Leitthema

Rechtsmedizin 2017 · 27:427–432DOI 10.1007/s00194-017-0190-xPublished online: 18 August 2017© The Author(s) 2017. This article is an openaccess publication.

K. J. Woźniak · A. Moskała · E. Rzepecka-Woźniak · P. Kluza · K. Romaszko ·O. LopatinChair and Department of Forensic Medicine, Jagiellonian University, Kraków, Poland

Post-mortem imagingin sudden death cases due toarterial or cardiac hemorrhage

Introduction

During the last decade post-mortemimaging has strengthened its positiongiving the opportunity for a revival ofmedico-legal autopsy examination. Themilestones of this examination tech-nique were set up by publications aboutVirtopsy® [1] as well as the secondedition of Brogdon’s forensic radiology[2]. Conventional autopsy replacementideas seem to be restricted to compati-bility between conventional and modernmethods of examination heading to op-portunities for higher level of objectivity[3]. Due to relatively good availabilityand moderate costs, the most populartechnology applied in modern post-mortem imaging is post-mortem com-puted tomography (PMCT); however,unenhanced PMCT in violent and nat-ural death cases may be insufficientsimilarly to conventional autopsy tech-niques in showing the actual sourceof bleeding related to the damage ofblood vessels and even worse referringto evaluation of internal organ injuries.The addition of contrast agent (CA)administration provides the opportu-nity for successful supplementation ofthis examination technique into PMCTangiography (PMCTA).

Material andmethods

In everyday practice of the authors’ De-partment of Forensic Medicine, PMCTacquisitions are performed in almost ev-erycasedirected tothedepartment. Withrespect to the PMCTA, we implementedtwo main indications for this examina-

tion: victims of potential homicide es-pecially due to sharp force trauma andcases screened by the PMCT with posi-tive findings showing high possibility ofinternal bleeding. As a member of theTechnical Working Group Postmortem

Fig. 18 A 52-year-old female found in bushes under circumstances that suggested sexual assault;however, post-mortem examination excluded any violent cause of death:a thin coronal plane sec-tionof theheadbasedonunenhancedPMCTshowingsignsofboth subarachnoidand intraventricularhemorrhage; the arrow shows the location of the possible source of bleeding,b thick coronal planeof the headbased on PMCTA in the dynamic phase showing CA extravasation at the base of the rightside of the brain, c the autopsy specimenof the arteries at the base of the brain, showing the rupturedaneurysm (arrow) of the rightmiddle cerebral artery (“inferior” view),dmicroscopic specimen, show-ing changes of the arterial wall and the aneurysm (H&E×40)

Angiography Methods (TWGPAM) [4]our Department took part in the multi-center study which included mostly vio-lent death cases, referring to sharp forcetrauma and gunfire injuries; however,other cases with the potential interesting

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Fig. 28 A41-year-oldmalepresentingwith complaints ofpain in thechest and theback,whohadbeenexamined twotimes(daybyday) inhospital, finallydischargedhomewherehediedthenextday. Post-mortemexaminationrevealedthe ruptureddissecting aortic aneurysm, spreading to carotid and iliac arteries, with two areas of rupture in the immediate vicinity of thebase of the heart and the aortic arch:a thin axial plane of the thorax based on unenhanced PMCT showing blood inside thepericardial sac,bVRT reconstruction based on PMCTAat the arterial phase showing CA inside both lumens of the dissectingaortic aneurysm aswell as CA extravasation into the pericardial sac, right posterior view, c the autopsy specimen showing in-ternalwall of the aortic archwith the rupture anddmicroscopic specimen, showingdissectionof theaorticwallwithbleeding(H&E×40)

prospects for PMCTA evaluation weretaken into consideration, including casesof natural deaths due to hemorrhage.In the current paper we present the re-sults of both conventional and PMCT/PMCTA evaluation of five cases, includ-ing four ruptured aneurysms (one at thebase of the brain, one of the abdomi-nal aorta and two dissecting aneurysmsof the thoracic aorta) and one cardiacrupture at the site of myocardial infarc-tion. The cases included adults of bothsexes, aged from 41 to 75 years old.The CT data acquisition was completedwithin 1–5 days after death. All caseswere scanned using 16-layer tomogra-phy (Somatom Emotion, Siemens, Mu-nich, Germany, kVp 130, mAs 50 and240), reconstructed slice thickness 0.75and 1.5, collimation 16 × 0.6, and pitch0.85 and 0.55. Before CA administra-tion all cadavers were examined usingunenhanced PMCT as well as externalconventional examination and materialsampling for toxicological examination

was performed. As a TWGPAM mem-ber, we applied whole-body examinationutilizing the standardized CA protocolwith the use of 6% oily liquid solutionof Angiofil® (Fumedica, Muri, Switzer-land), administered to femoral vessels.After imaging, a complete conventionalinternal autopsy examination was per-formed. Macroscopic examination wasaccompanied by histology with hema-toxylin-eosin(H&E)stainingoftheheart,brain, lungs, liver, kidneys as well as theregions of hemorrhage (arterial and car-diac walls). The PMCT/PMCTAacquisi-tion results were evaluated by two foren-sic pathologists with 9 years of experi-ence in such examination and evaluationusing the open source Digital Imagingand Communication (DICOM) viewer,OsiriX (Pixmeo SARL, Bernex, Switzer-land, version 5.0.2), including the analy-sis of two-dimensional (2D) slices, mul-tiplanar reformatted (MPR) images andformationof three-dimensional (3D) im-

ages by volume-rendered (VRT) recon-structions.

Results

The. Figs. 1, 2, 3, 4und5 show the resultsof both post-mortem imaging and con-ventional methods aimed at the sourceof bleeding/triggering cause of death.

Discussion

The PMCTA technique has only approx-imately 10 years of history of utilizationfor forensic pathology purposes [5]. Anincreasing number of forensic medicineinstitutes are using the PMCTA exami-nation technique. Different methods ofapproachwerepresented, referringtotar-geted examination of selected regions ofthe deceased person [6, 7], with the at-tempts of validation of methods in com-parison to microscopic [8] and conven-tional autopsy examinations [9]. Apartfrom different causes of vascular damage

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in violent and natural death cases, thereare other changes referring to blood ves-sel pathology taken into consideration,including diagnosis of pulmonary em-bolism [10], coronary thrombosis, anddifferent aspects of coronary artery dis-ease [11–13] including the possibility ofmyocardial changes visible after CA ad-ministration. Vascular changes at dif-ferent locations [14] and due to specificillnesses [15] were reported. The use ofPMCTA, at first aimed only at exami-nation of bodies of deceased adults, hasbeen introduced for other cases, evenwith problematic technical issues [16].There are also reports referring to eval-uation and visualization in cases aftermedical interventions related to the heartand great vessels [17, 18]. The publica-tionsare aimednotonlyat diagnostic effi-ciency but also present different methodsof CA administration [10, 19, 20] withthe propositions of standardized proto-cols [4, 21]. As we understand that thereare no universal “remedies” for evalua-tion of all cases, the advances and limita-tions in the development of examinationmethods with the use of administrationofCAtocadaverswerediscussed [22, 23].Avaluableachievementis thatthepresen-tation of cases referring to post-mortemimaging results are reaching scientificjournals not only dedicated to forensicpathologists/radiologists, but also clini-cal disciplines [24], which may give theopportunity for better understanding ofthe value of post-mortem diagnosis forevaluation of clinical problems. Recentpublications provide evidence that PM-CTA may give forensic post-mortem ex-amination additional strength [4]. Basedon the cases presented in the currentpaper we may even claim that the PM-CTA in selected cases might be the suf-ficient way of examination while com-bined with conventional external exam-ination and toxicological sampling (in-vestigation); however, histopathologicalexamination of specimens (at least in-ternal organs) seems to be necessary incases of alleged medical error: for exam-ple, itmay be crucial for the estimation oftiming of critical changes (e.g. rupturesand necrosis).

At thepresent time there arenodoubtsthat post-mortem imaging differs from

Abstract · Zusammenfassung

Rechtsmedizin 2017 · 27:427–432 DOI 10.1007/s00194-017-0190-x© The Author(s) 2017. This article is an open access publication.

K. J. Woźniak · A. Moskała · E. Rzepecka-Woźniak · P. Kluza · K. Romaszko · O. Lopatin

Post-mortem imaging in sudden death cases due to arterial orcardiac hemorrhage

AbstractThe authors present cases of natural deathdue to arterial or cardiac hemorrhageevaluated using both conventional autopsyexamination and post-mortem imaging,including post-mortem computed tomog-raphy angiography (PMCTA). Visualizationbased on CT scan acquisition are presentedcombined with the results of macroscopicand microscopic examination. Based oncases presented it can be seen that inselected cases PMCTA might be a sufficientmethod of examination while combinedwith conventional external examinationand toxicological investigation; however, in

investigations of allegedmedical malpracticecases, histopathological examination ofspecimens seems to be necessary. There areno doubts that post-mortem imaging differsfrom clinical examination. As we consider thehistory and the output of clinical imagingmethods, there are plenty of challengesawaiting in the field of post-mortem imaging.

KeywordsPost-mortem examination · PMCTA ·Aneurysm rupture · Cardiac rupture ·Visualization

Postmortale Bildgebung bei plötzlichen Todesfällen aufgrundarterieller oder kardialer Blutungen

ZusammenfassungDie Autoren präsentieren natürlicheTodesfälle aufgrund arterieller oderkardialer Blutungen, die sowohl durch einekonventionelle Autopsie als auch mittelspostmortaler Bildgebung, einschließlichpostmortaler Computertomographie-Angiographie (PMCTA), beurteilt wurden. DieCT-basierte Visualisierungwird vorgestellt,in Kombination mit den Ergebnissenmakroskopischer und mikroskopischerUntersuchungen. Anhand der vorgestelltenFälle wird deutlich, dass die PMCTA in selek-tierten Fällen als Untersuchungsverfahrenausreichend sein kann, wenn sie mit derkonventionellen externen Untersuchung undder toxikologischen Erhebung kombiniert

wird; jedoch scheint bei der Untersuchungvon Fällen, in denen angeblich ein ärztlicherBehandlungsfehler vorliegt, die histopatholo-gische Untersuchung von Proben notwendigzu sein. Es besteht kein Zweifel, dass sich diepostmortale Bildgebung von der klinischenUntersuchung unterscheidet. Betrachtetman die Entwicklung und die Ergebnisse derklinischen Bildgebungsverfahren, so wird eszahlreiche Herausforderungen im Bereich derpostmortalen Bildgebung geben.

SchlüsselwörterPostmortale Untersuchung · PMCTA · Aneu-rysmaruptur · Herzruptur · Visualisierung

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Fig. 38 A55-year-oldwomanwithahistoryofhypertensive andGraves-Basedowdiseases, under systematicmedical super-vision, collapsedanddiedunexpectedly.Post-mortemexamination revealedwideningof the circumferenceof theascendingaorta (upto10 cm), theruptureddissectingaorticaneurysmwithtworupturesoftheascendingaorta,bothdiametersapprox-imately1 cm: a thickaxialplaneofthethoraxbasedonunenhancedPMCTshowingbloodinsidethepericardial sac,b thinaxialplanebasedonPMCTAat thearterial phase showingdissectingaortic aneurysm, cVRT reconstructionbasedonPMCTAat thearterial phase showing CA inside both lumens of the dissected aortic aneurysmaswell as CA extravasation to the pericardialsac, left anterior view andd autopsy specimen showing dissecting aneurysmof the descending aorta

Fig. 48 A75-year-oldmale suffered frompain in the inguinal area andsubsequently lowerbackpain.Hehadbeenobservedfor several hours in hospital and discharged home,where he died on the same day:a thin axial plane of the abdomenbasedonunenhancedPMCTshowing the changes locatedanteriorly to the spineandat the right side (suggestingbleedingbecauseof rupturedaneurysm),b thin coronal plane basedonPMCTAat the arterial phase showing rupturedaneurysmof abdominalaortawith CA extravasation to the right, note the cannulation of femoral vessels at the right side and c VRT reconstruction ofthe aneurysmbased on PMCTA at the arterial phase, showing the leakage (arrow)

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Fig. 59 A 56-year-oldmalewithout previoustreatment died unexpect-edly in the street. Forensicautopsy revealed areas ofmyocardial necrosis (palered, partially yellowishtinted) of 9 × 3 cm in size,with the double ruptureof the posteriorwall (eachabout 1 cm) of the left ven-tricle at the apical region:a axial plane of the thoraxbased on unenhancedPMCT showing blood in-side the pericardial sac,b,c both based on PMCTA atthe arterial phase: thin ax-ial (b) and coronal (c) planeshowing CA leakage tothe pericardial sac (arrow),d the autopsy specimenshowing the apical part ofthe heart with the rupture(encircled), e the autopsyspecimenwith the cut inthe left ventricle, show-ing the area of necrosisand rupture (arrow) andfmicroscopic specimen,showing different stages ofnecrosis of cardiomyocytes(H&E× 40)

clinical examination [25]. As we con-sider the history and the output of clini-cal imaging methods, there are plenty ofchallenges awaiting in the field of post-mortem imaging [26].

Corresponding address

K. J. WoźniakChair and Department of Forensic Medicine,Jagiellonian UniversityGrzegórzecka 16, 31-531 Kraków, Polandkrzys.wozniak@uj.edu.pl

Acknowledgements. Some presented cases weresupported by the private company FUMEDICA AG,Muri, Switzerland, including free use of a Virtangio®device and free tubing sets and contrast agent forthe duration of the TWGPAMmulticenter study.

Compliance with ethicalguidelines

Conflict of interests. K. J.Woźniak, A.Moskała,E. Rzepecka-Woźniak, P. Kluza, K. Romaszko andO. Lopatin declare that theyhave no competing in-terests.

All studies described in this articlewere carriedoutin accordancewith national law and theHelsinkiDeclaration from1964 (in its current revised form).The PMCTA researchwas approvedby the appropriateUniversity Bioethics Committee (KBET/225/B/2012).

OpenAccess. Thisarticle isdistributedunderthetermsof the Creative CommonsAttribution 4.0 InternationalLicense (http://creativecommons.org/licenses/by/4.0/), which permits unrestricteduse, distribution,and reproduction in anymedium, provided yougiveappropriate credit to the original author(s) and thesource, providea link totheCreativeCommons license,and indicate if changesweremade.

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