Special Ar ticles • Original Research

Laurent et al.
CT After Fatal Diving Accidents

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Special Articles
Original Research

Postmortem CT Appearance
of Gas Collections in Fatal
Diving Accidents
Pierre-Eloi Laurent 1, 2
Mathieu Coulange 3,4
Julien Mancini 5
Christophe Bartoli 6
Jacques Desfeux 6
Marie-Dominique Piercecchi-Marti 6
Guillaume Gorincour 1,2
Laurent PE, Coulange M, Mancini J, et al.

Keywords: decompression illness, embolism, fatal diving
accident, gas, postmortem CT, virtopsy
DOI:10.2214/AJR.13.12063
Received October 7, 2013; accepted after revision
January 17, 2014.
Presented at the 2013 Congress of the International
Society of Forensic Radiology and Imaging, Zurich,
Switzerland.
1
Laboratoire d’Imagerie Interventionnelle ­E xpérimentale,
Aix-Marseille Université, 27 Blvd Jean Moulin,
13385 Marseille cedex 5, France. Address correspondence to P. E. Laurent (pierre-eloi.laurent@ap-hm.fr).
2
Pôle Imagerie Médicale, Assistance Publique des
Hôpitaux de Marseille, Marseille, France.
3
Service de Médecine Hyperbare, Pôle RUSH,
Hôpital Ste. Marguerite, Marseille, France.
4
UMR MD2, Dysoxie Tissulaire, Aix-Marseille Université,
Marseille, France.
5
LERTIM, EA 3283, Aix-Marseille Université,
Marseille, France.
6
Service de Médecine Légale et Droit à la Santé,
Assistance Publique des Hôpitaux de Marseille,
Marseille, France.

AJR 2014; 203:468–475
0361–803X/14/2033–468
© American Roentgen Ray Society

468

OBJECTIVE. The purpose of our study was to define the postmortem CT semiology of
gas collections linked to putrefaction, postmortem “off-gassing,” and decompression illness
after fatal diving accidents and to establish postmortem CT diagnostic criteria to distinguish
the different causes of death in diving.
SUBJECTS AND METHODS. A 4-year prospective study was conducted including
cases of death during diving. A hyperbaric physician analyzed the circumstances of death
and the dive profile, and an autopsy was performed. Subjects were divided into three groups
according to the analysis from their dive profile: decompression illness, death after decompression dive without decompression illness, and death after nondecompression dive without
decompression illness. Full-body postmortem CT was performed before autopsy.
RESULTS. The presence of intraarterial gas associated with death by decompression illness had a negative predictive value (NPV) of 100%, but the positive predictive value (PPV)
was only 54% because of postmortem off-gassing. The PPV reached 70% when considering
pneumatization of the supraaortic trunks. Pneumothorax, subcutaneous emphysema, and intraarterial gas, all of which are classic criteria for decompression illness diagnosis, are not
specific for decompression illness.
CONCLUSION. This study is the first to show that pneumothorax, subcutaneous emphysema, and intraarterial gas, all of which are classic criteria for decompression illness diagnosis, are not specific for decompression illness. Complete pneumatization of supraaortic
trunks is the best postmortem CT criteria to detect a fatal decompression illness when CT is
performed within 24 hours after death.

C

ross-sectional imaging has experienced an increasingly important role in legal medicine over
the past 10 years [1, 2]. In the
case of diving accidents, postmortem CT [3]
has facilitated the visualization of intravascular gas collections, which are difficult to
detect in autopsies [4]. The most frequent
cause of death in diving accidents is cardiovascular disease. Cold water leads to a redistribution of blood volume, with an increase
in cardiac work and sometimes cardiac decompensation [5, 6]. Drowning is also a frequent cause of diving fatalities but is often
secondary to technical incidents [7] or diving accidents. The third cause is decompression illness. Decompression illness includes
decompression sickness and arterial gas embolism secondary to pulmonary barotrauma
[8]. Decompression sickness is caused by
bubble formation (off-gassing) from dissolved inert gas. The solubility of the inert

gas in the blood decreases during ascent [9–
11]. When recommended decompression
procedures are not performed, off-gassing
can be violent and can cause bubbles to circulate in the body [9–13].
Gas embolisms can also affect the arterial
circulation (paradoxical embolism) [14–16]
by means of a patent foramen ovale [8, 17,
18], by a right-to-left intrapulmonary shunt
[14, 19], or by breaking through the pulmonary capillary filter [20, 21]. Pulmonary
barotrauma is linked to an increase in gas
volume during ascent (Boyle law). Pulmonary barotrauma can lead to a pneumothorax, pneumomediastinum, subcutaneous emphysema, or cerebral arterial gas embolism
(CAGE) [13, 22, 23].
Autopsies and imaging strive to detect the
presence of intravascular gas in victims of
diving accidents [23–27]. These postmortem
gas collections, whether intra- or extravascular, are characterized by their topography,

AJR:203, September 2014

The topography of the gas collections was divided into the following categories: arterial examining the entire arterial system including cerebral vascularization.org by 180. The radiologists were blinded to the circumstances of the accident and autopsy findings. 320 mAs with dose modulation. The following data were collected for each subject: early postmortem CT. unlike postmortem CT. and tends to underestimate the quantity of gas collections [4]. depth. Case information—The forensic pathologists conducting the autopsy and the hyperbaric physician collaborated to determine the medical history of the subjects. The autopsy criteria for decompression illness will be included later in this article. 33]. diving level). and pulmonary arteries. Siemens Healthcare). and pulmonary veins. FOV. venous including the entire venous system including cerebral vascularization. forensic pathologists. respect of decompression stops). A consensus was obtained from the forensic pathologists and the hyperbaric physician. These two elements are classically regarded as criteria for a barotrauma diagnosis [35]. All fatal diving accidents from September 2008 to September 2012 were included in the study.252. Studies have shown that these characteristics are different according to their cause [28–31]. the second included the arms. 37–40]. cardiopulmonary resuscitation (CPR) [33– 35. The visualization of gas collections during an autopsy is difficult. and autopsy. Dive Profile and Technical Equipment Analysis All involved dive computers and technical equipment were analyzed by the hyperbaric physician. and entire supraaortic trunk up to and including the Willis polygon completely filled with gas. without a visible blood-air level and pneumatization of the right ventricle with the entire right ventricle completely filled with gas. bodies that were collected more than 72 hours after the estimated time of death were excluded from the study because after 72 hours all vascular spaces become filled with putrefaction gasses [36]. Extravascular gas collections include pneumothorax and subcutaneous emphysema. and postmortem off-gassing [29–31]. and diving partners when possible. thorax. left cardiac cavities. pitch. Radiologic Interpretation Two board-certified radiologists with experience in forensic radiology jointly analyzed the radiologic data. and slice collimation. 240 mm. 0. color of the skin. The reconstructions and interpretations were performed with the Syngo workstation (Siemens Healthcare). The medical history was obtained by contacting the family and family doctor. The CT parameters for head and neck imaging were 140 kV.Downloaded from www. A hyperbaric physician coordinated the different teams in this study (rescue crews. All of the elements were correlated with the dive profile analysis and autopsy results to determine the cause of death. all rights reserved CT After Fatal Diving Accidents abundance. and gas embolism from decompression illness after fatal diving accidents. dive log. For personal use only. Postmortem CT Before the autopsy. To research postmortem CT diagnostic criteria that would lead to a CAGE diagnosis. Autopsy and Further Postmortem Analyses The autopsies were performed by two boardcertified pathologists. the hyperbaric physician and the forensic pathologists were in direct contact with the rescue crew to obtain information relevant to the accident [42]. A dive is considered to be a decompression dive when the depth and dive duration require one or multiple decompression stops according to French National Marine criteria (Marine Nationale MN90 table). An early analysis of the intravascular gas composition would enable identification of the gas from putrefaction (high levels of hydrogen) but would not enable differentiation between postmortem off-gassing and a decompression illness [41]. medical history. 31] have questioned a number of CAGE diagnoses. The autopsy criteria for drowning were autopsy findings including white foam at the mouth. and length of time spent in decompression stops. The purpose of this study was to define the postmortem CT semiology of different postmortem gas collections linked to putrefaction. but recent studies [28. Copyright ARRS. speed of ascent. To document the effects of CPR. this technique does not show the extent of the gas embolism. Each item in the analysis was recorded as present or absent. aortic cross. Information was collected from rescue crews. 500 mm. abdomen. and pleural effusion [44]. and so on). Study Groups Study groups were formed according to the data from the dive profile analysis. Subjects were classified in one of three groups on the basis of the circumstanc- AJR:203. and pleura including the presence of pneumothorax. and difference of blood strontium concentrations between the left and right ventricles [44]. we also looked for a cardiac event that would lead to death or to a rapid or ascent and that was secondary to decompression illness. They noted the data from the external examination of the body (foaming at the mouth.86 on 05/10/16 from IP address 180. pitch.6. 1 mm. witnesses. and legs.ajronline. September 2014 469 . postmortem off-gassing. The ethics committee of the university and the responsible justice department approved the study. The ascent speed is considered too fast when it exceeds 15 meters per minute.252. Our aim was to establish postmortem CT diagnostic criteria related to different causes of death in diving. The image acquisition was performed in the dorsal decubitus position with the arms along the body.86. Subjects and Methods A study protocol was developed in September 2008 for fatal diving accidents that took place in the Bouches-du-Rhône area in southern France. dive duration. pathologic findings including acute emphysema of the lung with edema and alveolar histiocytosis.4. Samples were collected for pathologic and toxicologic analyses. and the gas seen can result from putrefaction [33–36]. Postmortem CT was performed in two sets: the first included the head and neck. No contrast media was injected. and autopsy.19. timing of events (loss of consciousness on the surface or while diving.19. 400 mAs with dose modulation. At each inclusion. right cardiac cavities. The following parameters were recorded: start time diving. two supplementary criteria were defined [35]: complete pneumatization of the supraaortic trunks involving the left ventricle. 29. indentations of ribs in lungs. However. The CT parameters for full-body imaging (encephalon excluded) were 140 kV. 1 mm. the postmortem CT analysis also looked for subcutaneous emphysema limited to the thoracic area and fractured ribs. Intracardiac gas embolism has to be suspected at autopsy to prove it because it requires dissection of the pericardial sac under water [32. At autopsy. full-body CT was performed on each subject with a 64-MDCT bi-tube scanner (Definition. and radiologists). and ascent conditions (panicked ascent. clinical signs). Subjects Inclusion and exclusion criteria—All diving accidents in scuba diving and apnea free-diving (also called breath-hold diving) from September 2008 to September 2012 in the Bouches-du-Rhône area (the southeast of France) were included. FOV. and delayed postmortem appearance. A dive is considered to be a noncompression dive when no decompression stops are required. Autopsies were conducted using conventional protocols without the use of immersion [43]. diving profile analysis by a hyperbaric physician. water temperature. The CAGE diagnosis has been systematically made when intraarterial gas is found. To avoid known intravascular gas artifacts linked to putrefaction. CAGE is thought to be overdiagnosed. 0. and slice collimation. The criteria for questioning concerned the victim (medical history.

the accident occurred during a scuba dive. All analyses were conducted with help of SPSS 17. and the accident occurred while free diving (apnea).19.86 on 05/10/16 from IP address 180. bloody foam at the mouth.5 52 Cardiac failure Cardiac failure Decompression dive group 8 9 53 F 23 53 29 No 1 43. The results are presented in Tables 1 and 2. Statistics Quantitative variables are presented in the form of a median (minimum–maximum). notably from animal studies [30.0 24 CAGE 6 39 M 29 50 25 No 0 7. and predictive values. NR = not recorded.252. loss of consciousness during ascent or a few seconds after having come to the surface. 470 AJR:203.19. The median age was 47 years (age range.5 68 CAGE 4 45 F 25 42 56 No 1 4.0 25 Drowning 16 37 M 30 3 3 No 1 28. We purposely chose not to distinguish between deaths linked to severe decompression sickness and barotrauma. CPR = cardiopulmonary resuscitation. Results Subjects We examined 20 fatalities from September 2008 to June 2012. 23–74 years). between binary variables was evaluated with the kappa concordance coefficient. specificity. Because the circumstances of death are similar. Nondecompression group—The subjects in the nondecompression dive group did not perform a decompression dive and did not experience a decompression illness. 31].0 47 10 48 M 23 60 33 Yes 0 14. to study the gases respectively due to gas embolisms. the delay in performing CT was due to difficulty in recovering the bodies. autopsy findings of cyanosis. no decompression dive. The divers were respectful of the recommended decompression stops during the ascent or the death occurred on the sea floor. a1 = CPR performed. there are few criteria to differentiate between them in the autopsy and dive profile analysis. The following are the criteria for the classification of the decompression diving group: lack of evidence for a decompression illness. For all the bilateral tests.86.Downloaded from www. a p value less than 0. The median dive depth was 36 meters (range.0 53 Drowning 11 42 M 29 60 33 Yes 0 14. BMI = body mass index. 0 = CPR not performed. es in which the accident took place and the information from existing literature. The following criteria were chosen for inclusion as decompression illness: dive profile analysis including decompression scuba dive and fast ascent or diver did not follow advised decompression stops. 3–60 meters).0 24 Drowning Note—Subjects 13.0 53 CAGE 2 66 M 29 36 38 No 1 4. or presence of a patent foramen ovale (predisposing factor).0 50 Drowning 18 24 M 23 NR NR No 0 20. Copyright ARRS. and putrefaction. All accidents occurred in seawater. postmortem off-gassing. In both cases. The following are the criteria for the classification of the nondecompression diving group: lack of evidence for a decompression illness. including four women and 14 men. 17.0 24 CAGE 7 59 F 32 33 51 No 1 55.0 24 Drowning 14 28 M 25 3 20 No 1 8.252. Two divers were excluded from the study because the postmortem CT studies were performed more than 72 hours after death (91 and 183 hours). and the dive necessitated decompression stops.0 51 Drowning 12 51 M 23 35 19 No 1 8. Decompression diving group—Subjects in the decompression diving group did not experience a decompression illness but experienced a decompression dive.0 software. and pathologic findings of alveolar hemorrhage or rupture of interalveolar walls.0 27 Cardiac failure 13 23 M 23 NR NR No 1 7. and 18 were free divers. Decompression illness group (CAGE) —The decompression illness group consisted of subjects whose death was directly linked to CAGE. hemotympanum.0 21 Drowning No decompression dive group 15 60 M 25 6 3 No 1 15.org by 180. The association between the different postmortem CT criteria and the presence of a decompression illness was tested with the Fisher exact test then expressed as sensitivity. Eighteen subjects were eventually studied.5 27 CAGE 5 74 M 25 38 18 No 1 6.05 was considered statistically significant.ajronline.0 43 Cardiac failure 17 37 M 23 NR NR No 0 48.0 75 CAGE 61 F 25 31 23 No 1 3. The three study groups were compared with a Kruskal-Wallis analysis for quantitative variables and Fisher exact test for categoric variables.0 23 CAGE 3 42 M 52 25 16 No 1 4. The agreement TABLE 1: Subject Characteristics Subject Maximum Duration of Death on Sea Delay Before Delay Before Depth (m) Dive (min) Floor CPRa CT (h) Autopsy (h) Age (y) Sex BMI 1 49 M 27 52 17 Cause of Death Decompression illness group No 1 4. CAGE = cerebral arterial gas embolism. Only putrefaction gas was observed. Categoric variables were presented as counts (%). September 2014 . For personal use only. all rights reserved Laurent et al.

112 Delay before autopsy 27 (23–75) 51 (27–53) 27 (21–50) 35 (21–75) 0. was 8 hours (range. diving parameters. BMI = body mass index. Copyright ARRS.176) among these three groups. Group 1 = decompression illness. including three free divers. Study Groups On the basis of the medical history. We also did not find a statistically significant link between the presence of pneumothorax and death by decompression illness (p = 0. therefore. pneumothorax was found in no subject in the autopsies and in three subjects using postmortem CT.1 (22. TABLE 3: CT Results Containing Only Gas Subject Subcutaneous Arterial Venous Supraaortic Right Emphysema Limited PneumoGas Gas Trunks Ventricle to Thoracic Area thorax Decompression illness group 1 + + + + + − 2 + + + + − − 3 + + + + + − 4 + + + + − − 5 + + + + − − 6 + + + + − − 7 + + + + + − 8 + + − − − + 9 + + + + + − 10 + + + + − − 11 + + + + − − 12 + + − + − + 13 − + − − − − 14 − + − − − − 15 − + − − − − 16 − + − − − + 17 + + − − − − 18 − − − − − − Decompression dive group No decompression dive group Note—Presence indicated by + and absence by −.252.5–55. seven deaths were categorized in group 1 as decompression illness (Fig. AJR:203.084 Maximum depth 38 (25–52) 53 (31–60) 3 (3–6) 36 (3–60) NR Duration of dive 26 (17–56) 29 (19–33) 3 (3–20) 25 (3–56) NR Delay before CT 4.054).9) 23.org by 180.004 and 0.19. Tested Criteria Diagnostic criteria for decompression illness—Table 4 examines the presence or absence of postmortem CT criteria according to whether a decompression illness took place.013. including two subjects who died on the sea floor and two deaths without witnesses.5–43) 17.ajronline.6–29.252. The postmortem CT results for each included subject are collected in Table 3.86. There was no significant difference between body mass index (BMI) (p = 0.9) 0. time to postmortem CT (p = 0. 3. NR = not recorded. time to postmortem CT. Significant difference was considered p < 0.1–29. the cause of death was a cardiac incident for three subjects and asphyxia complicated by drowning for two subjects. However. For personal use only. TABLE 2: Statistical Analysis of Subjects Characteristic Age (y) BMI Group 1 Group 2 Group 3 49 (39–74) 51 (42–61) 33 (23–60) 29. and autopsy. The autopsy was performed at 35 hours (range.Downloaded from www.19. 21–75 hours) after death. It was not possible to measure the maximal depths reached and the duration of the immersion for the free divers and therefore the data were not integrated into the average calculations.05. and six divers were categorized in group 3 as nondecompression diving. There was no statistically significant link between the presence of arterial gas and death by decompression illness (p = 0. The autopsies were conducted with knowledge of the postmortem CT results.084). 3–56 minutes).86 on 05/10/16 from IP address 180. group 2 = death after decompression dive without decompression illness. No patent foramen ovale was found during the autopsies.245). In the decompression dive group. and subcutaneous emphysema limited to the thoracic area was found in two subjects in the autopsies and four patients using postmortem CT. The subjects in group 3 were significantly younger (33 vs 50 years.6–51.041 25 (22.2 (24. there was a significant difference concerning age.176 Note—Data are median with minimum–maximum in parentheses. calculated on the interval of the estimated time of death. and autopsy (p = 0. dive profile analysis. For the nondecompression dive group.8) Total p 47 (23–74) 0.5 (7–48) 8 (3.112). The details of the subjects. no unbiased statistical calculation could be made to compare autopsy and CT. the complete pneumatization of the supraaortic trunks and the pneumatization of the right ventricle statistically significantly favored a diagnosis of death by CAGE (p = 0.5–55) 0.5 (4–55) 14 (3. September 2014 471 . However.6–51.0 hours). and group 3 = death after nondecompression dive without decompression illness. five divers were categorized in group 2 as decompression diving. respectively).041). p = 0. all rights reserved CT After Fatal Diving Accidents and the median dive duration was 25 minutes (range.5 (23. Four subjects did not undergo CPR maneuvers. Arterial gas collections were found in eight subjects in the autopsies and in 13 subjects using postmortem CT. autopsy revealed the cause of death as drowning for five subjects and cardiac related for one subject.4) 24. The median time before postmortem CT. 1). The gas collections were not systematically identified by the forensic pathologists. and autopsies are presented in Table 1.

9 Right ventriclea 36.1 57. The autopsy sensitivity can be increased by complex techniques. we observed a significant difference concerning the presence of intraarterial gas.015). However. all rights reserved Tested Criteria Fig.8 100 Pneumothorax 27.245 0 72.252.8%). but the NPV was weak (30. PPV = positive predictive value (PPV). Black line indicates depth of diver. CPR maneuvers—The presence of subcutaneous emphysema limited to the thoracic area (Fig. which indicates decompression illness.05. 1—Dive log from fatal dive of 74-year-old man shows overly rapid ascent (32 m/min) (arrow). Postmortem CT Criteria for Decompression Illness Our study found that the diagnostic criteria that are classically used for decompression illness are of poor statistical value. Death on sea floor—Two of the included subjects died on the sea floor at great depths (60 meters). to our knowledge.19. Postmortem off-gassing—When comparing the decompression and nondecompression dive groups. complete pneumatization of the supraaortic trunks and left ventricle and pneumatization of the right ventricle (Fig. However. We did not find a statistically significant link between death by decompression illness and the 28 25 0 Three cases of free divers were included in our study.3 Supraaortic trunks and left ventriclea 27. Our study was purposely focused on gas collections.6 63. and right ventricle in both subjects. Even though the CPR performed never successfully resuscitated the victims in this study. Nondecompression dives were characterized by the absence of intraarterial gas (p = 0. Gray line indicates water temperature. We also think that the age difference between the groups in the study did not modify our postmortem CT diagnostic criteria.1 0. Copyright ARRS. dive profile analysis. Our study described the real situations that confront teams after a death while diving. This sport is mostly practiced by younger people. September 2014 . it was necessary to perform CPR for medicolegal and ethical reasons.047 57. but postmortem CT is faster.1 90.7 0 53. We observed a complete pneumatization of supraaortic trunks.org by 180. The ages of the subjects included were different within each group. 2).7 70 100 Subcutaneous emphysema limited to thoracic area 9.6 100 Note—CAGE = cerebral arterial gas embolism. every radiologist reading a postmortem CT has to bear in mind the classic criteria for drowning [45. excluding cases of barotrauma. such as underwater dissection [32. No CAGE (%) CAGE (%) p Sensitivity (%) Specificity (%) PPV (%) NPV (%) Intraarterial gas 54.886) because only one discordance was observed.3 100 0. This can be explained by the presence of three free divers in the nondecompression diving group. which has been reported previously [4].TABLE 4: Comparison of Different Criteria for Diagnosis of Decompression Illness Laurent et al. which was shown in our animal experiments [30] and in other studies [33.4 100 0. postmortem CT. 47]. AJR:203.013 100 63. 3) was not statistically linked to the practice of CPR maneuvers (p = 0. Significant difference was considered p < 0. For personal use only.86 on 05/10/16 from IP address 180.234). no physiopathologic elements exist that can modify the gas collections between a death caused by nondecompression scuba diving and a death caused by free diving. and autopsy. gas collections found on postmortem CT were not visible or highly underestimated in the autopsy. 46].9 80 76.252. 0 36 5 32 10 Depth (m) 15 20 24 20 16 30 12 35 8 40 4 472 5 10 Time (min) 15 20 Sensitivity of Postmortem CT for Gas Collections The aim of this study was not to compare the sensitivity of autopsy and postmortem CT for the detection of gas collections. NPV = negative predictive value. 40]. this is the largest study with as many subjects and containing thorough data including a detailed description of the circumstances of the accident.3 0 0. However.19. rib fractures and subcutaneous emphysema limited to the thoracic area were always associated (κ = 1). to our knowledge. The positive predictive value (PPV) was 100% for the practice of CPR maneuvers. This study concerned examination of gas collections and. CPR maneuvers were performed on 14 divers.054 100 45.5 100 0. This confirms the superiority of postmortem CT for the detection of gas collections.5 53.86. The complete pneumatization of the supraaortic trunks and the right ventricle had a strong concordance (κ = 0.ajronline. left heart ventricle. This can be explained by the prospective design of the study as well as the relative rarity of diving accidents. 32 m/min Downloaded from www. 25 Temperature (°C) Three criteria were systematically present after a death by CAGE (negative predictive value [NPV] = 100%): presence of intraarterial gas. The subjects in group 3 were younger than the subjects in the other groups. aContaining only gas. and reproducible. specifically the presence of intravascular gas collections.004 100 72. easier. CPR can generate artifact gas collections. Discussion Limitations The main study limitation is the small number of subjects in each group. 33.

This criterion had an NPV of 100% and a PPV of 63. the three subjects in our study with a pneumothorax did not experience barotrauma according to the dive profile analysis. Copyright ARRS. The absence of intraarterial gas therefore enables us to reject this diagnosis. but we did not find a statistical link between the two.86 on 05/10/16 from IP address 180. In the late postmortem CT (case nine. including common carotid arteries (arrows) and internal carotid arteries (arrowheads. It was strongly correlated with the pneumatization of the supraaortic trunks (κ = 0. A–D. we think that this emphysema was actually correlated with thoracic compressions performed during CPR and not with decompression illness. As we expected. IVC = inferior vena cava. Even though in our study it appeared to be relatively specific. there is no pulmonary filtration of dissolved gas and much larger quantities of gas are released postmortem. We propose two postmortem CT diagnostic criteria for a death by decompression illness. Origin of Arterial Gas We found arterial gas in all the subjects in the decompression illness group and the decompression diving group and in five sub- AJR:203. 31]. Pneumothorax is classically cited as a major criterion for decompression illness [29. Second.252. RA = right atrium. the presence of intraarterial gas was not specific to CAGE but had an NPV of 100%. The NPV was 100%. which occurs very quickly starting 4 hours after death and starts occupying the arterial topography. Because these circumstances were known during the analysis of the circumstances of death. One of the divers suffered iatrogenic pneumothorax during resuscitation. 35].19. A = aorta.org by 180. A strong discordance between the large amount of arterial gas and the small quantity of venous gas could have been proposed as a criterion for barotrauma if we take into account the physiopathology. in which the PPV was lower. the pneumatization of the right ventricle is also a good criterion for the diagnosis of a death by decompression illness. September 2014 473 . In our study. LPA = left pulmonary artery. air-filled arterial system (B). the intravascular gas quantities seen in the postmortem CT result in an increase over time. as shown by the animal model [30].004). and its presence is necessary to make this diagnosis. False-positive findings are most often due to off-gassing.Downloaded from www. venous air-filled vascular system (C). Subcutaneous emphysema limited to the thoracic area also appears to be a poor diagnostic criterion for decompression illness. RV = right ventricle. all rights reserved CT After Fatal Diving Accidents Fig. the false-positive findings for complete pneumatization of the supraaortic trunks were due to a long delay before conducting postmortem CT or a death on the sea floor in decompression diving. which has been reported previously [35].19. LA = left atrium. This result is consistent with results from experimental studies [30. Minimum-intensity-projection reconstruction images show air-filled cardiac cavities (A). complete pneumatization of the supraaortic trunks and left heart ventricle and decompression illness were statistically significantly linked (p = 0. LV = left ventricle. This sign also had a good PPV of 70%.252. First.86. We previously showed this in an animal model [30]. 43 hours after death). D). This criterion is therefore more relevant than the presence of intraarterial gas. For personal use only.886). a complete pneumatization of the supraaortic trunks seemed to be the best criteria in favor of decompression illness. This hypothesis is probably not valid and we systematically observed gas in the right cavities after decompression illness.ajronline. PA = pulmonary artery. On the contrary. SVC = superior vena cava.6%. A B C D presence of intraarterial gas. 2—49-year-old man with decompression illness. which explains the complete pneumatization of vessels. and intraarterial gas in supraaortic trunks (D). After a death on the sea floor.

Oesterhelweg L. we observed arterial gas linked to postmortem off-gassing. However. 9:100–104 2. References 1. Jackowski C. Brogdon G. postmortem off-gassing occurred 3 hours postmortem [30]. et al. Therefore. These results are disputed by recent studies that describe early intraarterial putrefaction gas [48]. Coulange M. Vann RD. Clin Physiol Funct Imaging 2010. Fatal diving accidents: two case reports and an overview of the role of forensic examinations. to avoid the presence of postmortem off-gassing and improve the relevance of a decompression illness diagnosis. Jackowski C. Moon RE. and the best criterion for decompression illness is complete pneumatization of the supraaortic trunks and left ventricle in death that did not occur on the sea floor. et al. Thali MJ. Dirnhofer R. subcutaneous emphysema is linked to chest compressions and should not be considered a diagnostic criterion. [in French] Ann Fr Anesth Reanim 2011. and all the CT technologists. This hypothesis is confirmed by another animal experimental study [31] and confirms our practice of performing postmortem CT as soon as possible to limit such artifacts. which will enable forensic pathologists and hyperbaric physicians to accurately determine the causes of diving fatalities. We suggest that the diagnostic criteria for barotrauma should be modified in the following ways: The presence of a pneumothorax is not a valid criterion. After exposing animals to hyperbaric conditions in a chamber and simulating the recommended decompression stops. To differentiate between postmortem off-gassing and decompression illness. 17]. Potter K. Virtopsy: postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) in a fatal scuba diving incident. and absence of arterial gas from putrefaction when CT was performed within 24 hours after death. or by permeabilization of a patent foramen ovale or any other right-to-left shunt [8.and extravascular gas collections. et al. September 2014 . in practice it is difficult to perform postmortem CT within this delay. 180:e1–e5 8. we advise always performing postmortem CT as early as possible to limit the possible causes of intravascular gas and to facilitate the interpretation. considering the time required for rescue teams to recover. Thali MJ. Olstad CS. 48:1347–1355 5. Plattner T. J Appl Physiol 1990. Coulange M. VIRTOPSY: the Swiss virtual autopsy approach.86. Thus. possible arterial topography of gas caused by off-gassing.19. and transport the body. by severe desaturation accident with nitrogen bubbles breaking through the pulmonary capillary filter with the opening of intrapulmonary shunts [20. Int J Legal Med 2013. 3—CT image in 59-year-old man shows subcutaneous emphysema limited to thoracic area (arrows) and intraarterial gas in supraaortic trunks. It was observed in four subjects. Mitchell SJ. Evelyne Basso. 21]. Lüderwald S. the subject with the longest delay before CT (48 hours postmortem).Downloaded from www. Intraarterial gas was only detected in subject 17. Polycarpe A. Origin of Venous Gas Our results. attempt to resuscitate. which does not usually occupy the arterial topography if CT is conducted within 24 hours postmortem. Pulmonary oedema in healthy SCUBA divers: new physiopathological pathways.19. These results confirm the utility of postmortem CT after diving accidents. For personal use only. Butler FK. Fig.ajronline.252. Forensic Sci Int 2008. Pierre Perich. RadioGraphics 2006. show an exclusive venous topography of putrefaction gases 474 when postmortem CT was performed within 24 hours. VIRTOPSY: minimally invasive. Decompression illness. Carrod G. We confirm the results of experiments conducted on animals that showed the nonspecificity of arterial gas for diagnosis of decompression illness. Rutty GN. We proposed a cutoff time of 3 hours before which arterial gas that is observed can only correspond to decompression illness. Eckenhoff RG. Cordier PY. Intraarterial gas can therefore have three origins. Zinka B. Gargne O. it is difficult to use the delay before gas appearance as a criterion. Leg Med (Tokyo) 2007. Nevertheless. Copyright ARRS. we proposed to use the length of time to CT appearance. Terminology used in publications for post-mortem crosssectional imaging. all rights reserved Laurent et al. Rossi P. CT must be performed as early as possible.252. Immersion pulmonary oedema: a rare cause of life-threatening diving accident.org by 180. Human dose-response relationship for decompression and endogenous bubble formation. Lancet 2011. 127:465–466 4. Dedouit F. However. the presence of intraarterial gas is necessary to make the diagnosis of decompression illness (NPV = 100%) but the PPV is weak. which supports our hypotheses. The only experimental study conducted with iterative postmortem CT in a porcine model did not find any intraarterial putrefaction gas in the 24 hours after death. 377:153–164 9. imagingguided virtual autopsy.86 on 05/10/16 from IP address 180. all of whom received CPR and all of whom presented rib fractures (κ = 1). These results also confirm the results from our animal study in which no arterial putrefaction gas was present on repeated CT performed up to 24 hours after death [30]. Acknowledgments The authors thank Pierre Champsaur. the analysis of intraarterial gas can affirm the presence of putrefaction gas [41] but does not differentiate between decompression illness and postmortem off-gassing. This adds to off-gassing that occurs quickly when the dive is deep and long. which is confirmed by the results of our animal study [30]. as expected. Peytel E. The second is postmortem off-gassing. which is confirmed by data from animal experiments [30] in which the same types of lesions were observed. The third is putrefaction gas. Puidupin A. and the postmortem intervals between death and postmortem CT were not controlled. 26:1305–1333 3. 69:914–918 AJR:203. We observed that in animal models. Dirnhofer R. Subcutaneous Emphysema Subcutaneous emphysema limited to the thoracic area presents a PPV of 100% for CPR maneuvers. Yen K. The first is decompression illness by barotrauma with a rupture of the alveolar-capillary membrane and arterial gas embolism. 30:699 6. J Forensic Sci 2003. jects in the nondecompression diving group. Conclusion Postmortem CT is a powerful tool to analyze intra. Subject 16 did show the presence of intraarterial gas because CT was performed 28 hours after death. Among the three possible causes. these studies did not include repetitive postmortem CT to monitor gas collections. Vock P. Thali MJ. This concordance confirms our hypothesis that chest lesions can be caused by CPR. Ross SG. 30:181–186 7.

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