Comparison of the diagnostic efficacy of postmortem computed tomography and traditional autopsy in fracture detection: a meta-analysis.

BackgroundVirtopsy is “a virtual alternative to the traditional autopsy, conducted with scanning and imaging technology,” mainly with the use of postmortem computed tomography (PMCT). It is still in the budding stage in India. The Department of Forensic Medicine and Toxicology, All India Institute of Medical Science, New Delhi, is the first center in the country that has established a facility for virtual autopsy. This facility aims to supplement the traditional autopsy findings and also to replace/curtail internal dissection in autopsy in the future, for which there has always been an aversion in relatives of the deceased due to emotional and religious reasons. The PMCT being a noninvasive, preservative, and objective procedure would be preferred by relatives than traditional autopsy. So, in this regard, this pilot study was conducted with the objective for comparison of PMCT vs traditional autopsy findings in fatal road traffic accidents to analyze its advantages and limitations in order to replace/augment the traditional autopsy with PMCT in the near future in road traffic accident cases.ResultsThe authors evaluated 10 cases of road traffic accident victims. In each case, an autopsy was preceded by a PMCT examination using a 16-slice Multi-Slice CT spiral scanner. The fractures of the skull, facial bones, clavicle, scapula, and vertebra were located more precisely as compared to traditional autopsy. Interpretation of the ventricular hemorrhages of the brain is much better in PMCT. PMCT should be the investigation of choice for pneumothorax, pneumoperitoneum, pneumocephalus, and hemosiuns, while it needs further exploration to detect injuries of soft tissues as out of 14 injuries only 2 were identified by PMCT.ConclusionsThe procedure of whole-body PMCT followed by region-wise CT can be studied for a better PMCT acquisition to detect soft tissue injury findings more precisely. However, the PMCT in this study was able to conclude the cause of death in a more scientific way than the traditional autopsy.

Background: The use of advanced radiological techniques is rising in the field of forensics to supplement and validate the evidence. Postmortem Computed Tomography (PMCT) is now used as a standard procedure in many institutions to augment traditional autopsy findings. The application of PMCT in hanging cases will greatly reduce the number of invasive traditional autopsies, as hanging is the most common method of suicide in Northern parts of India. Therefore this observational study was conducted to compare PMCT with traditional autopsy in fifty hanging cases. Result: Out of 50 cases, the age of the subjects ranged between 14 years and 70 years. PMCT with the help of 3D reconstruction was able to detect external ligature marks on the neck in 92% (N=46) of cases giving a sensitivity of 92% (CI = 80.77% to 97.78%). Skin and subcutaneous tissue desiccation were identifiable in 96% (N=48) by PMCT, giving a sensitivity of 96% (CI= 86.29% to 99.51%). The muscle hemorrhage was identified in 4% (N=2) of the cases in traditional autopsy while the authors found difficulty in interpreting the muscle hemorrhage in PMCT. In detecting thyroid cartilage fracture, the sensitivity of PMCT was found to be 100% (CI= 15.81% to 100.00%) and specificity of 100% (CI=92.60% to 100.00%). In detecting hyoid bone fracture, the sensitivity was 100% (CI= 2.50% to 100.00%), and specificity of 100% (CI=92.60% to 100.00%). In addition, there was a great degree of agreement between the two observers for these findings suggesting the reproducibility of the result. Conclusions: A consistency in findings of both the PMCT and traditional autopsy was found. However, CT was unable to detect muscle hemmorhages, compared to traditional autopsy. Authors suggest the use of CT angiography to overcome this shortcoming, till then CT can only augment invasive autopsy findings not replace it

ObjectivesTo assess the diagnostic performance of chest CT in the detection of rib fractures in children investigated for suspected physical abuse (SPA).MethodsMedline, Web of Science and Cochrane databases were searched from January 1980 to April 2020. The QUADAS-2 tool was used to assess the quality of the eligible English-only studies following which a formal narrative synthesis was constructed. Studies reporting true-positive, false-positive, true-negative, and false-negative results were included in the meta-analysis. Overall sensitivity and specificity of chest CT for rib fracture detection were calculated, irrespective of fracture location, and were pooled using a univariate random-effects meta-analysis. The diagnostic accuracy of specific locations along the rib arc (anterior, lateral or posterior) was assessed separately.ResultsOf 242 identified studies, 4 met the inclusion criteria. Of these, 2 were included in the meta-analysis. Chest CT identified 142 rib fractures compared to 79 detected by initial skeletal survey chest radiographs in live children with SPA. Post-mortem CT (PMCT) has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures when compared to the autopsy reference standard. PMCT has low sensitivity (45%, 21% and 42%) but high specificity (99%, 97% and 99%) at anterior, lateral and posterior rib locations, respectively.ConclusionsChest CT detects more rib fractures than initial skeletal survey chest radiographs in live children with SPA. PMCT has low sensitivity but high specificity for detecting rib fractures in children investigated for SPA.Key Points• PMCT has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures; extrapolation to CT in live children is difficult.• No studies have compared chest CT with the current accepted practice of initial and follow-up skeletal survey chest radiographs in the detection of rib fractures in live children investigated for SPA.

BackgroundRecently, post-mortem photon-counting CT (PMPCCT) has been introduced to forensic imaging. Compared to conventional energy integrating post-mortem CT (PMCT), PMPCCT enables ultra-high resolution (UHR) imaging, which is particularly suitable for visualizing fine fractures and fissures. These are often found in rib trauma, which is usually relevant in forensic medicine. The aim of this study was to evaluate the diagnostic accuracy of rib fracture detection using PMPCCT compared to PMCT and forensic autopsy.MethodsA total of n = 20 bodies that had suffered blunt chest trauma before death and n = 5 non-trauma control cases were investigated. PMCT and PMPCCT were conducted prior to forensic autopsy. Two observers (radiologist and forensic pathologist) analyzed PMCT images (reconstructed with a slice thickness of 0.5 mm in a 512 matrix) and PMPCCT images (reconstructed with slice thicknesses of 0.5 mm and 0.2 mm (UHR) in a 1024 matrix). Imaging diagnosis of rib fractures was compared to autopsy diagnosis as gold standard. The diagnosis of different types of rib fractures assessed at imaging was compared between PMCT and PMPCCT.ResultsInter-rater agreement between the two observers was good (κ = 0.79). Both PMCT and PMPCCT diagnosed less rib fractures than the autopsy (n = 356 fractures). Compared to PMCT, UHR-PMPCCT demonstrated slightly higher sensitivity (e.g., 92% vs. 82% in observer 1), slightly higher specificity (e.g., 97% vs. 95%), and lower positive predictive value (e.g., 75% vs. 82%) for the diagnosis of all rib fractures. Chi-squared tests showed significant differences (p-value < 0.05 in both observers) between UHR-PMPCCT and PMCT for the diagnosis of incomplete rib fractures with visible dehiscence of one cortical line.ConclusionBased on the results, it is questionable whether PMPCCT offers additional forensic value over PMCT for the specific forensic issue of diagnosing rib fractures.

Postmortem computed tomography (PMCT) is a procedure fairly unfamiliar to many US radiologists. We embarked on a collaboration between the department of radiology and the medical examiner's office (MEO) with the purpose of introducing PMCT into the autopsy workflow and the goal of assisting forensic pathologist decision-making regarding the need for autopsy in determining cause of death. Establishing this service involved coordination, education, and extensive planning involving numerous professionals volunteering their time and effort. For the last 2 years, PMCT has been performed on cases requested by the MEO. Two emergency radiologists issued double-read reports detailing the PMCT findings, and the MEO completed a report detailing the PM examination process, which always included an external examination and often included an autopsy. Shared documentation summarized decedent and case information (eg, medical history), radiology primary findings and impressions, and the pathology report findings (including autopsy conclusions, when performed). As of July 2024, 116 PMCT examinations have been performed, of which 64 (55.2%) underwent formal autopsy, 2 (1.7%) received limited autopsy, and 50 (43.1%) had no subsequent autopsy performed. MEO conducted external exam only when PMCT findings were conclusive for the cause of the death, demonstrating that CT had a role in supplanting the need for an autopsy. Indications for PMCT included Rule out trauma, assess extent of trauma, and family/religious objection. The manner of death for these cases was classified as accident, homicide, natural, suicide, traffic related, or undetermined. PMCT can be a valuable service to decedent families as well as to forensic pathologists who often operate in a limited resource environment. We anticipate that PMCT will become a standard discipline in forensic analysis. This service can often reduce the need for traditional autopsy and provides the potential to honor cultural sentiments and religious needs surrounding traditional autopsy. Establishing such a service requires the co-operation of many stakeholders, sometimes across institutional boundaries. PMCT broadens the experience of the radiologist and provides the potential for collaborative research and educational opportunities between radiology and the MEO. Lessons learned from this study may be useful for other jurisdictions implementing PMCT.

Virtual autopsies (VAs) are non-invasive, bypassing many of the challenges posed by traditional autopsies (TAs). This is a literature review about the sensitivity of the main VA techniques: post mortem (PM) computed tomography (PMCT) and PM magnetic resonance (PMMR). This could help to identify the most appropriate uses for VA, and where future research should focus. A review was performed, searching for literature from the last 10 years regarding how sensitive VA is at detecting common lesions that could cause or contribute to death. 33 studies were included. There was strong agreement that PMCT had strengths in detecting: free gas; fractures; large fluid accumulations; and calcifications. PMCT’s weaknesses included missing: pulmonary emboli; myocardial infarctions; and visceral/soft tissue lesions. The strengths of PMMR were less widely agreed, but included detecting: large fluid collections; myocardial infarctions; and visceral/soft tissue lesions. There were no wide agreements on PMMR’s weaknesses due to a lack of literature. Therefore, VA is a useful adjunct to TA; however, its drawbacks in reliably detecting common causes of death restrict its ability to fully replace TA. Novel imaging techniques are being developed in order to bridge the current gaps of VA, and make autopsies even less invasive.

Cases of suicidal hanging are a common death referred for medico-legal autopsy throughout the world. Although some advocate using postmortem computed tomography (PMCT) without traditional invasive autopsy (TIA) to investigate such deaths, others reject this approach. There is currently limited evidence to guide practice. In this context, the TIA reports and PMCT images of 50 cases of suspected suicidal hanging during an 11-month period were reviewed. The reviewers were blinded to the findings of the other modality. A Cohen’s Kappa coefficient (K) was calculated to assess agreement between TIA and PMCT across a range of pertinent findings. This analysis demonstrated perfect agreement for identification of a ligature (K = 1.00) and a strong level of agreement for identification of a ligature suspension point (K = 0.832) but only a minimal level of agreement for overall ligature mark (K = 0.223). PMCT demonstrated a weak level of agreement for fractures of hyoid bone (K = 0.555) and thyroid cartilage (K = 0.538). Three probable fractures not identified at TIA were identified on PMCT. TIA was shown to be superior in the identification of intramuscular and laryngeal fracture–related haemorrhage/bruising whereas PMCT was superior to TIA in identifying body gas deposition. There was overall good correlation between the natural disease and trauma identified elsewhere in the body during the TIA and PMCT. The study demonstrates that PMCT can assist the investigation of suspected suicidal hangings. However, the accuracy of many findings is limited, and if it is used as an alternative to the TIA, potentially pertinent findings, such as fractures of the laryngeal cartilages, could be missed.

The use of postmortem computed tomography (PMCT) to support autopsy pathology has increased in recent decades. To some extent, PMCT has also been contemplated as a potential alternative to conventional postmortem examination. The purpose of this study was to investigate the ability of PMCT to detect specific pathologic findings in the head and brain in natural hospital deaths.We examined postmortem CT images and autopsy data from 31 subjects who died at SUNY (State University of New York) Upstate University Hospital between 2013 and 2018. Each subject underwent a noncontrast PMCT and a traditional autopsy. A neuroradiologist analyzed PMCT images for head and brain abnormalities. The autopsies were performed by pathologists who were aware of the radiology results.In our series, PMCT was able to detect the majority of the significant space-occupying lesions, although it was not always reliable in ascertaining their nature. Postmortem computed tomography revealed findings usually challenging to detect at autopsy. Unfortunately, there were also situations in which PMCT was misleading, showing changes that were difficult to interpret, or that could be related to postmortem events. Therefore, we conclude PMCT should be used as an adjunct rather than a substitute to autopsy.

Rib fractures: elusive, but important

Computed tomography (CT) and other advanced diagnostic imaging techniques are gaining popularity in forensic pathology. This paper aims to define and offer complete and easily accessible "state of the art" for post-mortem computed tomography (PMCT), by reviewing the latest international literature. The proposed format answers the "five Ws" that follows: (1) What: We report the different kinds of CT scan and settings generally used in post-mortem imaging. The machine most employed is a 8/16-slice spiral CT, usually without contrast enhancement. The introduction of some variables, such as CT-guided biopsies, post-mortem ventilation, and PMCT angiography is becoming increasingly useful. (2) Why: Literature highlights the many advantages of PMCT. Limitations can be partly overcome by modern imaging techniques and combined evaluation with traditional autopsy. (3) Who: Most authors agree that collaboration between different specialists, i.e., radiologists and pathologists, is the best scenario, since radiologic, anatomic, and forensic skills are needed simultaneously. The most important human factor is "teamwork". (4) When: Literature provides no absolute limits for performing PMCT. Some authors have tested PMCT as a replacement for conventional autopsy but found some limitations. Others evaluated PMCT as a guide or screening tool for traditional autopsy. (5) Where: Many research groups around the world have performed studies on the use of PMCT. Although few countries adopt PMCT in routine practice, its use is rapidly spreading.

Choking is a serious yet often overlooked risk among individuals with Down syndrome (DS), primarily due to their anatomical and neuromuscular vulnerabilities. This case report discusses the sudden choking-related death of an 11-year-old child with DS, emphasizing both clinical and forensic perspectives. The child developed respiratory distress while eating and became unresponsive, leading to a medicolegal investigation. A comprehensive postmortem examination, including verbal autopsy, postmortem computed tomography (PMCT), and traditional autopsy, was performed. PMCT revealed a foreign body obstructing the laryngeal inlet, along with pulmonary interstitial emphysema and diffuse pulmonary edema - findings that strongly suggested antemortem choking. The traditional autopsy also confirmed the presence of a soya chunk completely blocking the laryngeal inlet, with all findings aligning with the PMCT results. This case highlights the role of PMCT as a valuable, non-invasive tool in diagnosing choking-related deaths, especially in cases with minimal external indicators. Given that swallowing difficulties in DS persist into adulthood, early screening, caregiver education, and dietary modifications are critical preventive measures. Training caregivers to recognize choking risks, adopt safe feeding practices, and respond promptly to airway obstruction could significantly reduce such fatalities. Forensic pathologists should also consider choking as a differential diagnosis in sudden unexplained deaths, with PMCT aiding in a thorough assessment of airway compromise. Strengthening preventive strategies and improving diagnostic approaches can help mitigate the risk of choking-related deaths in individuals with DS.

A meta-analysis was performed to estimate the diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) in suspected recurrent ovarian cancer. PubMed, The Cochrane Library, Embase, and Web of Science were systematically searched. Studies that compared PET/CT and reference standards within patients for diagnosis of suspected recurrent ovarian cancer were included. Twenty-nine studies involving 1651 patients with ovarian cancer were analyzed. For recurrent versus nonrecurrent ovarian cancer, the pooled sensitivity, specificity, positive likelihood (LH) ratio, negative LH ratio, and diagnostic odds ratio of ovarian carcinoma were 88.6% (95% confidence interval [CI], 86.6%-90.3%), 90.3% (95% CI, 87.6%-92.7%), 6.104 (95% CI, 3.904-9.543), 0.122 (95% CI, 0.077%-0.192%), and 57.032 (95% CI, 30.764-105.73), respectively, for recurrence in the PET/CT. Because sensitivity, specificity, positive LH ratio, and negative LH ratio were all heterogeneous, random effects model was used, and a summary receiver operating characteristic curve was generated. The area under the curve was 0.9445 for recurrent versus nonrecurrent ovarian cancer. Positron emission tomography/computed tomography is a useful tool for predicting the diagnosis and restaging of suspected recurrent ovarian carcinoma.

Use of post-mortem computed tomography during the COVID-19 pandemic

Post-mortem computed tomography (PMCT) has been increasingly used as routine examination in forensic pathology. No recent review of the growing number of papers on the ability of PMCT to detect skull fracture exists, and original papers report sensitivities from 0.85 to 1.00. This systematic review (PROSPERO: CRD42021233264) aims to provide a meta-analysis of sensitivity and specificity of PMCT in skull fracture detection. We searched PubMed, MEDLINE and Embase for papers published between January 2000 and August 2021 reporting raw numbers, sensitivity and specificity or Abbreviated Injury Score for PMCT compared to autopsy. Papers without both PMCT and autopsy, no separate reporting of the neuro-cranium, exclusively on children, sharp trauma, gunshot or natural death as well as case reports and reviews were excluded. Two authors independently performed inclusion, bias assessment and data extraction. QUADAS-2 was used for bias assessment and a random effects models used for meta-analysis. From 4.284 hits, 18 studies were eligible and 13 included in the meta-analysis for a total of 1538 cases. All deceased were scanned on multi-slice scanners with comparable parameters. Images were evaluated by radiologists or pathologists. Intra- and inter-observer analyses were rarely reported. In summary, sensitivity of PMCT for detection of fractures in the skull base was 0.87 [0.80; 0.92] with specificity 0.96 [0.90; 0.98], and sensitivity for the vault was 0.89 [0.80; 0.94] with specificity 0.96 [0.91; 0.98]. The mixed samples are a limitation of the review.

Virtual autopsy is a significant innovation in the field of forensic medicine and medicolegal investigations. This systematic review aims to evaluate the accuracy and practical utility of virtual autopsy in medicolegal investigations. The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed in the conduct of this systematic review. The literature search encompassed an extensive database including PubMed, ScienceDirect, Cochrane Library, and Google Scholar. Studies published from 2014 to 2024 were included in the analysis. The quality of the included studies was evaluated using the proper tools suited to the study design. The synthesis and analysis of data included a narrative summary of study characteristics, aims and objectives, techniques, and main findings of the study. Sample sizes in the selected studies ranged from 16 to 145 cases. The most common virtual autopsy techniques used were postmortem computed tomography (PMCT). Some studies used PMCT and conventional autopsy, while some studies used only PMCT, and a few studies applied combinations of PMCT and conventional autopsy, along with other techniques such as postmortem magnetic resonance, PMCT angiography, and traditional invasive autopsy to evaluate various conditions in medicolegal investigations. This systematic review concludes that virtual autopsy offers significant benefits, such as noninvasiveness and the ability to document findings digitally, but its limitations in differentiating ante mortem and postmortem changes, lack of tissue sampling, and challenges in soft tissue analysis restrict its ability to fully replace conventional autopsies.