The value of postmortem computed tomography as an alternative for autopsy in trauma victims: a systematic review

The aim of this study was to assess the role of postmortem computed tomography (PMCT) as an alternative for autopsy in determining the cause of death and the identification of specific injuries in trauma victims. A systematic review was performed by searching the EMBASE and MEDLINE databases. Articles were eligible if they reported both PMCT as well as autopsy findings and included more than one trauma victim. Two reviewers independently assessed the eligibility and quality of the articles. The outcomes were described in terms of the percentage agreement on causes of death and amount of injuries detected. The data extraction and analysis were performed together. Fifteen studies were included describing 244 victims. The median sample size was 13 (range 5–52). The percentage agreement on the cause of death between PMCT and autopsy varied between 46 and 100%. The overall amount of injuries detected on CT ranged from 53 to 100% compared with autopsy. Several studies suggested that PMCT was capable of identifying injuries not detected during normal autopsy. This systematic review provides inconsistent evidence as to whether PMCT is a reliable alternative for autopsy in trauma victims. PMCT has promising features in postmortem examination suggesting PMCT is a good alternative for a refused autopsy or a good adjunct to autopsy because it detects extra injuries overseen during autopsies. To examine the value of PMCT in trauma victims there is a need for well-designed and larger prospective studies.     

“Blind spots” in forensic autopsy: Improved detection of retrobulbar hemorrhage and orbital lesions by postmortem computed tomography (PMCT)

ObjectivesThe purpose of this study was to correlate the occurrence of retrobulbar hemorrhage (RBH) with mechanism of injury, external signs and autopsy findings to postmortem computed tomography (PMCT).MethodsSix-teen subjects presented with RBH and underwent PMCT, external inspection and conventional autopsy. External inspection was evaluated for findings of the bulbs, black eye, raccoon eyes and Battle’s sign. Fractures of the viscerocranium, orbital lesions and RBH were evaluated by PMCT. Autopsy and PMCT was evaluated for orbital roof and basilar skull fracture.ResultsThe leading manner of death was accident with central regulatory failure in cases of RBH (31.25%). Imaging showed a high sensitivity in detection of orbital roof and basilar skull fractures (100%), but was less specific compared to autopsy. Volume of RBH (0.1–2.4 ml) correlated positively to the presence of Battle’s sign (p < 0.06) and the postmortem interval. Ecchymosis on external inspection correlated with RBH. There was a statistical significant correlation between bulbar lesion and RBH. Orbital roof fracture count weakly correlated with the total PMCT derived RBH volume. Maxillary hemosinus correlated to maxillary fractures, but not to RBH.ConclusionsRBH are a specific finding in forensically relevant head trauma. PMCT is an excellent tool in detecting and quantifying morphological trauma findings particularly in the viscerocranium, one of the most relevant “blind spots” of classic autopsy. PMCT was superior in detecting osseous lesions, scrutinizing autopsy as the gold standard.     

Accuracy of non-contrast PMCT for determining cause of death

The aim of this study was (1) to compare levels of accuracy regarding the categorization of causes of death between non-contrast post-mortem computed tomography (PMCT) and the final forensic report as well as between autopsy and the final forensic report, and (2) to assess levels of confidence regarding the categorization of causes of death after non-contrast PMCT and after autopsy. This prospective study was conducted over a 5 month period during which 221 cases were admitted to our institute for forensic investigations. Whole-body PMCT and forensic autopsy were performed in every case. Of these, 101 cases were included in the final study population. Inclusion criteria were: (1) age > 18 years, (2) presence of at least one of the two principal investigators at the time of admission. One radiologist and one forensic pathologist independently read all PMCT datasets using a report template. Cause of death category and confidence levels were determined by consensus. Forensic autopsy was performed by two forensic pathologists; both unblinded to imaging results. Both post-imaging and post-autopsy cause of death categorization were compared against the final cause of death, as stated in the forensic expert report, which included findings from histology and/or toxicology. Accuracy of post-imaging cause of death categorization in reference to the final cause of death category was substantial (82%, 83/101 cases, Kappa 0.752). Accuracy of post-autopsy cause of death categorization in reference to the final cause of death category was near perfect (89%, 90/101 cases, Kappa 0.852). Post-imaging sensitivity and specificity regarding the categorization of causes of death were 82% and 97%, respectively. Post-autopsy sensitivity and specificity regarding the categorization of causes of death were 89% and 98%, respectively. There was a high consistency between the accuracy of post-imaging cause of death categorization and post-imaging levels of confidence. There was less consistency between accuracy of post-autopsy cause of death categorization and post-autopsy levels of confidence. In this study categorization of causes of death based on non-contrast enhanced PMCT alone, and on PMCT and macroscopic autopsy together, proved to be consistent with the final cause of death-category as determined based on all available information including PMCT, autopsy, and (if available) histology and/or toxicology in more than 82% and 89% of all cases, respectively. There was higher consistency between levels of confidence and accuracy of causes of death categorization was higher post-imaging than post-autopsy. These results underline the fact that the diagnostic potential of PMCT goes beyond the assessment of trauma cases.     

Spinal hyperostosis as an important sign indicating spine injuries on postmortem computed tomography

Although spine injuries are not always detectable on postmortem computed tomography (PMCT), spinal hyperostosis, an important risk factor for spine injury, is relatively easily detectable on PMCT. We therefore examined the utility of the detection of spinal hyperostosis on PMCT as an indicator of spine injury. Full-body PMCT images of 88 autopsy cases with a bruise on the face or forehead but no identifiable skull fracture were reviewed prior to autopsy for the identification and classification of spinal hyperostosis. Spine injuries were observed in 56.0% of cases with spinal hyperostosis and 1.6% of cases without spinal hyperostosis. Among the cases with spinal hyperostosis, spine injuries were observed in 66.7% of cases at stage 2 or 3 and in 88.9% of cases at stage 3. Spine injuries were diagnosed on PMCT in 33.3% of cases prior to autopsy. A significant association was found between spinal hyperostosis and presence of spine injury that cannot be detected on PMCT, indicating that the identification of spinal hyperostosis on PMCT may assist in detecting spine injuries. This finding suggests that investigation of the presence of spine injury based on the identification of spinal hyperostosis on PMCT may assist in determining the correct cause of death by autopsy.     

The significance of evaluating sphenoid sinus fluid by postmortem computed tomography in cases of drowning

PurposeIn cases of drowning, the presence of sphenoid sinus fluid is a non-specific autopsy finding. However, studies have reported that fluid accumulation in the paranasal sinuses is more commonly observed in drowning victims. Furthermore, some laboratory tests, such as diatom and electrolyte analysis, can serve as supplementary diagnostic tools for diagnosing drowning. Therefore, accurate sphenoid sinus fluid sampling is an important aspect of an autopsy in suspected drowning cases. The aim of this study was to identify the significance of evaluating sphenoid sinus fluid by PMCT images in cases of drowning.MethodsWe retrospectively reviewed 54 drowning victims who underwent PMCT and forensic autopsy. Fluid volume in the sphenoid sinus was measured using a graduated syringe during autopsy and a three-dimensional (3D) workstation based on PMCT images was used for the purpose of comparison. The Mann–Whitney U test and Spearman's rank correlation coefficient was used to evaluate statistically significant differences and correlations. Additionally, a Bland-Altman plot was employed to assess the agreement between PMCT and autopsy.ResultsThe median volume was 1.65 (range 0.00–12.4) ml and 1.55 (range 0.00–7.00) ml in the PMCT and autopsy, respectively, showing a statistically insignificant difference (p = 0.294) and a significant correlation (Rs = 0.896). In 35 cases, the PMCT overestimated the fluid volume more than the autopsy, whereas in 14 cases, the PMCT underestimated the fluid volume. No fluid was identified in seven cases during the autopsy, whereas in five patients, no fluid was found in both PMCT and autopsy. By analyzing the Bland-Altman plot, a bias of 0.73 ± 1.4 ml and limits of agreement ranging from −2.04 to 3.51 ml were observed for sphenoid sinus fluid volume measurements.ConclusionsBased on the limitations of traditional fluid volume measurement in the sphenoid sinus during autopsy, we propose the utilization of PMCT volumetric analysis prior to autopsy as a means to enhance the detection of sphenoid sinus fluid in cases of drowning.     

Post-mortem computed tomography compared to forensic autopsy findings: a French experience

Objectives

The principal aim of our study was to establish concordance between post-mortem CT (PMCT) and forensic standard autopsy (SA) in detecting lesions according to different anatomical regions. A secondary aim was to determine the efficacy of PMCT in showing lethal lesions.

Methods

PMCTs were compared with autopsies in 236 cadavers in different contexts of death. PMCT findings were assessed by two independent radiologists.

Results

Concordance between PMCT and autopsy was almost perfect in showing skull, basal skull and hyoid bone fractures as well as in detecting facial, vertebral or pelvic fractures. Both examinations were discordant in demonstrating some intracranial injuries, vascular or organ wounds (more findings showed by autopsy), as well in showing free air in anatomical cavities (more findings detected by PMCT). Moreover, PMCT was effective in determining lethal lesions in the context of craniofacial trauma or after a gunshot wound. Concordance between the findings of the two radiologists was almost perfect for each type of lesion.

Conclusion

PMCT could be considered as effective as SA in determining the cause of death in certain traumatic events. It was also effective in showing lethal lesions and could be a useful tool in reducing the number of SA.

Key Points

? Post-mortem CT is increasingly performed as an alternative/adjunct to formal autopsy. ? More modern CT systems provide greater anatomical scope. ? PMCT can usually determine the cause of most deaths following trauma. ? Prospective studies are still required to establish an algorithm for forensic CT.     

Cardiothoracic ratio in postmortem computed tomography: reliability and threshold for the diagnosis of cardiomegaly

The aim of this study was to evaluate the reliability of the cardiothoracic ratio (CTR) in postmortem computed tomography (PMCT) and to assess a CTR threshold for the diagnosis of cardiomegaly based on the weight of the heart at autopsy. PMCT data of 170 deceased human adults were retrospectively evaluated by two blinded radiologists. The CTR was measured on axial computed tomography images and the actual cardiac weight was weighed at autopsy. Inter-rater reliability, sensitivity, and specificity were calculated. Receiver operating characteristic curves were calculated to assess enlarged heart weight by CTR. The autopsy definition of cardiomegaly was based on normal values of the Zeek method (within a range of both, one or two SD) and the Smith method (within the given range). Intra-class correlation coefficients demonstrated excellent agreements (0.983) regarding CTR measurements. In 105/170 (62 %) cases the CTR in PMCT was >0.5, indicating enlarged heart weight, according to clinical references. The mean heart weight measured in autopsy was 405 ± 105 g. As a result, 114/170 (67 %) cases were interpreted as having enlarged heart weights according to the normal values of Zeek within one SD, while 97/170 (57 %) were within two SD. 100/170 (59 %) were assessed as enlarged according to Smith’s normal values. The sensitivity/specificity of the 0.5 cut-off of the CTR for the diagnosis of enlarged heart weight was 78/71 % (Zeek one SD), 74/55 % (Zeek two SD), and 76/59 % (Smith), respectively. The discriminative power between normal heart weight and cardiomegaly was 79, 73, and 74 % for the Zeek (1SD/2SD) and Smith methods respectively. Changing the CTR threshold to 0.57 resulted in a minimum specificity of 95 % for all three definitions of cardiomegaly. With a CTR threshold of 0.57, cardiomegaly can be identified with a very high specificity. This may be useful if PMCT is used by forensic pathologists as a screening tool for medico-legal autopsies.     

The importance of post-mortem computed tomography (PMCT) in confrontation with conventional forensic autopsy of victims of motorcycle accidents

Since traffic accidents are an important problem in forensic medicine, there is a constant search for new solutions to help with an investigation process in such cases. In recent years there was a rapid development of post-mortem imaging techniques, especially post-mortem computed tomography (PMCT). In our work we concentrated on a potential advantage of PMCT in cases of motorcycle accident fatalities. The results of forensic autopsy were compared with combined results of the autopsy and PMCT to check in which areas use of these two techniques gives statistically important increase in number of findings. The hypothesis was confirmed in case of pneumothorax and fractures of skull, spine, clavicle, scapula, lower leg bones. As for majority of other bone fractures locations and brain injures there were single cases with pathologies visible only in PMCT, but too few to reach expected level of p-value. In case of injuries of solid organs and soft tissues statistical analysis did not confirmed any advantage of unenhanced PMCT use. On the whole it has been shown that PMCT used as an adjunct to forensic autopsy can cause an increase in information about vitally important regions in case of motorcycle accident fatalities.     

Can cervical spine injury be correctly diagnosed by postmortem computed tomography?

We discuss the usefulness of postmortem computed tomography (PMCT) by reviewing cases of cervical spine injury. A merit of PMCT is that it can identify injury that cannot be found on autopsy; however, peculiar defects of it may exist. While PMCT can identify bone fractures, it cannot indicate whether the injury was inflicted while the deceased was still alive or not because of its inability to clearly image bleeding around the fracture. Furthermore, CT often misses some types of cervical spine injuries, such as laceration of an intervertebral disk and incomplete fracture of the cervical spine. On the other hand, cervical spine injury on CT images occasionally has an appearance similar to subarachnoid hemorrhage due to rupture of the cerebral artery, indicating that cervical spine injury can be misdiagnosed as a disease by PMCT. When PMCT is used for screening trauma, caution must be observed regarding its limitations. If the possibility of trauma of the neck or head is not completely ruled out from the personal history of the victim, autopsy is strongly recommended, even when PMCT findings indicate that the cause of death may be due to disease, such as subarachnoid hemorrhage.     

New bone post-processing tools in forensic imaging: a multi-reader feasibility study to evaluate detection time and diagnostic accuracy in rib fracture assessment

Purpose

The aim of this multi-reader feasibility study was to evaluate new post-processing CT imaging tools in rib fracture assessment of forensic cases by analyzing detection time and diagnostic accuracy.

Materials and methods

Thirty autopsy cases (20 with and 10 without rib fractures in autopsy) were randomly selected and included in this study. All cases received a native whole body CT scan prior to the autopsy procedure, which included dissection and careful evaluation of each rib. In addition to standard transverse sections (modality A), CT images were subjected to a reconstruction algorithm to compute axial labelling of the ribs (modality B) as well as “unfolding” visualizations of the rib cage (modality C, “eagle tool”). Three radiologists with different clinical and forensic experience who were blinded to autopsy results evaluated all cases in a random manner of modality and case.

Results

Rib fracture assessment of each reader was evaluated compared to autopsy and a CT consensus read as radiologic reference. A detailed evaluation of relevant test parameters revealed a better accordance to the CT consensus read as to the autopsy. Modality C was the significantly quickest rib fracture detection modality despite slightly reduced statistic test parameters compared to modalities A and B.

Conclusion

Modern CT post-processing software is able to shorten reading time and to increase sensitivity and specificity compared to standard autopsy alone. The eagle tool as an easy to use tool is suited for an initial rib fracture screening prior to autopsy and can therefore be beneficial for forensic pathologists.

     

Epicardial adipose tissue volume estimation by postmortem computed tomography of eviscerated hearts

Epicardial adipose tissue (EAT) may play a role in the development of coronary artery disease. The purpose of this study was to evaluate a method based on postmortem computed tomography (PMCT) for the estimation of EAT volume. We PMCT-scanned the eviscerated hearts of 144 deceased individuals, who underwent a medicolegal autopsy. Using Mimics® we performed segmentation of the images and obtained the volumes of EAT and myocardium. Total heart volume was calculated by adding the volumes of EAT and myocardium. Total heart weight, including EAT, myocardium and attached vessels, was measured during autopsy. Inter-observer analysis was performed on 30 randomly chosen subjects. We included 132 individuals in the results (age range: 22–94 years; 56% men). Twelve individuals were excluded due to inadequate PMCT scanning. Median EAT volume was 73.0 mL (Interquartile range; IQR: 45.6–113.7 mL) in men and 64.8 mL (IQR: 44.0–98.0 mL) in women, which accounted for 20.4 ± 10.2% and 21.9 ± 9.5% of total heart volume, respectively. This corresponded with former autopsy studies. Total heart volume measured by PMCT was highly correlated with heart weight (R² = 90%). Mean inter-observer difference of EAT volume was ?1.7 mL (95% limits of agreement: ?37.0-33.6 mL), with an Intra Class Correlation of 0.91. It was possible to estimate EAT volume using PMCT on eviscerated human hearts. Our method was fast and accurate with good inter-observer agreement. This is a useful method to determine EAT at autopsy, and we will apply this method in future research.     

Whole-body post-mortem computed tomography compared with autopsy in the investigation of unexpected death in infants and children

Objectives

To investigate the contribution of whole-body post-mortem computed tomography (PMCT) in sudden unexpected death in infants and children.

Methods

Forty-seven cases of sudden unexpected death in children investigated with radiographic skeletal survey, whole-body PMCT and autopsy were enrolled. For imaging interpretation, non-specific post-mortem modifications and abnormal findings related to the presumed cause of death were considered separately. All findings were correlated with autopsy findings.

Results

There were 31 boys and 16 girls. Of these, 44 children (93.6 %) were younger than 2 years. The cause of death was found at autopsy in 18 cases (38.3 %), with 4 confirmed as child abuse, 12 as infectious diseases, 1 as metabolic disease and 1 as bowel volvulus. PMCT results were in accordance with autopsy in all but three of these 18 cases. Death remains unexplained in 29 cases (61.7 %) and was correlated with no abnormal findings on PMCT in 27 cases. Major discrepancies between PMCT and autopsy findings concerned pulmonary analysis.

Conclusions

Whole-body PMCT may detect relevant findings that can help to explain sudden unexpected death and is essential for detecting non-accidental injuries. We found broad concordance between autopsy and PMCT, except in a few cases of pneumonia. It is a non-invasive technique acceptable to relatives.

Key Points

? Whole-body post-mortem computed tomography (PMCT) is an effective non-invasive method. ? Whole-body PMCT is essential for detecting child abuse in unexpected death. ? There is concordance on cause of death between PMCT and autopsy. ? Whole-body PMCT could improve autopsy through dissection and sampling guidance. ? PMCT shows findings that may be relevant when parents reject autopsy.     

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.     

Hepatic portal venous gas and hyper-dense aortic wall as postmortem computed tomography finding

Postmortem computed tomography (PMCT) is useful for diagnosis of cause of death not only by emergency physicians but also medical examiners or police surgeons conducting postmortem studies. However, postmortem biological conditions are quite different from those in the living body. Hepatic portal venous gas (HPVG) and a hyperdense aortic wall (HDAW) are often found by PMCT, although no significant autopsy findings are evident in the liver or aorta. In this study we compared the findings of PMCT with those obtained at autopsy, and discussed the cause of these PMCT features. PMCT was conducted in 12 autopsy cases, comprising eight cases of natural death and four of unnatural death. HPVG was seen in five cases and HDAW in seven. In the cases showing HPVG, visceral abdominal injury, bowel distention or acute circulatory dysfunction was found at autopsy. In the cases showing HDAW, atherosclerosis or an increase in blood viscosity due to dehydration or postmortem changes was evident. Although the precise causes of these PMCT findings are not completely clear, the changes evident at autopsy provide some clues.     

Virtopsy: CT and MR imaging of a fatal head injury caused by a hatchet: A case report

Hatchet blows to the human skull often cause fatal injuries. We present a case of homicide by hatchet blow that underwent CT, MRI, and autopsy examination. Skull fragmentation, fracture lines, and brain injuries were demonstrated prior to autopsy. Many of the hatchet-specific characteristics (flaking, crushing, shattering, and fracture lines) described in literature were observed in the post-mortem imaging of this case.     

Incidental occult gunshot wound detected by postmortem computed tomography

The body of a 59 year old woman underwent postmortem computed tomography (PMCT) examination prior to forensic autopsy, using a 256 slice multidetector row computed tomography scanner. A large left tension pneumothorax detected on the PMCT was considered to be a likely cause of death and this was confirmed at autopsy. In addition there was an unsuspected PMCT finding of a probable gunshot injury traversing the right orbit, facial bones and frontal sinus. The autopsy technique was adjusted accordingly and PMCT findings confirmed. PMCT in this case was not only diagnostic of cause of death, but also revealed retained projectile fragments of an old gunshot wound to the face. Without prior imaging such findings would have been undetected at autopsy. This case further underscores the contribution of routine PMCT examination to forensic autopsy practice.     

A New MRI Grading System for Cervical Foraminal Stenosis Based on Axial T2-Weighted Images

ObjectiveThe purpose of this study was to evaluate the reliability of a new magnetic resonance imaging (MRI) grading system for cervical neural foraminal stenosis (NFS).ResultsFor the distinction among the three individual grades at all six neural foramina, the ICC ranged from 0.68 to 0.73, indicating fair to good reproducibility. The percentage agreement ranged from 60.2% to 70.6%, and the kappa values (κ = 0.50-0.58) indicated fair to moderate agreement. The percentages of intraobserver agreement ranged from 85.4% to 93.8% (κ = 0.80-0.92), indicating near perfect agreement.ConclusionThe new MRI grading system shows sufficient interobserver and intraobserver agreement to reliably assess cervical NFS.     

Investigation of a fatal airplane crash: autopsy, computed tomography, and injury pattern analysis used to determine who was steering the plane at the time of the accident. A case report

A fatal accident is reported in which a small single-engine light airplane crashed. The airplane carried two persons in the front seats, both of whom possessed valid pilot certificates. Both victims were subject to autopsy, including post-mortem computed tomography scanning (PMCT) prior to the autopsy. The autopsies showed massive destruction to the bodies of the two victims but did not identify any signs of acute or chronic medical conditions that could explain loss of control of the airplane. PMCT, histological examination, and forensic chemical analysis also failed to identify an explanation for the crash. A detailed review of an airplane identical to the crashed airplane was performed in collaboration with the Danish Accident Investigation Board and the Danish National Police, National Centre of Forensic Services. The injuries were described using the abbreviated injury scale, the injury severity score, 3-dimensional reconstructions of the PMCT, and an injury pattern analysis. We describe how, on basis of these data, we reached a conclusion about which of the two victims was the most likely to have been in control of the airplane at the time of accident. Furthermore, we argue that all victims of fatal airplane crashes should be subject to forensic autopsy, including PMCT and forensic chemical analysis. The continuous accumulation of knowledge about injury patterns from “simple” accidents is the foundation for the correct analysis of “difficult” accidents.     

Differentiation of hemopericardium due to ruptured myocardial infarction or aortic dissection on unenhanced postmortem computed tomography

The aim of the study was to evaluate unenhanced postmortem computed tomography (PMCT) in cases of non-traumatic hemopericardium by establishing the sensitivity, specificity and accuracy of diagnostic criteria for the differentiation between aortic dissection and myocardial wall rupture due to infarction. Twenty six cases were identified as suitable for evaluation, of which ruptured aortic dissection could be identified as the underlying cause of hemopericardium in 50% of the cases, and myocardial wall rupture also in 50% of the cases. All cases underwent a PMCT and 24 of the cases also underwent one or more additional examinations: a subsequent autopsy, or a postmortem magnetic resonance (PMMR), or a PMCT angiography (PMCTA), or combinations of the above. Two radiologists evaluated the PMCT images and classified each case as “aortic dissection”, “myocardial wall rupture” or “undetermined”. Quantification of the pericardial blood was carried out using segmentation techniques. 17 of 26 cases were correctly identified, either as aortic dissections or myocardial ruptures, by both readers. 7 of 13 myocardial wall ruptures were identified by both readers, whereas both readers identified correctly 10 of 13 aortic dissection cases. Taking into account the responses of both readers, specificity was 100% for both causes of hemopericardium and sensitivity as well as accuracy was higher for aortic dissections than myocardial wall ruptures (72.7% and 87.5% vs 53.8% and 75% respectively). Pericardial blood volumes were constantly higher in the aortic dissection group, but a statistical significance of these differences could not be proven, since the small count of cases did not allow for statistical tests. This study showed that diagnostic criteria for the differentiation between ruptured aortic dissection and myocardial wall rupture due to infarction are highly specific and accurate.     

Is post-mortem CT of the dentition adequate for correct forensic identification?: comparison of dental computed tomograpy and visual dental record

The gold standard for identification of the dead is the visual dental record. In this context, several authors emphasize computed tomography (CT) as valuable supportive tool for forensic medicine. However, studies focusing on diagnostic accuracy of post-mortem computed tomography (PMCT) are still missing. Therefore, the aim of this study was to compare diagnostic accuracy of the visual dental record and post-mortem computed tomography (PMCT) of the dentition for identification of the dead. Ten whole skulls were included into the study. The entire dentition of each skull was first examined with the visual dental record as a gold standard and second using dental PMCT scans, performed on a 64-multi-detector CT (MDCT). 3D reformations, multi-planar reformations (MPR), and CT–orthopantomography (OPG) were performed in the post-processing. All examinations were analyzed by three independent investigators regarding the criteria for identification of the dead, e.g., in case of disaster. PMCT for the dental identification of the dead was difficult to perform and time consuming. Due to dental overlays and corresponding artifacts, the definite periphery of the dental fillings/inlays was not accurately defined resulting in 2.9% incorrect and 64.1% false negative findings, especially synthetic inlays were hardly or not recognizable at all. For the identification of the dead especially in case of disasters with large numbers of victims, the visual dental record is still to be considered the gold standard. In the identification process itself, there is no room for error at all, although some non-concordant information may occur. Thus, PMCT should only be performed for identification in individual cases due to the relatively high error rate. S. Kirchhoff and F. Fischer contributed equally to this work.