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Postmortem Imaging of Blunt Chest Trauma
Using CT and MRI: Comparison With Autopsy
ARTICLE in JOURNAL OF THORACIC IMAGING · MARCH 2008
Impact Factor: 1.74 · DOI: 10.1097/RTI.0b013e31815c85d6 · Source: PubMed

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except for hemomediastinum (70%). Bern. Sonnenhof Spital AG. Copyright r 2008 by Lippincott Williams & Wilkins 20 medicine as a supplement to autopsy. Results: Using combined CT and MRI.*z Martin Sonnenschein. as these findings were not mentioned at the autopsy. MD. MD. the mortality rate for chest trauma was approximately 16%. were discovered. diaphragmatic ruptures (50%.zy Kathrin Yen. these findings were clearly seen radiologically. The aim of the following study was to evaluate the usefulness and to define the benefits and limitations of postmortem CT and MRI of chest injuries in forensic J Thorac Imaging  Volume 23.* and Peter Vock. MRI (J Thorac Imaging 2008. between 75% and 100% of the investigated findings. MD. Stauffacherstrasse 78. Key Words: virtopsy. Number 1.1 In the last several years. publications on postmortem cross-sectional imaging in the literature either simply describe the postmortem radiologic appearance of forensically relevant findings. the comparison of findings of postmortem imaging and autopsy in chest trauma was performed. virtual autopsy.3–6 Up to now. postmortem. blind to the autopsy findings. CH-3014 Bern. MD. Since the implementation of crosssectional imaging methods in forensic medicine such as computed tomography (CT) and magnetic resonance imaging (MRI). which is today performed using autopsy. and autopsy. a number of advantages in comparison with autopsy have been described. rarely. blunt chest trauma. Further radiologicpathologic case studies are necessary to define the role of postmortem CT and MRI as a single examination modality. MDz Objective: Postmortem examination of chest trauma is an important domain in forensic medicine. MRI. February 2008 .2 The current gold standard for forensic postmortem chest examination is forensic autopsy. Methods: This retrospective study includes 24 cases with chest trauma that underwent postmortem CT. MD. In addition.23:20–27) A pproximately one-third of the time required for an autopsy is dedicated to examining the chest and one of the important chest examination issues with autopsy is the diagnosis of traumatic injuries. Two board-certified radiologists.* Christian Jackowski. The comparison of the results of the radiologic assessment with the autopsy and a calculation of interobserver discrepancy was performed. Reprints: Emin Aghayev.* Michael J. pneumopericardium.ch). MD. is necessary. wInstitute for Evaluative Research in Orthopedic Surgery. Although the sensitivity and specificity regarding pneumomediastinum. Each radiologist interpreted postmortem CT and MRI data together for every case. Conclusion: The sensitivity and specificity of our results demonstrate that postmortem CT and MRI are useful diagnostic methods for assessing chest trauma in forensic From the *Institute of Forensic Medicine. Switzerland (e-mail: emin. Within the scope of validation of crosssectional radiology in forensic medicine. The main limitations of autopsy are that it is subjective and observer-dependent. and yDepartment of Diagnostic Radiology.8 report on the abilities of CT and MRI in forensic routine9 or. MD. Thali. and pericardial effusion were not calculated.ORIGINAL ARTICLE Postmortem Imaging of Blunt Chest Trauma Using CT and MRI Comparison With Autopsy Emin Aghayev.* Richard Dirnhofer. zInstitute of Diagnostic Radiology. CT. Switzerland.*w Andreas Christe. aimed at determining the advantages and limitations of both methods. University of Bern.4. n = 2) and heart injury (38%). it can hardly be the basis for a second opinion owing to the fact that the topographic relations are changed and the body tissues and organs are cut and cannot be stored for a longer time except for small specimens. University of Bern. Presently. This allows for the direct gaining of information by inspection and palpation. Inselspital. The averaged interobserver concordance was 90%. MD. present small studies on the comparison between radiologic methods and autopsy regarding some specific forensic issues. MEM Research Center. Institute of Evaluative Research in Orthopedic Surgery. The majority of blunt chest trauma occurs due to motor vehicle accidents (90%) together with falls and work-related accidents (7%). evaluated the radiologic data independently. for validation purposes of cross-sectional radiology in forensic medicine a direct comparison of the radiologic methods and autopsy. Conflict of Interest: None of the authors has any conflicts of interest for this study. the use of postmortem computed tomography (CT) and magnetic resonance imaging (MRI) is growing in forensic medicine from year to year. unibe.7.5 However.aghayev@memcenter.

The mean age of the 22 adult cases was 50 (age range 18 to 80 y) and the remaining 2 cases were children of 2 and 3 years of age. blind to the autopsy findings. rupture of the diaphragm (Diaph). sagittal and coronal reformations were also used. GE. pneumothorax (Pneu). the number of findings detected by imaging methods was equal to or higher than the number diagnosed with autopsy (Diagram 1). The manner of death is presented in Table 1. In most of the cases. pulmonary laceration (PuLac). February 2008 cases and to compare these with conventional autopsy in its role as the current gold standard. MRI examinations of the thorax required between 45 minutes and 1. the individuals died at the accident scene or within the first 2 to 3 hours in hospital. and rupture of the aorta (Aorta) (Table 1). gap 1 mm) r 2008 Lippincott Williams & Wilkins Postmortem Imaging of Blunt Chest Trauma (n = 8) were also obtained. pulmonary atelectasis including compression atelectasis (PuAt). gap 1 mm) (n = 11) and of the STIR sequence (TE/TR/TI 14/3000/ 130 or 22/4120/150 ms. Autopsy All 24 cases underwent conventional autopsy with opening of all cavities approximately 12 hours after radiologic scanning. The interobserver discrepancy was also assessed.25 mm. Axial planes of the T1-weighted fast spin echo sequence (TE/TR 14/400 ms. Axial and coronal planes of the T2-weighted fast spin echo sequence [TE/TR 98/4000 ms. 24 cases with chest trauma that were examined using CT. Some findings. gap 1 mm] with (n = 22) and/or without (n = 9) fat saturation were most frequently used. respectively. MATERIAL AND METHODS This study was approved by the responsible justice department and also by the ethics committee of the University of Bern. the dorsal spine (SFx). A CT scan of the full body took between 5 and 20 minutes. Statistical analyses of the results of the radiologic imaging with calculations of sensitivity and specificity in comparison with autopsy results were performed. Each radiologist interpreted postmortem CT and MRI data together for every case. 5.J Thorac Imaging  Volume 23. The number of the findings diagnosed with autopsy and by the radiologists is shown in Diagram 1. the findings were diagnosed with autopsy and using radiologic methods (Table 1). and 21 . muscle tissue hemorrhage (MusH). who obtained a rough knowledge of preliminary radiologic diagnoses supplied by a forensic resident. The mean weight of the 22 adult cases was 75 kg (range 43 to 100 kg) and the mean height was 174 cm (range 153 to 193 cm). two-thirds of all cases with a heart lesion remained radiologically undetected.8 unit. the 3-year-old child weighted 12 kg and was 96 cm tall. Both radiologists were specialists in clinical radiology with approximately 6 months experience in postmortem CT and MRI imaging. The sensitivity and specificity of the results of the first and second radiologist in comparison with autopsy are shown in Diagram 2. the heart and the hemomediastinum. Autopsy was carried out by 1 or 2 board-certified forensic pathologists. Postmortem Cross-sectional Imaging Postmortem cross-sectional imaging of the body using CT and MRI was performed before autopsy after the virtopsy approach. slice thickness 5 mm (range 3 to 7 mm). soft tissue emphysema (STEm). Subjects Between July 2000 and 2005. were the following: subcutaneous fat tissue hemorrhage (FatH).5-T scanner (Signa Echospeed Horizon.5 hours. For case examinations. In contrast. such as fractures of the spine. Number 1. which were evaluated in the postmortem radiologic data of the chest. continuous multiplanar reconstructions using 1. pneumomediastinum (PnMed). Six cases that showed putrefaction (n = 5) or the ones not examined using standard MRI sequences (n = 3) were excluded from the study. pneumopericardium. both arms were completely elevated to avoid imaging artifacts from extremity bones. fracture of the ribs or the sternum (RFx).3 Radiologic examinations were carried out at an average of 1. mediastinal shift (MedSh). On a dedicated workstation. In all cases. Radiologic Evaluation and Data Analysis The radiologic data were independently evaluated by 2 board-certified radiologists. USA) using a collimation of 4  1. RESULTS Radiologic Evaluation Versus Autopsy Results The results of the autopsy and radiologic examinations are presented in Table 1. hemomediastinum (HeMed). standard MRI sequences. pericardial effusion (PeEf). There were 15 males and 9 females in the group.25 or 8  1.3 days after death (range 0 to 5 d). Except for the findings of diaphragm. slice thickness 5 mm. slice thickness 5 mm.25-mm reconstruction intervals were obtained. pulmonary contusion (PuCon). Thus. MRI of the thorax was carried out after CT on a 1. pulmonary aspiration (PuAs). GE. Full body CT scanning was performed on a 4-row or 8-row scanner (Lightspeed QX/I unit. During the thorax CT scanning. pneumopericardium (PnPer). and autopsy were included in this retrospective study. contusion or rupture of the heart (Heart). pleural effusion (PleEf). USA). sometimes together with a board-certified radiologist during the scan procedure. The 2-year-old child weighted 9 kg and was 71 cm tall. The diagnoses. mediastinal shift and the findings of gas were more frequently found via imaging rather than with autopsy. The sensitivity and specificity regarding pneumomediastinum. 30 forensic cases with chest trauma were examined at our Institute of Forensic Medicine in collaboration with the Department of Diagnostic Radiology at the local University Hospital using postmortem CT and MRI before autopsy.

pulmonary laceration. pericardial effusion. heart injuries. PnPer.Aghayev et al 22 TABLE 1. STEm. diaphragmatic rupture. soft tissue emphysema. pulmonary contusion. spine fractures. The Findings Diagnosed at Autopsy (A). pulmonary atelectasis. PuAs. Rib fracture. pneumopericard. N. VA. pneumomediastinum. mediastinal shift. PuAt. MusH. RFx. Diaph. MedSh. FatH. Heart. pleural effusion. blunt chest trauma was caused by a vehicle accident. February 2008 r The findings detected both at autopsy and using CT+MRI by both radiologists are additionally marked. Number 1. PnMed. PuCon. muscle tissue hemorrhage. by the First (1) and the Second Radiologist (2) Manner of Death Sex Age FatH MusH RFx 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 VA VA VA Fall BT VA VA VA VA VA Fall VA Fall VA VA VA VA BT VA BT VA VA VA VA M M M M M M M M F M M F F F M F M M M F F F M F 47 67 25 33 67 40 3 52 56 32 53 65 65 40 17 2 54 80 61 42 75 52 34 47 A12 A12 2 A12 A12 A12 A12 A12 A12 A12 A12 A12 2 A12 A12 A12 A12 A12 A12 A12 2 2 A12 A12 12 2 A12 A12 A12 A12 A12 A12 A12 A12 2 2 A12 A12 12 A12 A1 A12 A12 2 A12 2 A12 A12 A12 A12 A12 A12 A12 A12 A12 A12 2 A12 A12 A12 A12 A12 A12 A12 A12 SFx MedSh PleEf STEm Pneu PnMed PnPer PuLac PuCon PuAs PuAt PeEf Heart HeMed 12 A2 1 Diaph A12 12 12 12 12 1 A A12 2 A12 12 A12 2 A12 A12 A12 A12 12 A12 A12 A12 1 12 A12 A12 1 12 A1 12 A12 A12 A12 A12 2 A12 A12 A12 A12 A12 A12 A12 A12 A12 A12 A12 23 A12 A12 2 2 2 A12 A12 A12 A12 A12 A12 12 A12 A12 A12 A12 1 1 2 2 12 12 2 12 12 2 12 A12 A12 12 12 12 A12 A A12 2 12 12 A12 A12 A12 A12 12 A12 A12 A12 A12 12 2 A12 A12 A12 A12 12 A12 A12 A12 12 2 A12 A 2 A12 2 A12 A12 A12 A12 1 A12 12 12 12 12 A12 12 12 A12 1 A12 1 A12 A12 12 A12 A12 A12 12 12 A12 A12 12 1 1 1 1 1 1 A12 A12 A12 12 A12 A12 1 A1 2 1 A12 A12 A12 A2 A12 A12 2 A12 A12 A12 A12 A12 A12 A12 A12 A12 A12 1 Aorta A12 2 A12 A 1 1 A12 A12 1 A 2 1 A12 A2 A12 A12 A12 A12 A12 A12 1 2 A12 2 A A2 A2 A1 A12 2 J Thorac Imaging N  2008 Lippincott Williams & Wilkins Volume 23. pulmonary aspiration. BT. PuLac. PleEf. Pneu. in 3 by a fall from height and in the other 3 by blows with a body part. fat tissue hemorrhage. vehicle accident. In 18 cases out of 24. SFx. numbers. Aorta indicates aortic rupture. pneumothorax. . PeEf. HeMed. blunt trauma. hemomediastinum.

the specificity values were at least 75% (Diagram 2). a correlation equal to 75% or higher was observed. The specificity of the second radiologist was between 29% and 44% for muscle hemorrhage. pulmonary lacerations (71%). The diagram presents the sum of all findings detected at autopsy by the first and the second radiologist.J Thorac Imaging  Volume 23. n = 2) and heart trauma (38%). and heart trauma (38%). and heart injury (38%). diaphragmatic rupture (50%. rib fractures and pulmonary contusions (60%). and diaphragmatic rupture. The averaged concordance was 90%. rupture of the heart with heart dislocation in 2 cases and a contusion in 1 case were detected. and spine fractures (73%). rupture of the heart remained undiscovered in 5 cases and contusion in 1. In the remaining findings. n = 2). spine fracture. For the remaining findings. pericardial effusion were not calculated as these findings were not found in autopsy protocols. hemomediastinum. the number of findings diagnosed radiologically exceeded the number diagnosed at autopsy. The averaged sensitivity of the first radiologist was 89% and that of the second was 90%. CT and MRI are used more and more often for postmortem forensic examination as methods supplementing conventional autopsy. our results show that between 75% and 100% of autopsy findings can be discovered using combined CT and MRI examinations. Although findings such as pneumomediastinum. The specificity of the first radiologist for soft tissue emphysema. the second radiologist described all findings with sensitivity equal to or higher than 75% except for diaphragmatic rupture (50%. and pericardial effusion were not documented at autopsy they were seen using radiologic methods. fat tissue hemorrhage (57%). Pleural effusion and pneumothorax (50%). Summarizing the findings of both radiologists together and correlating them with autopsy results.8 Our collected material permitted the comparison of results 23 . This improved average sensitivity at imaging by 3% to 4% but reduced average specificity by 7% to 16%. It is already 3 decades that cross-sectional imaging has been used for the clinical chest assessments. and soft tissue emphysema. mediastinal shift (65%). pneumopericardium. The averaged specificity of the first radiologist was 75% and that of the second was 66%. except for hemomediastinum (70%). February 2008 Postmortem Imaging of Blunt Chest Trauma DIAGRAM 1. n = 2). r 2008 Lippincott Williams & Wilkins In summary. pulmonary aspiration. especially CT is presently the method of choice in assessing chest trauma patients. the question of benefits and limitations of postmortem CT and MRI arises. postmortem CT findings of the nontraumatic lung have been reported. and pneumothorax was between 33% and 50% followed by pulmonary laceration (57%). DISCUSSION Currently. Interobserver Correlation The correlation between the findings of the radiologists is presented in Diagram 2. Except for heart injuries. diaphragmatic rupture (50%. a sensitivity of 93% and a specificity of 59% were attained. Regarding heart trauma. The first radiologist detected all findings with sensitivity equal to or higher than 75% except for hemomediastinum (70%). and spine fractures (73%) followed. pulmonary aspiration. Number 1. Recently. The correlation of only 55% was seen in diagnosing pulmonary atelectasis and no correlation was seen in pericardial effusion. pulmonary atelectasis (72%). On the other hand. pulmonary contusion (60%). Within the scope of validation of cross-sectional imaging in forensic medicine. The specificity of the second radiologist for the remaining findings was equal to or above 75% (Diagram 2).

1). One can suppose that the pathologists have had the benefit of the imaging data. even before they have been recognized and quantified. CT also is the method of choice for detecting difficult rib and spine fractures. and r 2008 Lippincott Williams & Wilkins . In clinical medicine.10 For the autopsy detection of such gas. for example. Radiologic Evaluation Versus Autopsy Although the formal specificity of both radiologists was low for soft tissue emphysema. both radiologists showed a relatively high sensitivity (89% to 100%) but a low-to-moderate specificity (33% to 71%) (Diagram 2). as generally known in clinical medicine and recently reported in the forensic context. partly.11–13 The high sensitivity of both radiologists in detecting bony injuries in this study supports this statement. detection of gas within the heart. This is primarily important for findings such as mediastinal shift and pneumothorax. Number 1. The pathologists performing the autopsies usually obtained a rough knowledge about the injured body parts as well as about some of the findings. and. special techniques that are not regularly performed are required. but also for pleural effusion (Fig. and even aspiration. One of the important advantages of postmortem cross-sectional imaging of the body before autopsy is the documentation of the full body in situ. for example. such as opening of the heart under water. of postmortem radiologic and autopsy examinations of blunt chest trauma. blood may be present in the alveoli of the lung. misses many of these findings related to the presence of gas in the body that cross-sectional radiologic methods and especially CT are superior in detecting. However. when one radiologist reads a small mediastinal blister as a pneumomediastinum and the other does not. even in small amounts (Fig. The fact that many of these findings are small may also explain the different 24 specificities of the 2 radiologists in this regard. Autopsy. This may explain some of the differences between autopsy and radiologic examinations. 1).11 We therefore assume that the autopsy findings with gas have been overlooked5. February 2008 DIAGRAM 2. 1). This means that radiologic recognition of pathologic changes to the lungs is relatively easily performed but that differentiation is currently unsatisfying. pneumothorax. Interobserver differences in the postmortem assessment easily arise. contusion. It is likely that both the appearance and the amount of these findings will be changed during the section of the thoracic cavity. The aim of the present study was to evaluate the usefulness and to define the benefits and limitations of postmortem CT and MRI of blunt chest trauma in forensic cases in comparison with those of conventional autopsy. Again. for example. the inclusion of a fractured spondylophyte among spine fractures. autopsy is accepted as the gold standard for postmortem chest examinations meaning that autopsies detect the maximum findings. the findings can be assessed before any changes in the location of the organs and tissues occur. artificially caused a low specificity for these findings (Fig. and the imaging methods were compared with the autopsy procedures. currently.Aghayev et al J Thorac Imaging  Volume 23. by definition. pneumomediastinum. This can be due to the nature of these findings. the differences in specificity between the readers were unimportant and supposedly due to a different interpretation of tiny findings. The diagram shows the sensitivity and specificity of the first and second radiologist in comparison with autopsy. In detecting pulmonary laceration. and aspiration.5. In laceration. we believe that this is a problem of the verification standard. contusion. By doing so.11 and that this.

According to a recent pilot study in postmortem angiography using cross-sectional techniques. The usual preparation of a window in the intercostal muscles and penetration of the parietal pleura are shown (arrow). the meglumine-ioxithalamate as a contrast medium permitted an excellent visualization of the coronary arteries at postmortem. Two cases with ventricle rupture and dislocation of the heart as well as 1 case with ventricle contusion were detected. These 2 detected ruptures of the heart ventricle were the 2 largest ones. Note the mediastinal shift to the right.14 Interobserver Difference In our assessment of chest trauma. Check for pneumothorax in the right thoracic cavity at autopsy in the same case. Further autopsy-radiologic correlation studies on the differentiation of these findings are necessary (Fig. 2 cases with rupture of heart atrium. we estimate the FIGURE 2. Pulmonary laceration (thick arrow).3 Our results seem to indicate that rupture of the heart atrium is more difficult to detect in postmortem CT or MRI in comparison to the rupture of the heart ventricle. internal livores (double arrow) meaning livores within an organ as reported by Jackowski et al. Thus. In these 2 cases with heart dislocation. a rupture of the heart ventricle was suspected and then confirmed using autopsy results. Axial CT image. we observed a 90% concordance between the first and the second radiologist. our currently used techniques (CT with the collimation of 4  or 8  1. this usually used technique for the assessment of pneumothorax might have contributed for the discrepancy in the imaging and autopsy results. both dislocations of the heart were seen by the radiologists. Both radiologists exhibited the same low sensitivity and high specificity for heart injuries. Thus. r 2008 Lippincott Williams & Wilkins 25 . Axial T2-weighted MRI image. and we thus assume that its detection is clearly possible using radiologic methods. Two cases with rupture of the heart ventricle. Axial cut of the left lung after fixation in paraformaldehyde. and 1. This unsatisfying situation was already mentioned in a previous study.25 mm. and 1 case with heart contusion remained radiologically undiscovered. The right lung sinks down indicating no pneumothorax. A. Accordingly. Number 1. Tension pneumothorax (P) in the left thoracic cavity in a victim of blunt trauma. February 2008 Postmortem Imaging of Blunt Chest Trauma FIGURE 1.5-T MRI with the slice thickness of 5 mm) permit postmortem detection of heart injury in only one third of the cases. Furthermore. measuring between 3 and 4 cm at autopsy. B and C. and C. Note pleural effusion (arrow PleEf) in both radiologic images and the foci of aspiration in the upper left lobe on the autopsy image (dotted arrow). We assume that postmortem application of contrast media might significantly improve the detection of the traumatic heart injury. B. 2). additional differentiating features are rather discrete. A. and blood aspiration to the main bronchus (arrow Bro) of a victim of blunt trauma. Knowing that postmortem radiology is a very young domain combining forensic pathology and clinical imaging methods and that in this study 2 clinically experienced radiologists were employed. the size of heart muscle rupture plays a role in its detection using postmortem radiology.J Thorac Imaging  Volume 23. It is well imaginable that the appearance of the mediastinal shift after use of this technique was changed owing to the adjustment of the intrathoracic and ambient pressure.

although it provides clearly better contrast of soft tissues. Forensic Sci Int. La sante publique en Suisse. we used CT and MRI. concerning the number of false positive findings responsible for the low specificity of radiologic methods. Jackowski C. cross-sectional radiologic-autopsy correlation studies are still a young approach and. We suppose that close radiologic-autopsy casework within the scope of the evaluation of CT and MRI as noninvasive examination methods in forensic medicine will lead to a quality improvement of both forensic pathologic and radiologic examinations. Verena Beutler and Karin Zwygart (Department of Clinical Research.26:892–893. et al. thus. Postmortem radiology of fatal hemorrhage: measurements of cross-sectional areas of major blood vessels and volumes of aorta and spleen on MDCT and volumes of heart chambers on MRI. Thali MJ. et al. it is currently the method of choice for diagnosis of bone and lung pathology and for the detection of gas within the body. The recent and ongoing technical progress in radiology promises a great potential for forensic cross-sectional imaging. which of course are expensive in routine forensic work. 6. However. 4. Pneumomediastinum and soft tissue emphysema of the neck in postmortem CT and MRI. Bern University) for the excellent help in data acquisition during the radiologic examinations and the forensic autopsies. Sonnenschein M. prix. uses subjective and observer-dependent assessment of the findings in many respects. Schweitzer W. Wicky S. Ohashi N. Jackowski C. 5. MRI is more expensive. Furthermore. AJR. Kohno M. Carolina Dobrowolska.25 mm between CT or the 5 mm between MRI images. they were detected using combined radiologic methods. 8. The use of supplemental minimally invasive postmortem examination techniques. despite the assumption that autopsy as the gold standard for 26 J Thorac Imaging  Volume 23. Plattner T. 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