Virtual autopsy and forensic anthropology of a mummified fetus: a report of one case.

A jar containing the mummified body of a fetus was found in a bush near a building. Full-body multislice computed tomography (MSCT) was performed prior to autopsy to study the bones and internal organs. Age was estimated by measuring femoral and tibial lengths and examining the temporal and occipital bones. The results were then compared with the autopsy and histopathological findings. MSCT was superior to autopsy for examination of the bones and internal organs. Autopsy was difficult because of the fragility of the dried corpse. MSCT determined the gestational age of the fetus and excluded skeletal abnormalities. Estimated age was similar with the two methods used. However, the major advantage of MSCT was rapid measurement of bones or anatomical regions which are difficult to examine during autopsy and which required specific preparation for further anthropological study. This case report illustrates the possibilities offered by MSCT for studying mummified bodies, even fetuses.

Application of the Iscan method to two- and three-dimensional imaging of the sternal end of the right fourth rib.

Age determination is a major field of interest in physical and forensic anthropology. Among the different methods based on macroscopic skeletal study, the Iscan method, which analyzes the sternal end of the right fourth rib, is one of the most reliable. We applied the Iscan method to two- and three-dimensional multislice computed tomography (MSCT) reconstructions of the sternal end of the right fourth rib on 39 ribs. The intra-observer variability on MSCT reconstructions was good (gamma coefficient equal to 0.86; value of the Krippendorff's alpha reliability equal to 0.79); inter-observer variability on MSCT reconstructions was also good (gamma coefficient ranging from 0.82 to 0.88; value of the Krippendorff's alpha reliability ranging from 0.78 to 0.86). We demonstrated excellent agreement between the results of analysis of bone samples and those of the two- and three-dimensional images, in particular regarding bone projections, morphology of the pit and of its rim. The accuracy of age estimation did not significantly differ between the Iscan method applied to dry bones and the same method applied to MSCT images. Determination of the Krippendorff's alpha reliability coefficient for the inter-error method confirmed the agreement between phase estimations obtained with the two methods (ranging from 0.55 to 0.71). The real civil age was comprised in 21 cases out of 36 for assessment performed on dry bones and in 23 cases out of 36 on MSCT reconstructions, which represented 58.3% and 63.9%, respectively. Use of MSCT reconstructions in forensic anthropology offers many advantages: no bone preparation, no damage to bone material, and the possibility of application to living individuals.

Magnetic resonance imaging measurements of vascular permeability and extracellular volume fraction of breast tumors by dynamic Gd-DTPA-enhanced relaxometry.

Vascular permeability (k(ep), min(-1)) and extracellular volume fraction (v(e)) are tissue parameters of great interest to characterize malignant tumor lesions. Indeed, it is well known that tumors with high blood supply better respond to therapy than poorly vascularized tumors, and tumors with large extracellular volume tend to be more malignant than tumors showing lower extracellular volume. Furthermore, the transport of therapeutic agents depends on both extracellular volume fraction and vessel permeability. Thus, before treatment, these tissue parameters may prove useful to evaluate tumor aggressiveness and to predict responsiveness to therapy and variations during cytotoxic therapies could allow to assess treatment efficacy and early modified therapy schedules in case of poor responsiveness. As a consequence, there is a need to develop methods that could be routinely used to determine these tissue parameters. In this work, blood-tissue permeability and extracellular volume fraction information were derived from magnetic resonance imaging dynamic longitudinal relaxation rate (R(1)) mapping obtained after an intravenous bolus injection of Gd-DTPA in a group of 92 female patients with breast lesions, 68 of these being histologically proven to be with carcinoma. For the sake of comparison, 24 benign lesions were studied. The measurement protocol based on two-dimensional gradient echo sequences and a monoexponential plasma kinetic model was that validated in the occasion of previous animal experiments. As a consequence of neoangiogenesis, results showed a higher permeability in malignant than in benign lesions, whereas the extracellular volume fraction value did not allow any discrimination between benign and malignant lesions. The method, which can be easily implemented whatever the imaging system used, could advantageously be used to quantify lesion parameters (k(ep) and v(e)) in routine clinical imaging. Because of its large reproducibility, the method could be useful for intersite comparisons and follow-up studies.

Virtual autopsy and forensic identification-practical application: a report of one case.

The body of an unidentified elderly woman was found trapped in a floodgate. Prior to autopsy, full-body multislice computed tomography (MSCT) was performed for study of bone lesions and cause of death. Age was estimated by analysis of the sternal end of the fourth rib and of the pubic symphyseal medial articular surfaces. The results were then compared with the autopsy findings. MSCT was superior to autopsy in diagnosis of traumatic bone lesions and also revealed dental anomalies and signs of drowning. Age estimation gave a similar result for both methods. This case report illustrates the potential value of MSCT for medico-legal investigations of death: diagnosis of injuries, possibility of determining the cause of death, and anthropological study in order to estimate age or to visualize features likely to enable identification of a corpse.

[Conservative management of renal haemangioma: value of a synergistic combination of flexible ureteroscopy and CT angiography]. / Traitement conservateur d'un hémangiome rénal: intérêt de la synergie urétéroscopie souple et artériotomodensitométrie.

Renal haemangioma (RH) is a rare congenital vascular lesion that is frequently responsible for macroscopic haematuria. This lesion is difficult to diagnose preoperatively despite progress in imaging techniques. These diagnostic difficulties account for the high rate of radical treatment (nephrectomy or nephro-ureterectomy) due to a suspicion of renal carcinoma or upper urinary tract tumour. However, conservative diagnostic and therapeutic management can be performed by a combination of CT angiography, flexible ureteroscopy and selective embolization.

Post-traumatic venous and systemic air embolism associated with spinal epidural emphysema: multi-slice computed tomography diagnosis.

A 30-year-old man was admitted with chest trauma after a road traffic accident. The patient was paraplegic and suffered from transient monoparesia of the left arm. The chest X-ray revealed a severe right tension pneumothorax and thoracic spine fractures. Emergency right thoracic drainage was carried out followed by angiography. Unfortunately the patient died and an autopsy was not permitted. Consequently post-mortem multi-slice computed tomography (MSCT) was performed, revealing presence of air inside the right cerebral arteries, bilateral pneumothorax accompanied by a severe right tension pneumothorax, bilateral haematic pleural effusion, pneumomediastinum and bilateral lung contusions. Air was also observed within the right coronary artery, ascending aorta and right ventricle. Thoracic and cervical spinal epidural emphysema were diagnosed. Venous air embolism followed by arterial air embolism producing paradoxical embolism was diagnosed. To the best of our knowledge, this is the first case illustrating by post-mortem MSCT such simultaneous complications after chest trauma as spinal epidural emphysema and cerebral and coronary air embolism.

SFE/SFHTA/AFCE consensus on primary aldosteronism, part 4: Subtype diagnosis.

To establish the cause of primary aldosteronism (PA), it is essential to distinguish unilateral from bilateral adrenal aldosterone secretion, as adrenalectomy improves aldosterone secretion and controls hypertension and hypokalemia only in the former. Except in the rare cases of type 1 or 3 familial hyperaldosteronism, which can be diagnosed genetically and are not candidates for surgery, lateralized aldosterone secretion is diagnosed on adrenal CT or MRI and adrenal venous sampling. Postural stimulation tests and (131)I-norcholesterol scintigraphy have poor diagnostic value and (11)C-metomidate PET is not yet available. We recommend that adrenal CT or MRI be performed in all cases of PA. Imaging may exceptionally identify adrenocortical carcinoma, for which the surgical objectives are carcinologic, and otherwise shows either normal or hyperplastic adrenals or unilateral adenoma. Imaging alone carries a risk of false positives in patients over 35 years of age (non-aldosterone-secreting adenoma) and false negatives in all patients (unilateral hyperplasia). We suggest that all candidates for surgery over 35 years of age undergo adrenal venous sampling, simultaneously in both adrenal veins, without ACTH stimulation, to confirm the unilateral form of the hypersecretion. Sampling results should be confirmed on adrenal vein cortisol assay showing a concentration at least double that found in peripheral veins. Aldosterone secretion should be considered lateralized when aldosterone/cortisol ratio on the dominant side is at least 4-fold higher than contralaterally.

SFE/SFHTA/AFCE primary aldosteronism consensus: Introduction and handbook.

The French Endocrinology Society (SFE) French Hypertension Society (SFHTA) and Francophone Endocrine Surgery Association (AFCE) have drawn up recommendations for the management of primary aldosteronism (PA), based on an analysis of the literature by 27 experts in 7 work-groups. PA is suspected in case of hypertension associated with one of the following characteristics: severity, resistance, associated hypokalemia, disproportionate target organ lesions, or adrenal incidentaloma with hypertension or hypokalemia. Diagnosis is founded on aldosterone/renin ratio (ARR) measured under standardized conditions. Diagnostic thresholds are expressed according to the measurement units employed. Diagnosis is established for suprathreshold ARR associated with aldosterone concentrations >550pmol/L (200pg/mL) on 2 measurements, and rejected for aldosterone concentration<240pmol/L (90pg/mL) and/or subthreshold ARR. The diagnostic threshold applied is different if certain medication cannot be interrupted. In intermediate situations, dynamic testing is performed. Genetic forms of PA are screened for in young subjects and/or in case of familial history. The patient should be informed of the results expected from medical and surgical treatment of PA before exploration for lateralization is proposed. Lateralization is explored by adrenal vein sampling (AVS), except in patients under 35 years of age with unilateral adenoma on imaging. If PA proves to be lateralized, unilateral adrenalectomy may be performed, with adaptation of medical treatment pre- and postoperatively. If PA is non-lateralized or the patient refuses surgery, spironolactone is administered as first-line treatment, replaced by amiloride, eplerenone or calcium-channel blockers if insufficiently effective or poorly tolerated.

Diagnostic management of pulmonary embolism using clinical assessment, plasma D-dimer assay, complete lower limb venous ultrasound and helical computed tomography of pulmonary arteries. A multicentre clinical outcome study.

The objective of the study was to assess the clinical validity of a non-invasive diagnostic strategy for acute pulmonary embolism using clinical assessment combined with both ELISA D-dimer and complete lower limb ultrasound (US) examination of proximal and distal veins, before single-detector helical computed tomography (CT) of pulmonary arteries. We expected the strategy to have a high diagnostic exclusion power and to safely decrease the number of CT scans. This prospective, multicenter outcome study included 274 consecutive outpatients. All underwent a priori clinical probability, D-dimer and bilateral complete lower limb US assessments. Only patients with a high clinical probability and both tests negative, or positive D-dimer and negative US assessments, underwent CT. This was deemed necessary in 114 patients (42%). At baseline, venous thromboembolism (VTE) was detected in 110 patients (40%), either by US showing proximal (n=65) or distal (n=36) thrombosis, or by CT (n=9). Anticoagulant was withheld in the remaining patients with negative results in both D-dimer and US but a non-high clinical probability (n=59), or in both US and CT (n=90), or with negative US (n=6) and inadequate CT (n=9). All patients underwent a three-month clinical follow-up. VTE occurred in one patient with inadequate CT, yielding an incidence of 0.6% [95% confidence interval: 0.1-3.4]. No patient died from VTE or had major bleeding. Using clinical probability, ELISA D-dimer and complete US before helical CT is a safe strategy resulting in a substantial reduction in CT scans.

Application of the Suchey-Brooks method to three-dimensional imaging of the pubic symphysis.

Age determination is a major field of interest in forensic anthropology. Among the different methods based on macroscopic skeletal study, the Suchey-Brooks method, which analyzes the pubic symphysis, is one of the most reliable. We applied the Suchey-Brooks method to three-dimensional computed tomographic reconstructions of the pubic symphysis. We demonstrated excellent agreement between the results of analysis of bone samples and those of the three-dimensional images, in particular regarding ridges of the articular surface and delimitation of the extremities. The accuracy of age estimation did not significantly differ (Wilcoxon test) between the Suchey-Brooks method applied to bones and the same method applied to CT images. Using high-quality images, this approach seems as reliable as the standard Suchey-Brooks method and offers several advantages: no bone preparation, no damage to bone material, and the possibility of application to living individuals.

Adolescents with partial growth hormone (GH) deficiency develop alterations of body composition after GH discontinuation and require follow-up.

It is now a consensus to resume GH treatment in adolescents with severe GH deficiency (GHD) at retesting to prevent the occurrence of adult GHD syndrome. However, we do not have any data on the follow-up of adolescents with nonsevere GHD at completion of treatment. This report presents preliminary data from a 1-yr prospective study that includes the first 91 patients retested. Anthropometric data, IGF-I and IGF binding protein-3 levels, glycemia and insulinemia, lipid profile, and body composition using dual x-ray absorptiometry and abdominal computed tomography scan were recorded at completion of GH treatment and 1 yr later. Body composition was significantly different at both evaluations, with increased total body fat and decreased lean body mass in the partial GHD group vs. the normal group. Moreover, these alterations worsened after 1 yr without GH in the partial GHD group, whereas there were no modifications in the normal group. We did not find any metabolic alterations such as elevated triglyceride, total cholesterol, or insulin levels. Adolescents with reconfirmed partial GHD exhibit alterations in body composition after 1 yr without GH, whereas those retested normal do not. These changes are similar to those described in severe GHD, although less marked, and justify a precise follow-up.

Diagnostic performance of complete lower limb venous ultrasound in patients with clinically suspected acute pulmonary embolism.

A limited ultrasound (US) confined to the popliteal and femoral veins is usually performed to detect deep vein thrombosis (DVT) in patients with clinically suspected acute pulmonary embolism (PE). Our objective was to assess the diagnostic accuracy of complete lower limb US examining both the proximal and distal veins in this setting. In this prospective study, 210 consecutive patients were included. Complete US was performed by independent operators and compared blindly with a reference strategy combining clinical probability, ventilation perfusion scan and pulmonary angiography to a three-month clinical follow-up. Simultaneously, VIDAS D-dimer (DD) assay and helical computed tomography (HCT) of the lungs were assessed independently and blindly. PE was present in 74 patients (35%). Complete US detected DVT in 91 patients (43%), proximal in 51 and distal in 40. Sensitivity and specificity with a 0.95 confidence interval were respectively 0.93 [0.85 - 0.97] and 0.84 [0.77 - 0.89]. Limited US detected DVT in only 46 patients (22%). Sensitivity and specificity were respectively 0.55 [0.44 - 0.66] and 0.96 [0.92 - 0.98]. For DD they were 0.92 [0.83 - 0.96] and 0.24 [0.17 - 0.32] and for HCT 0.84 [0.73 - 0.90] and 0.87 [0.80 - 0.92]. Complete lower limb US has higher sensitivity and capacity to exclude PE than limited US, but a slightly lower specificity. Complete US results also compared favourably with those of HCT and DD. The utility of including this method in diagnostic strategies for PE needs to be assessed in cost-effectiveness analysis and in outcome studies.

Magnetic resonance imaging contrast-enhanced relaxometry of breast tumors: an MRI multicenter investigation concerning 100 patients.

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) using extracellular contrast agents has proved to be useful for the characterization of breast tumors. DCE-MRI has demonstrated a high sensitivity (around 95%) but a rather poor and controversial specificity, varying, according to the different studies, from 45% to 90%. In order to increase (a) the specificity and (b) the robustness of this quantitative approach in multicenter evaluation (five MRI units), a quantitative approach called dynamic relaxometry has been developed. According to the proposed method, the time-dependent longitudinal relaxation rate measured on region of interest of the lesion was calculated during the contrast uptake, after intravenous bolus injection of contrast agent. A specifically developed method was used for fast R(1) measurements. Relaxometry time curves are fitted to the Tofts model allowing the measurement of the parameters describing the enhancement curve (maximum relation rate enhancement, initial, 30-s and 60-s slopes) and the tissue parameters [transfer constant (K(trans) min(-1)) and extracellular extravascular space fraction (v(e))]. Correspondence factorial analysis followed by hierarchical ascendant classification are then performed on the different parameters. Higher K(trans) values were observed in infiltrative ductal carcinomas than in infiltrative lobular carcinomas, in agreement with data published by other groups. Specificity of DCE-MRI has been increased up to 85%, with a sensitivity of 95% with K(trans)/v(e) and enhancement index I (ratio of initial slope by maximum relaxation rate enhancement). A multiparametric data analysis of the calculated parameters opens the way to include quantitative image-based information in new nosologic approaches to breast tumors.

[Imaging of the aorta]. / Imagerie de l'aorte.

Imaging of the aorta has greatly been improved by the recent development of helical computed tomography and magnetic resonance imaging. This report develops typical features of variety of aortic diseases including dissections, aneurysms, aortic rupture, non aneurismal atherosclerotic diseases, arteritis, aortic coarctation and postoperative aorta. The place for the different imaging modalities is discussed according to the disease involved.

Endovascular techniques for the treatment of renal artery aneurysms.

PURPOSE: Our goal was to analyze the indications and limitations of the different percutaneous endovascular approaches reported for the treatment of renal artery aneurysms (RAAs) and to develop a scientific approach for optimum selection of treatment strategy of RAAs through analyzing our experience and reviewing available literature. METHODS: This retrospective study was designed to evaluate the treatment and follow-up of 13 consecutive patients who presented with 13 RAAs by using a variety of endovascular interventional techniques. Different combinations of coil embolization, liquid embolization, stenting, and stent-graft exclusion were used in correlation with variable-specific aneurysm criteria. RESULTS: All patients were successfully treated with no significant short- or long-term complications. Patients were followed for an average period of 43 (range 13-103) months. CONCLUSIONS: Ten different determinants were found to affect our decision making: shape, size, neck, position of aneurysm on artery, branches arising, artery involved, condition of the artery, age, general condition of the patient, and renal function.