Traumatic axonal injury revealed by postmortem magnetic resonance imaging: A case report

In forensic investigations, it is important to detect traumatic axonal injuries (TAIs) to reveal head trauma that might otherwise remain occult. These lesions are subtle and frequently ambiguous on macroscopic evaluations. We present a case of TAI revealed by pre-autopsy postmortem magnetic resonance imaging (PMMR).A man in his sixties was rendered unconscious in a motor vehicle accident. CT scans revealed traumatic mild subarachnoid hemorrhage. Two weeks after the accident he regained consciousness, but displayed an altered mental state. Seven weeks after the accident, he suddenly died in hospital. Postmortem computed tomography (PMCT) and PMMR were followed by a forensic autopsy.PMMR showed low-intensity lesions in parasagittal white matter, deep white matter, and corpus callosum on three-dimensional gradient-echo T1-weighted imaging (3D-GRE T1WI). In some of these lesions, T21-weighted imaging also showed low-intensity foci suggesting hemorrhagic axonal injury. The lesions were difficult to find on PMCT and macroscopic evaluation, but were visible on antemortem MRI and confirmed as TAIs on histopathology.From this case, it can be said that PMMR can detect subtle TAIs missed by PMCT and macroscopic evaluation. Hence, pre-autopsy PMMR scanning could be useful for identifying TAIs during forensic investigations.     

Isolated traumatic gallbladder avulsion: a case report

While the incidence of blunt traumatic gallbladder injury is uncommon, occurring in only 2% of patients who undergo laparotomy, the presence of an isolated injury to the gallbladder is very rare since other associated intraabdominal injuries are also usually found. However, we present a case of isolated gallbladder avulsion involving an unrestrained driver in a high-speed motor vehicle collision that was suggested based on imaging findings and corroborated at surgery. Since gallbladder injury can be a difficult diagnosis to make both clinically and radiologically, early detection with computed tomography (CT) is essential in decreasing patient morbidity and mortality. We discuss the different types of gallbladder injuries as well as the CT imaging findings associated with traumatic gallbladder injury, many of which are illustrated with our case. The importance of delayed postcontrast imaging in distinguishing traumatic from nontraumatic gallbladder findings is also emphasized.     

Tracheal and main bronchial diverticula simulating pneumomediastinum following a motor vehicle collision

Tracheal and bronchial diverticula are outpouchings arising from the trachea or bronchus. We present a case of a 35-year-old female who presented to the emergency department following a motor vehicle accident and was found to have multiple round, air-filled structures within the mediastinum on computed tomography of the thorax, concerning for pneumomediastinum. The patient had a negative fluoroscopic esophagography and subsequent imaging indicated tracheal and bronchial diverticula. While they are often asymptomatic and incidentally found, tracheal and bronchial diverticula may be misdiagnosed as pneumomediastinum, especially in the setting of blunt or penetrating trauma to the thorax.     

Traumatic basal ganglia hematoma in a fatal traffic accident victim

A 41-year-old male driver involved in a fatal traffic accident presented with a basal ganglia hematoma on postmortem computed tomographic imaging. Clinicians could not exclude the possibility of non-traumatic intracerebral hemorrhage as the underlying cause of the traffic accident. However, analysis of the head injuries showed that the hematoma was caused by an impact to the front-parietal region directed toward the tentorium. The absence of hypertensive arteriolar changes and hemosiderin deposits in the brain supported the traumatic origin of the hematoma.     

Aortic rupture: comparison of three imaging modalities

We report a case of a 56-year-old man with traumatic aortic rupture (TAR) sustained in a motor vehicle accident diagnosed by helical computed tomography, aortography, and transesophageal echocardiography. A large majority of patients with TAR never make it to the hospital, and for those who do, a timely diagnosis is critical for survival. We discuss the merits and pitfalls of the three imaging modalities.     

Reconstruction of the dynamic in a fatal traffic accident with prolonged dragging of the victim

The post-mortem examination of victims of fatal road crashes and the reconstruction of the dynamic of traffic accidents are fundamental in vehicular homicides, where the degree of negligence/careless of the driver has to be established. Here we present a case in which a pedestrian was dragged along an SUV for 3.5 km, until the vehicle was parked at the house of the driver, arising the suspect of vehicular manslaughter and failure to provide assistance.On the basis of death scene investigation, analysis of video recording from a surveillance camera, post-mortem computerized tomography (PMCT) and complete post-mortem examination, including gross and microscopical findings, the accident was reconstructed as a frontal collision between the right portion of the bumper and the right side of the body of a standing pedestrian, with deformation of the bumper and production of a metal sheet hook; secondary run-over the right feet, cranio-facial trauma against the bodywork of the vehicle and hooking of the right hand of the victim to the metal sheet; prolonged dragging of the pedestrian over the road surface and severe bleeding.A multidisciplinary-multimodal methodology, including PMCT, allowed to assess the cause of death as hemorrhagic shock, suggested that the victim would have likely survived if the vehicle had stopped, and is increasingly recommendable in fatal road accidents.     

Differentiating suspected nasopharyngeal infection from carcinoma using dual-tracer and multiple time-point technetium-99m sestamibi and white blood cell SPECT/CT imaging

The role of molecular and functional imaging lies in its capability to more accurately define and characterize pathologies, with a host of varied radiotracers and techniques being available to the clinician for use. We present a case in which dual-tracer and multiple time-point single photon emission computed tomography/computed tomography imaging using technetium-99m sestamibi and white blood cell radiotracers was used to characterize an indeterminate base of skull lesion.     

Value of diffusion-weighted magnetic resonance imaging in the diagnosis of pyomyoma

Pyomyomas are rare lesions that develop from the suppurative degeneration of ischemic leiomyomas. Pyomyomas can lead to sepsis, so early diagnosis is crucial. Due to their rarity and often nonspecific findings on ultrasonography and computed tomography diagnosis is often delayed. We present a case of a woman who presented with abdominal pain and fever. The computed tomography showed a large hypodense uterine lesion with slight peripheral enhancement without gas in the lesion. The diffusion-weighted magnetic resonance imaging showed restricted diffusion, demonstrating the presence of pus and confirming the diagnosis of pyomyoma. Diffusion-weighted imaging should be done in cases of suspected pyomyomas when computed tomography findings are nonspecific.     

Three-dimensional image-based planning for cervix brachytherapy with bilateral hip prostheses: A solution using MVCT with helical tomotherapy

PurposeWe present a method of three-dimensional image-based planning for cervix high-dose-rate (HDR) brachytherapy for patients with bilateral metal hip prostheses using megavoltage computed tomography (MVCT) imaging.Methods and MaterialsTwo patients with bilateral metal hip prostheses were treated with our standard HDR brachytherapy fractionation and critical structure tolerance limits for cervical cancer. MVCT imaging was used for treatment planning because of artifacts present in kilovoltage computed tomography (kVCT), which did not allow visualization of the organs of interest.ResultsThe MVCT images provided adequate contrast to allow the contouring of organs at risk and the digitization of HDR applicators. HDR brachytherapy treatment planning was successfully accomplished based on MVCT images for 2 patients with bilateral metal hip prostheses.ConclusionsUsing MVCT imaging eliminated streak artifacts, which improved the image quality for treatment planning. MVCT offers an option for three-dimensional planning for cervix brachytherapy in patients with bilateral hip prostheses.     

A fatal case of adult small bowel volvulus

A 56-year-old man was hit by a car while riding a bicycle, immediately brought to the hospital, and treated. Four days after the accident, he reported abdominal pain and vomiting in the night, and he died the next day. A forensic autopsy was performed, and almost of the entire small bowel had gangrenous swelling. The mesentery was twisted 180° with clockwise rotation along the vascular axis, and pre-autopsy computed tomography scan showed a whirl sign.     

Integrating engineering principles into the medico-legal investigation of a rare fatal rollover car accident involving complex dynamics

Rollover car accidents can be the result of forceful steering or hitting an obstacle that acts like a ramp. Mortality from this type of car accident is particularly high, especially when occupants are thrown out of the vehicle. We report a case of a 67-year‐old man who died after a rollover accident that occurred when he was driving a car equipped with a glass moonroof. He was found inside his car with his safety belt correctly fastened and the roof shattered. At autopsy, a wide avulsion injury of the head was observed, which was associated with an atlanto-axial dislocation and full‐thickness fracture of the cervical body and posterior facet joints of the seventh cervical vertebra. The data collected at the scene of the accident were integrated with the autopsy results to yield a forensic engineering reconstruction. This reconstruction elucidated the dynamics of the event and correctly ascribed the lesions observed at autopsy to the phases of the rollover. Afterward, an analysis of the scientific literature concerning rollover crash tests was conducted to understand why the driver sustained fatal injuries even though his seatbelt was properly fastened.     

Cardiac metastasis from squamous cell lung carcinoma – An uncommon presentation

Cardiac metastasis represent an uncommon entity which may present with symptoms mimicking myocardial infarction. The present case highlights a case of cardiac metastasis from a lung carcinoma with the typical appearances on computed tomography and MR imaging.     

18F]Fluoro-L-dopa PET/CT in congenital hyperinsulinism

Congenital hyperinsulinism can be divided into diffuse or focal form. The treatment and outcome depend on distinguishing between the 2 forms. Pancreatic venous sampling was the only method available to localize the insulin secretion. [F]Fluoro-levodopa, 3,4-dihydroxy-L-phenylalanine positron emission tomography/computed tomography is a noninvasive imaging investigation and increasingly used to determine the type of hyperinsulinism preoperatively. We present a case of diffuse form of congenital hyperinsulinism demonstrated by the [F]levodopa, 3,4-dihydroxy-L-phenylalanine positron emission tomography/computed tomography preoperatively and review the literature.     

CT characterization of myocardial substrate in hypertrophic cardiomyopathy

We present a case that demonstrates myocardial fibrosis detected on a cardiac computed tomography study performed for the evaluation of chest pain in a patient with hypertrophic cardiomyopathy. We describe the correlation between echocardiographic strain imaging, quantitative positron emission tomography, and computed tomographic evidence of fibrosis and its implications in hypertrophic cardiomyopathy.     

Brain metastases with exceptional features from papillary thyroid carcinoma: report of three cases

We present three papillary thyroid carcinoma PTC patients with brain metastases who are unusual in many aspects. The first case is a unique 3mm papillary thyroid microcarcinoma (PTMC) patient with metastases to the cerebrum and lung. The solitary cerebral lesion was identified by iodine-131 whole- body scan ((131)I-WBS) and (131)I single photon emission tomography/computed tomography (SPET/CT). Almost complete response achieved after radiosurgery. The second case is a unique PTC patient with coexistent (131)I-negative cerebrum, adrenal gland and ilium metastases, which were identified by (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging (MRI). Partial response achieved after radiosurgery. The third case is a patient with an incident solitary cystic cerebellar mass as a primary presentation of follicular variant of PTC and absent other distant metastases. In conclusion, widespread metastases from small PTMC may occur. Concomitant brain and adrenal metastases may occur in a same PTC patient. Brain metastasis may present as a cystic lesion.     

Inflammatory pseudotumor-like follicular dendritic cell tumor of the spleen: a case report and approach to differential diagnosis

We present a case of an inflammatory pseudotumor-like follicular dendritic cell tumor of the spleen. The patient is a 44-year-old woman, without significant underlying history, who presented with nonspecific abdominal pain for a few months. Both a contrast enhanced computed tomography and magnetic resonance imaging revealed a new 2.5 cm enhancing splenic lesion, which demonstrated hypermetabolic activity on subsequent positron emission tomography and computed tomography scan. Since the lesion was new compared to more remote imaging and hypermetabolic, a splenectomy was performed.  Pathology confirmed the diagnosis and demonstrated positivity for Epstein-Barr Virus .     

A rare case of ruptured liver metastases from a laryngeal cancer

Rupture of a metastatic liver tumor associated with laryngeal cancer is a very rare complication with no previous case in the literature. We present a case of ruptured liver metastases which was treated conservatively. Dynamic contrast-enhanced computed tomography demonstrated active extravasation and discontinuity of liver capsule. When the patient came to our hospital from the external medical center, we did not see active extravasation on control computed tomography. This case highlights the role of radiologic imaging in the diagnosis and follow-up of ruptured hepatic metastases.     

Death of a driver due to an atypical missile

A road traffic accident of an unusual nature is presented. The driver of a pickup cab sustained fatal injuries by a large piece of concrete (missile) set in motion consequent to a car crashing onto the centre island of a highway.     

Biomarkers of recent drinking, retrograde extrapolation of blood-alcohol concentration and plasma-to-blood distribution ratio in a case of driving under the influence of alcohol

This case report describes the police investigation of a road-traffic accident involving a collision at night (01.00 am) between a car and a truck in which a passenger in the car was killed. The driver of the truck was found responsible for the crash although a roadside breath-alcohol test was negative (<0.1?mg/L breath or 20?mg/100?mL blood). Because of injuries sustained in the crash, the female driver of the car was not breath-tested at the time but was transported to a local hospital for emergency treatment. After swabbing the skin with isopropanol an indwelling catheter was inserted at 01.40 am. A blood sample was taken at 02.10 am and the plasma portion contained 8?mmol/L ethanol according to analysis at the hospital clinical laboratory using a gas chromatographic method. Another blood sample was taken at 05.45 am for analysis of ethanol at a forensic toxicology laboratory, although the result was negative (<10?mg/100?mL). The police authorities wanted an explanation for the discrepancy between the clinical and forensic laboratory results and inquired whether the driver of the car was above the legal alcohol limit (>20?mg/100?mL) at the time of the crash. The scientific basis for converting a plasma-ethanol concentration into a blood-ethanol concentration and back extrapolation of the driver's blood-alcohol concentration (BAC) is explained. The risk of contaminating a blood sample by swabbing the skin with isopropanol is discussed along with the use of alcohol biomarkers (ethyl glucuronide and ethyl sulphate) as evidence of recent drinking.     

Ct detection of cerebral metastases inapparent on magnetic resonance imaging scan

We report a case of malignant melanoma, metastatic to the brain, in which disease was not detected by magnetic resonance imaging but was detected by contrast enhanced computed tomography. At least in some instances, magnetic resonance imaging fails to detect disease that is apparent by computed tomography.