Selective postmortem arterial angiography of head and neck using digital x-ray or computed tomography: A practical and rapid method to identify vascular injuries.

Identification of vascular injuries is crucial for complete postmortem evaluation and understanding of trauma deaths by the Medical Examiner. Some vascular injuries are difficult to evaluate due to challenging anatomic locations, especially in the head and neck. Documenting injuries of the facial and vertebral arteries is challenging and necessitates time-consuming dissections that can create artifacts and disfigurement. In busy medical examiner offices with a significant number of traumatic injuries, finding a creative solution to employ reliable postmortem angiography is desirable. At the Office of the Chief Medical Examiner for the State of Maryland (OCME), we created and effectively implemented a selective angiography procedure using traditional indwelling Foley catheters and water-soluble barium swallow contrast to evaluate arterial injuries using either digital radiography or computed tomography imaging modalities. This technique and imaging interpretation can be performed by a medical examiner or forensic pathology fellow after basic technical training and basic radiology training. This study outlines the technique, methods, and utilization of the procedure and describes the findings of six deaths due to vascular lesions from different injury mechanisms and disease processes and describes the ease of implementation on a broader scale in busy Medical Examiner's offices.

Fat embolism syndrome associated with atraumatic compartment syndrome of the bilateral upper extremities: An unreported etiology.

Fat embolism syndrome (FES) is a potentially life-threatening condition that develops when fat embolism leads to clinical symptoms and multisystem dysfunction. The classic triad of respiratory distress, neurologic symptoms, and petechial rash are non-specific, and the lack of specific laboratory tests makes the diagnosis of FES difficult. Although FES is most common after long bone fractures, multiple conditions some of which are atraumatic have been associated with the development of FES. We report a case of FES that occurred in the setting of a non-traumatic compartment syndrome of the upper extremities. The pathologic and clinical findings, pathophysiology, diagnostic challenges, and pathologic methods to properly diagnose FES are discussed with a review of the relevant literature. This case highlights the importance of the autopsy in making a diagnosis of FES in cases where death could otherwise be incorrectly attributed to multi-organ system failure, shock, or sepsis.

Postmortem Imaging of an Unusual Case of Fatal Heart and Lung Perforation Due to Self-Treatment.

Intentional or accidental cardiothoracic injuries caused by needles and pins are rare and commonly reported in individuals with psychiatric conditions or intravenous drug users. Although rare, these cases could result in serious injury during the performance of an autopsy and highlight the importance of post-mortem radiology. Therapeutic complications with cardiac perforation have been reported due to pericardiocentesis and acupuncture. The majority of reported cases were not fatal and some had a prolonged asymptomatic period of weeks or even years after insertion. Needles or other sharp objects can reach the cardiovascular system directly through the chest wall, indirectly from any segment of the gastrointestinal tract after swallowing needles, or through migration of broken needles from distant injection sites in intravenous drug users. We report a case of rapidly fatal cardiopulmonary injuries following "self-treatment" to "pop" a cyst with a piercing needle. The scene, autopsy, computed tomography, and digital x-ray findings of this unique case are discussed with a review of selective literature. In this case, the right lung and heart showed multiple perforations, possibly resulting from heartbeats or respirations pushing the organs against the needle. To our knowledge, perforations in this setting of "self-treatment" have not been previously reported in the literature.

Severe Acute Respiratory Syndrome Coronavirus 2 Antibody Status in Decedents Undergoing Forensic Postmortem Examination in Maryland, May 24 to June 30, 2020.

Seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies was 10% among the subset of decedents undergoing forensic postmortem examination in June in Maryland. Decedents of motor vehicle crashes had similar seroprevalence compared with those with a natural death (including decedents with SARS-CoV-2 infection). Decedents of motor vehicle crashes may be a sentinel surveillance population.

A Pilot Study Comparing Postmortem and Antemortem CT for the Identification of Unknowns: Could a Forensic Pathologist Do It?

Forensic pathologists are commonly tasked with identifying human remains. Although DNA analysis remains the gold standard in identification, time and cost make it particularly prohibitive. Radiological examination, more specifically analog imaging, is more cost-effective and has been widely used in the medical examiner setting as a means of identification. In the United States, CT imaging is a fairly new imaging modality in the forensic setting, but in more recent years, offices are acquiring CT scans or collaborating with local hospitals to utilize the technology. To broaden the spectrum of potential identifying characteristics, we collected 20 cases with antemortem and postmortem CT images. The results were qualitatively assessed by a forensic pathologist and a nonmedically trained intern, and all cases were correctly identified. This study demonstrates that identification of human remains using visual comparison could be performed with ease by a forensic pathologist with limited CT experience.

Quantitative measurement of lipid rich plaque by coronary computed tomography angiography: A correlation of histology in sudden cardiac death.

BACKGROUND AND AIMS: Recent advancements in coronary computed tomography angiography (CCTA) have allowed for the quantitative measurement of high-risk lipid rich plaque. Determination of the optimal threshold for Hounsfield units (HU) by CCTA for identifying lipid rich plaque remains unknown. We aimed to validate reliable cut-points of HU for quantitative assessment of lipid rich plaque. METHODS: 8 post-mortem sudden coronary death hearts were evaluated with CCTA and histologic analysis. Quantitative plaque analysis was performed in histopathology images and lipid rich plaque area was defined as intra-plaque necrotic core area. CCTA images were analyzed for quantitative plaque measurement. Low attenuation plaque (LAP) was defined as any pixel < 30, 45, 60, 75, and 90 HU cut-offs within a coronary plaque. The area of LAP was calculated in each cross-section. RESULTS: Among 105 cross-sections, 37 (35.2%) cross-sectional histology images contained lipid rich plaque. Although the highest specificity for identifying lipid rich plaque was shown with <30 HU cut-off (88.2%), sensitivity (e.g. 55.6% for <75 HU, 16.2% for <30 HU) and negative predictive value (e.g. 75.9% for <75 HU, 65.9% for <30 HU) tended to increase with higher HU cut-offs. For quantitative measurement, <75 HU showed the highest correlation coefficient (0.292, p = 0.003) and no significant differences were observed between lipid rich plaque area and LAP area between histology and CT analysis (Histology: 0.34 ±â€¯0.73 mm2, QCT: 0.37 ±â€¯0.71 mm2, p = 0.701). CONCLUSIONS: LAP area by CCTA using a <75 HU cut-off value demonstrated high sensitivity and quantitative agreement with lipid rich plaque area by histology analysis.

Estimating Sex Using Metric Analysis of the Scapula by Postmortem Computed Tomography.

Postmortem computed tomography (CT) has been extensively used in the last decade for identification purposes and in various anthropologic studies. Postmortem CT measurements of scapulae, analyzed using logistic discriminant function developed in this study, showed 94.5% accuracy in estimating sex. Data analyzed using the Dabbs and Moore-Jansen (2010) discriminant function and the discriminant function generated in this study provided nearly identical results with disagreement in only one case. Height and weight were not statically significant in sex prediction. The results of this study show that data obtained from volume rendered postmortem CT images can be considered reliable and treated as a practical option to standard anthropological methods, especially in mass fatalities as a rapid triage tool for sex determination.

En Bloc Examination of the Neck in Pediatric Homicide Cases: A Proper Way for Complete Assessment of Neck Trauma.

The necks of infants and young children are not only anatomically different from adults, but are also supported by much weaker musculoskeletal systems and are therefore prone to trauma as a result of extension/flexion (shaking) or contact trauma to the head. Shaking cervical spine injuries can occur at much lower levels of head velocity and acceleration than those reported for shaken baby syndrome. The proper method for a comprehensive and detailed examination of the neck in pediatric homicide and suspected homicide cases is the en bloc examination of the neck, because the standard examination of the spinal cord not only distorts the anatomical relationship of the cord and osteocartilagenous structures, but also excludes the cervical nerves, ganglia, and the vertebral arteries from being evaluated. Interpretation of gross and microscopic findings using this method requires experience and knowledge of the anatomical relationship and common artifacts, such as epidural, focal intradural, or even isolated nerve hemorrhage to avoid misinterpretation. It is our opinion that this method should be applied to all pediatric homicide or suspected homicide cases, but is not suited for routine or nonsuspicious cases as it will add to the time and cost of medical examiner's operations.

Systemic air embolism complicating upper gastrointestinal endoscopy: a case report with post-mortem CT scan findings and review of literature.

Endoscopy of the gastrointestinal and biliary tract is a common procedure and is routinely performed for therapeutic and diagnostic purposes. Perforation, bleeding and infection are some of the more common reported side effects. Air embolism on the other hand, is a rare complication of gastrointestinal endoscopy. We report a 77-year-old African-American female with a history of pancreatic cancer, which was resected with a Whipple procedure. As part of diagnostic and therapeutic procedure, an endoscopic retrograde cholangiopancreatography was planned several months after the surgery. The patient's heart rate suddenly slowed to 40 bpm during the procedure and she became cyanotic and difficult to oxygenate after the endoscope was introduced and CO2 gas was insufflated. A forensic autopsy was performed with post-mortem computed tomography (PMCT) and revealed extensive systemic air embolism. The detailed PMCT and autopsy findings are presented and current literature is reviewed.

Generalized arterial calcification of infancy--Findings at post-mortem computed tomography and autopsy.

Generalized arterial calcification in infancy is a rare genetic disorder characterized by abnormal calcification of large and medium sized arteries and marked myointimal proliferation resulting in arterial stenosis. The condition is often fatal secondary to complications of cardiac ischemia, hypertension and cardiac failure. In this report we describe the findings at post mortem computed tomography, histology and autopsy.

Case report of a fatal intoxication by Nucynta.

Tapentadol (Nucynta) is a centrally acting opioid analgesic prescribed for the treatment of moderate to severe acute pain. Its efficacy is believed to be due to µ-opioid receptor agonist activity and inhibition of norepinephrine reuptake resulting in increased norepinephrine concentrations. There is only one other case in the literature relating to the toxicity of this agent or report of a fatality. This case report documents a case in which tapentadol was identified as the cause of death. The tapentadol concentration found in the heart blood submitted in this case was more than 20 times the upper limit of the therapeutic range. Possible mechanisms of death include respiratory depression, central nervous system depression, and serotonin syndrome. Based on the scene investigation and autopsy findings in this case, the medical examiner determined that the cause of death was narcotic (Nucynta) intoxication and the manner of death was undetermined.

Accuracy and reliability of measurements obtained from computed tomography 3D volume rendered images.

Forensic pathologists commonly use computed tomography (CT) images to assist in determining the cause and manner of death as well as for mass disaster operations. Even though the design of the CT machine does not inherently produce distortion, most techniques within anthropology rely on metric variables, thus concern exists regarding the accuracy of CT images reflecting an object's true dimensions. Numerous researchers have attempted to validate the use of CT images, however the comparisons have only been conducted on limited elements and/or comparisons were between measurements taken from a dry element and measurements taken from the 3D-CT image of the same dry element. A full-body CT scan was performed prior to autopsy at the Office of the Chief Medical Examiner for the State of Maryland. Following autopsy, the remains were processed to remove all soft tissues and the skeletal elements were subject to an additional CT scan. Percent differences and Bland-Altman plots were used to assess the accuracy between osteometric variables obtained from the dry skeletal elements and from CT images with and without soft tissues. An additional seven crania were scanned, measured by three observers, and the reliability was evaluated by technical error of measurement (TEM) and relative technical error of measurement (%TEM). Average percent differences between the measurements obtained from the three data sources ranged from 1.4% to 2.9%. Bland-Altman plots illustrated the two sets of measurements were generally within 2mm for each comparison between data sources. Intra-observer TEM and %TEM for three observers and all craniometric variables ranged between 0.46mm and 0.77mm and 0.56% and 1.06%, respectively. The three-way inter-observer TEM and %TEM for craniometric variables was 2.6mm and 2.26%, respectively. Variables that yielded high error rates were orbital height, orbital breadth, inter-orbital breadth and parietal chord. Overall, minimal differences were found among the data sources and high accuracy was noted between the observers, which prove CT images are an acceptable source to collect osteometric variables.

Fatal caffeine intoxication: a series of eight cases from 1999 to 2009.

Caffeine, 1,3,7-trimethylxanthine, is the most widely consumed legal stimulant. The most potent form is over the counter oral tablets. The estimated average daily adult caffeine consumption is 300 mg. Rarely, serious toxicities such as seizure and cardiac arrhythmias have caused death. Caffeine concentrations of 80 mg/L are considered lethal. Cases investigated over 10 years by the Office of the Chief Medical Examiner for the State of Maryland (OCME) whose cause of death was solely or in combination due to caffeine intoxication were reviewed. A total of eight adult cases were identified consisting of two suicides and six undetermined manners. The average postmortem caffeine concentration was 140.4 mg/L. This is the largest case series reported to date of lethal caffeine intoxication. Large doses of prescription medications and/or over the counter medications were abused. No overdoses were from consumption of caffeine-containing foods. Comprehensive postmortem toxicological testing should test for caffeine to capture these rare deaths.

Anaphylaxis after the injection of buprenorphine.

Cause of death rulings in cases when the concentration of a drug or drugs is higher than observed following therapeutic use are generally straightforward "drug deaths." However, when toxicology testing identifies drug concentrations consistent with therapeutic use or detects no drugs at all, then the cause of death determination is more complicated. Given the rapidity and protean manifestations of anaphylaxis, it should be considered in deaths where no other cause of death is apparent in a suspected drug death. This article reports two cases where an anaphylactic reaction was observed following either the actual or alleged use of therapeutic formulations of buprenorphine intravenously.

Comparison of whole-body post mortem 3D CT and autopsy evaluation in accidental blunt force traumatic death using the abbreviated injury scale classification.

Although 3D CT imaging data are available on survivors of accidental blunt trauma, little similar data has been collected and classified on major injuries in victims of fatal injuries. This study compared the sensitivity of post mortem computed tomography (PMCT) with that of conventional autopsy for major trauma findings classified according to the trauma Abbreviated Injury Scale (AIS). Whole-body 3D PMCT imaging data and full autopsy findings were analyzed on 21 victims of accidental blunt force trauma death. All major injuries were classified on the AIS scale with ratings from 3 (serious) to 6 (unsurvivable). Agreement between sensitivity of autopsy and PMCT for major injuries was determined. A total of 195 major injuries were detected (mean per fatality, 9.3; range, 1-14). Skeletal injuries by AIS grade included 37 grade 3, 45 grade 4, 12 grade 5, and 2 grade 6 major findings. Soft tissue injuries included 10 grade 3, 68 grade 4, 16 grade 5, and 5 grade 6 major findings. Of these, PMCT detected 165 (88 skeletal, 77 soft tissue), and autopsy detected 127 (59 skeletal, 68 soft tissue). PMCT agreed with autopsy in 86% and 76% of skeletal and soft tissue injuries, respectively. PMCT detected an additional 37 skeletal and 31 soft tissue injuries that were not identified at autopsy. Autopsy detected 8 skeletal and 22 soft tissue injuries that were not detected by PMCT. PMCT was more sensitive for skeletal (P=0.05) and head and neck region injury (P=0.043) detection. PMCT showed a trend for greater sensitivity than autopsy, but this did not reach statistical significance (P=0.083). 3D PMCT detected significantly more skeletal injuries than autopsy and a similar number of soft tissue injuries to autopsy and promises to be a sensitive tool for detection and classification of skeletal injuries in fatal blunt force accidental trauma. Use of the AIS scale allows standardized categorization and quantification of injuries that contribute to death in such cases and allows more objective comparison between autopsy and PMCT.

Diabetic ketoacidosis: a silent death.

Diabetic ketoacidosis (DKA) results from severe insulin deficiency and can be diagnosed at autopsy despite no known history of the disease. Diabetic ketoacidosis may be the initial manifestation of type 1 diabetes or may result from increased insulin requirement in type 1 diabetic patients. The purpose of this study was to determine the percentage of DKA death investigated by the Office of Chief Medical Examiner that was not associated with a known history of diabetes.Cases investigated by the Office of Chief Medical Examiner during a 6-year period whose cause of death was DKA were identified using a centralized database. To determine the percentage with known history of diabetes, investigation reports were reviewed for any documentation of this history. The toxicology reports of all DKA deaths were reviewed together with histologic slides, if available, for possible microscopic changes. Concentrations of vitreous glucose, vitreous acetone, and blood acetone were used to diagnose DKA in these autopsied cases.Nearly a third of all death from DKA (32 of 92 during a 6-year period) occurred in individuals who had no known history of diabetes, emphasizing the importance of regular physicals that include a check of glucose concentration, and especially if any warning signs are present. In a case of sudden death, it is recommended that the volatile toxicology analysis at a medical examiner's office should include tests for acetone concentration, which when elevated, together with an elevated vitreous glucose, indicates DKA.

Rat bite fever, a fatal case of Streptobacillus moniliformis infection in a 14-month-old boy.

Streptobacillus moniliformis is the primary cause of rat bite fever in North America. Children under 12 years of age are primarily infected, presenting with an acute syndrome of fever, rash, and polyarthritis. Common vectors include rats and mice. Transmission is predominantly from a bite or scratch, but contact with or ingestion of food contaminated with feces or saliva has also been reported. We report a fatal case of S. moniliformis infection in a 14-month-old-boy. At home, the child was exposed to filthy living conditions and the family had pet ferrets. Autopsy revealed a red-pink, mostly confluent rash and a circumscribed area suspicious for a possible bite mark. Cerebrospinal fluid cultures were positive for S. moniliformis. This case highlighted key features, such as the morbiliform rash, but lacked lymphadenopathy or joint manifestations. It is important to consider rat or rodent exposure as a source of infection.