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Harcke et al. MDCT of Projectile Injury Forensic Radiology Pictorial Essay

MDCT Analysis of Projectile Injury in Forensic Investigation

H. Theodore Harcke1,2 Angela D. Levy 2 John M. Getz 3 Stephen R. Robinson 3
Harcke HT, Levy AD, Getz JM, Robinson SR

OBJECTIVE. This article illustrates the MDCT postmortem imaging features that have the potential to enhance forensic investigation and conventional autopsy. COnClusIOn. MDCT may guide, direct, or limit forensic autopsy in projectile injury cases, thereby eliminating the need for a complete invasive autopsy.

Keywords: forensic autopsy, MDCT, projectile injury DOI:10.2214/AJR.07.2754 Received June 19, 2007; accepted after revision August 16, 2007. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army, Navy, or Defense.
1 Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington, DC. Address correspondence to H. T. Harcke, c/o Michelle Stofa, PO Box 269, Wilmington, DE 19899 (howard.harcke@us.army.mil). 2 Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, MD. 3 Office of the Armed Forces Medical Examiner, Armed Forces Institute of Pathology, Rockville, MD.

WEB This is a Web exclusive article. AJR 2008; 190:W106W111 0361803X/08/1902W106 American Roentgen Ray Society

DCT is an effective imaging technique to localize gunshot wound tracks and aid in the forensic autopsy of gunshot wound victims [13]. Projectiles include a diverse group of metallic objects such as bullets, components of explosive devices, or secondary projectiles from explosions that may inflict injury or cause death. In the forensic investigation of death by suspected projectile injury, determination of the projectiles entry and exit locations, path, and associated tissue injury is important in the determination of the cause and manner of death [4, 5]. The purpose of this article is to illustrate the noninvasive characterization of projectile wounds on postmortem full-body, thinsection MDCT images. In all cases, imaging was performed on a 16-MDCT scanner. Images were interpreted using multiplanar 2D reconstruction, minimum intensity projection, and 3D volume rendering to critically and accurately analyze the 3D paths and features of projectile injury. The study was performed with the approval of the institutional review board of the Armed Forces Institute of Pathology and was HIPAA-compliant. Total-body MDCT scans were obtained on a LightSpeed 16 (GE Healthcare) within 24 days after death. Subjects were scanned at 1.25 0.625 mm; pitch, 0.935:1; rotation speed, 0.5 second; and table speed, 17.2 mm per rotation. Images were viewed and measured on an Advantage Workstation, software version 4.2 (GE Healthcare), using 2D and 3D multiplanar reconstructions.

Projectile Injury Projectile injury is classified by the location of the entrance and exit wounds and the course of the projectile path. The projectile path is customarily described in three directions, defining the direction of projectile travel. The description indicates whether the projectile enters the body from anterior or posterior, left or right, and superior or inferior. The presence or absence of foreign material within the body (e.g., bullet, metallic fragment, or other material) is always noted and characterized because recovery of fragments is important for ballistics documentation. Entrance wounds are usually smaller than exit wounds [5]. When a bullet has passed through bone, close examination may show beveling of the bone in the direction of travel. Beveled edges are directed inward at the bone margin of the entrance wound and directed outward at the exit wound [5]. Metallic particles and bone fracture fragments are an additional indicator of directionality because they are usually carried along the direction of projectile travel. If a projectile fragments, pieces of metal will be distributed along the track and mix with bone fragments (Fig. 1). Wound tracks through soft tissue are characterized by gas collections or evidence of tissue and organ damage [3]. Postmortem gas collections in a wound track may result from the temporary cavities created when projectile energy is transmitted to the tissue surrounding the track. Gas may also be introduced along the track when the projectile passes through an air- or gas-containing organ, such

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MDCT of Projectile Injury as lung and bowel. Because gas readily dissects through tissue planes, scattered gas collections may also be noted in surrounding tissues. Generalized decomposition also produces tissue gas and should not be confused with a wound track. A collection of blood and other body fluids can occur in the wound track or pool away from it (Fig. 2). Penetrating Wounds When projectiles enter the body but do not exit, forensic pathologists term these penetrating wounds [5] (Figs. 3 and 4). The projectile can remain intact or be fragmented within the body. Wound track direction can change depending on the shape and kinetic energy of the projectile and its interaction with tissue, especially bone. When interpreting postmortem CT images, it is important to remember that a straight-line path between an entrance wound and the postmortem position does not necessarily represent the antemortem path of the projectile because the trajectory may have been altered by the intervening tissues. Intermediate targets such as bone may produce a ricochet phenomenon within the body. Moreover, organ size and shape often change postmortem (for example, lung volume may be altered by a pneumothorax or hemothorax caused by projectile injury) [2, 3]. Perforating Wounds When projectiles enter and exit the body, forensic pathologists term these perforating wounds [5] (Fig. 5). The projectile may exit without fragmentation, in which case there is residual material, or, similar to the tracks of penetrating wounds, projectile fragments may be deposited within the tissue. Analysis of postmortem CT images should always consider the position of the body at the time of injury, especially when entry and exit wounds do not match other points on the track, such as fractures. This should raise suspicion that the postmortem position is significantly different from the position of the body at the time of injury [5] (Fig. 6). Combination Wounds and Special Cases Projectiles that break into several fragments within the body may create secondary penetrating wounds. In such cases, a single entry wound can become a series of penetrating wounds with retained fragments along one or more secondary perforating wounds. One or more fragments may continue and pass outside the body. Thus, there may be one entry site and more than one exit site. Keyhole fractures of the skull are a special type of perforating wound in which the entry and exit are close together. These occur when the projectile strikes the surface of the calvaria in a tangential manner. The entry is the smaller part of the keyhole, and the exit is the larger (Fig. 7). Limitations of MDCT Analysis of Projectile Injury in Forensic Investigation Soft-tissue differentiation between organs and vascular structures is poor on postmortem CT images because of the lack of IV contrast material. Consequently, vascular injury is often undetected. However, the detection of hematomas or gas or fluid collections in the course of a wound track permits prediction of vascular injury. Postmortem angiography can augment MDCT for the assessment of vascular integrity [6]. Gas associated with projectile tracks is variable. The amount of gas within the projectile path depends on the anatomic structures involved and the ballistic characteristics of a particular projectile. Wounds easily visible on gross inspection may be subtle or not present on MDCT because entry and exit wound characteristics may change due to effects such as extrinsic pressure from an adjacent body part, clothing, and dependent postmortem positioning. In some cases, 3D surface rendering may be helpful to show wounds not easily seen on 2D reconstructions [2]. MDCT is typically performed with the victim in the supine position. Projectile tracks are related to the position of the victim at the time of lethal injury and may be difficult to appreciate in the postmortem supine position (Fig. 6). Specifically, the lungs, mediastinum, and heart may be shifted significantly during or after death by hemorrhage or pneumothorax. Conclusions Applying essential concepts of projectile trajectory and track analysis to MDCT permits characterization of penetrating and perforating injuries. Postmortem MDCT is a noninvasive technique with the potential to enhance forensic investigation and conventional autopsy. References
1. Thali MJ, Yen K, Vock P, et al. Image-guided virtual autopsy findings of gunshot victims performed with multi-slice computed tomography and magnetic resonance imaging and subsequent correlation between radiology and autopsy findings. Forensic Sci Int 2003; 138:816 2. Levy AD, Abbott RM, Mallak CT, et al. Virtual autopsy: preliminary experience in high-velocity gunshot wound victims. Radiology 2006; 240:522528 3. Harcke HT, Levy AD, Abbott RM, et al. Autopsy radiography: digital radiographs (DR) vs. multidetector computed tomography (MDCT) in highvelocity gunshot-wound victims. Am J Forensic Med Pathol 2007; 28:1319 4. Brogdon BG. Forensic radiology. Boca Raton, FL: CRC Press, 1998 5. Di Maio VJM. Gunshot wounds: practical aspects of firearms, ballistics, and forensic techniques. Boca Raton, FL: CRC Press, 1999 6. Grabherr S, Djonov V, Yen K, Thali MJ, Dirnhofer R. Postmortem angiography: review of former and current methods. AJR 2007; 188:832838

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Fig. 1Single gunshot wound to head. A, Three-dimensional reconstruction image shows midline frontal entrance (solid arrow) and right occipital exit (dashed arrow). B, Axial CT image shows frontal entrance wound has internal beveling (arrowheads) and occipital exit wound has external beveling (arrows). C, Reconstructed oblique sagittal image shows bone and metallic fragments are distributed along track within soft tissue.

Fig. 2Gunshot wound to chest. Images show evidence of tissue and organ damage and bone interaction with bilateral pleural fluid. A, Axial image of chest shows wound entrance in right chest wall (arrow). Bullet passes through posterior mediastinum (arrowhead). B, Axial image of abdomen shows left lower rib fracture at site of exit (arrow).

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Fig. 3Penetrating projectile injury of head. A, Three-dimensional reconstruction of skull shows occipital entry fracture defect. B, Coronal reconstruction image shows projectile in right parietal lobe (arrow). C, Sagittal oblique reconstruction image shows wound path is determined by bone fragments along right petrous ridge and high-attenuation hemorrhage in wound path (arrowhead). Projectile struck petrous bone after entry and changed direction to its final location. Note bone fragments adjacent to right petrous bone (arrow).

Fig. 4Penetrating projectile wound of head. A, Photograph shows entry wound through nose. B, Sagittal reconstructed CT image shows projectile wound track passes into posterior fossa through inferior portion of petrous ridge. Nonlinear path of projectile indicates that it was diverted by impact on occipital bone. C, Sagittal reconstructed CT image shows final position of projectile. D, Photograph shows gross pathology. Note right petrous fracture at skull base (arrow). E, Photograph shows recovered projectile.

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Fig. 5Perforating gunshot wound of head and neck. A, Photograph shows entrance wound of left cheek. B, Coronal CT image at entry shows fractures of left mandible (arrow). C, Coronal CT image shows C2 and C3 fractures and wound track (arrows). D, Coronal CT image shows exit wound in right track (arrow). E, Photograph shows exit wound. F, Oblique sagittal reconstruction image approximating wound track.

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Fig. 6Perforating gunshot wound of thorax. Postmortem CT shows malalignment of three distinct landmarks in wound path. A, Axial CT image shows entrance wound in anterior left chest (arrowhead). Note right pneumothorax and bilateral hemothoraces. B, Axial CT image shows path crosses mediastinum and exits through right posterior rib (arrowhead). C, Axial chest CT image shows fracture defect in right scapula. Note this image is more cranial than where rib fracture occurred. D, Three-dimensional reconstruction image of thorax viewed from posterior shows bone fracture defects in right sixth rib and medial margin of right scapula. Note malalignment in autopsy position. E, Autopsy photograph shows rod demonstration of wound track. Note that with flexion of upper arm, scapula rotates, and alignment is achieved.

Fig. 7Keyhole fracture of skull caused by tangential gunshot. A, Sagittal reconstruction image at entry impact shows internal beveling (arrows). B, Sagittal reconstruction image at exit shows larger defect and external bevel (arrows). C, Three-dimensional reconstruction image of skull shows smaller entry (arrows) and larger exit. D, Photograph shows gross pathology.

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