applicable.

[Unnatural death due to child abuse--forensic autopsies 1996-2009]. / Niet-natuurlijk overlijden door kindermishandeling; gerechtelijke secties 1996-2009.

OBJECTIVE: To evaluate the number of cases of fatal child abuse in minors on whom forensic autopsy was carried out in the Netherlands during the period 1996-2009 and to compare the 1996 data with Dutch data published earlier by Kuyvenhoven et al. (a questionnaire study among general practitioners and paediatricians). DESIGN: Descriptive retrospective study. METHOD: Cases of unnatural death from all forensic autopsies on fetuses, children and young adults (> 24 weeks and < 18 years; n = 688) over the past 14 years (1996-2009) were retrospectively analyzed for child abuse. By means of death certificates and suspected cause of death, the actual outcomes of the 1996 data were compared with those of the study of Kuyvenhoven et al. RESULTS: Over the past 14 years, in 445 of 688 forensic cases (65%) in this study population, cause of death was demonstrated to be unnatural. Of these deaths, 54% (n = 239/445) were unnatural and non-accidental due to child abuse. This corresponded with an annual average of 15 (30%) 'proven' and 2 (5%) 'highly probable' cases of fatal child abuse. The total number of abandoned babies, foundlings and otherwise, was on average 4 per year. In 1996 57% (13/23) of fatal child abuse cases were not represented in the data published by Kuyvenhoven et al. CONCLUSION: Of the 49 foetuses, children and young adults on whom forensic autopsy was carried out in the Netherlands each year, 17 (35%) died due to proven or highly probable child abuse. In 1996 more than half of the number of fatal cases of child abuse of the Netherlands Forensic Institute were not represented in the study of Kuyvenhoven et al. In both this study and in the one of Kuyvenhoven underreporting is highly probable.

Embryology, normal anatomy, and imaging techniques of the hyoid and larynx with respect to forensic purposes: a review article.

Experiences with pre- and postmortem imaging in a forensic setting create more and more interest. If autopsy is permitted, forensic pathologists perform careful examination of the neck structures, which plays an important role as this is decisive in the diagnostics of compressive neck injury. Primary tools are important: forensic pathologists and radiologists are supposed to be aware of the complex anatomy of the neck, especially the laryngeal region, to interprete their findings at autopsy and after imaging. It is of great interest whether CT and MR imaging techniques would be useful in comparing findings of autopsy and document findings if autopsy is refused. In the light of this, the embryology, anatomy and a review of imaging techniques of the neck will be highlighted in this article, with special attention to the value of updated imaging techniques of the larynx for forensic purposes in living people and postmortem.

Bone scintigraphy predicts the risk of spinal cord compression in hormone-refractory prostate cancer.

In prostate cancer, confirmation of metastatic involvement of the skeleton has traditionally been achieved by bone scintigraphy, although the widespread availability of prostate-specific antigen (PSA) measurements has tended to eliminate the need for this investigation. The potential of bone scintigraphy to predict skeletal-related events, particularly spinal cord compression, after the onset of hormone refractoriness has never been investigated. The aim of this study was to establish whether a new method of evaluating bone scintigraphy would offer a better predictive value for this complication of the metastatic process than is achieved with currently available grading methods. We studied 84 patients with hormone-refractory prostate cancer who had undergone bone scintigraphy at the time of hormone escape. Tumour grading and parameters of tumour load (PSA and alkaline phosphatase activity) were available in all patients. The incidence of spinal cord compression was documented and all patients were followed up until death. Bone scintigraphy was evaluated by the conventional Soloway grading and by an additional analysis determining total or partial involvement of individual vertebrae. In contrast to the Soloway method, the new method was able to predict spinal cord compression at various spinal levels. Our data suggest that there is still a place for bone scintigraphy in the management of hormone-refractory prostate cancer.