Intensive Care Med
DOI 10.1007/s00134-014-3520-4 LETTER
Claire Pichereau last decades for many reasons, the
Eric Maury most frequent being family refusal.
Laurence Monnier-Cholley Post-mortem imaging using CT scan
Simon Bourcier (virtopsy) is emerging as an alterna-
Gabriel Lejour tive to conventional autopsy.
Mikael Alves However, virtopsy is performed
Jean-Luc Baudel without contrast injection because of
Hafid Ait Oufella blood flow cessation making pul-
Bertrand Guidet monary embolism diagnosis
Lionel Arrivé impossible [1]. Recently, protocols
derived from forensic medicine
allowing vascular opacification have
Post-mortem CT scan been reported [2]. However they
require cannulation of femoral vessels
with contrast injection and the connection to a modified
and chest compression heart–lung machine [3]. This
to diagnose pulmonary approach is rather cumbersome and
embolism not routinely feasible.
We recently diagnosed pulmonary
Accepted: 10 October 2014 embolism immediately after death
using CT scan imaging with periph-
Ó Springer-Verlag Berlin Heidelberg and eral contrast injection followed by
ESICM 2014 chest compressions to restore partial
blood flow [4]. This prompted us to
implement a protocol of contrast
injection for post-mortem imaging. In
Dear Editor, cases of sudden death in the ICU and
Post-mortem examination relying on after family consent, virtopsy is per-
medical autopsy is the standard of formed at the radiology department of
reference in clinical medicine. our hospital as soon as possible. For
Unfortunately, medical autopsy rate the purpose of the procedure, central
has declined worldwide in the few or peripheral venous catheters
Fig. 1 a Maximum intensity reconstruction (MIP) image improves visualization of distal subsegmental arteries. b Axial image from
contrast-enhanced CT scan demonstrates large emboli within right and left pulmonary arteries (white arrows)
inserted before death are not
removed. The procedure is as fol-
lows: first an unenhanced contrast
medium CT scan from head to pelvis
is performed; thereafter the contrast
medium (2 mL/kg) is injected manu-
ally via the venous catheter. A chest
CT scan is then performed after one
or two rounds of 20 chest compres-
sions (as required to restore partial
blood flow). This procedure has been
approved by the institutional review
board of our hospital. From February
to August 2014, 16 ICU patients who
died unexpectedly (median age 60.5
[34; 88], 13 male (81 %), median
SAPS II at admission 59 [29; 112],
having echographic signs of acute cor
pulmonale immediately before death
6/16) were subjected to post-mortem
CT scans with contrast injection. The
median delay between death and
examination was 68.5 min [0; 206].
In all cases, the procedure described
above allowed a high quality opaci-
fication of the right ventricle and
pulmonary arteries up to subsegmen-
tal division (Fig. 1a), independently
of venous catheter location (central or
peripheral). Pulmonary embolism
diagnosis was retained relying on
post-mortem CT scan in three out of
16 cases. In two other cases with a
delay between death and CT scan of
more than 2 h, large contrast defects
in the pulmonary trunk and right
ventricle were observed but could be
related more likely to post-mortem
clotting rather than pulmonary
embolism. In the 11 remaining cases,
complete pulmonary arteries and right
ventricular opacification ruled out
pulmonary embolism. The incidence
we observed is consistent with the
rate of 15 % of pulmonary embolism
identified during conventional autop-
sies [5]. Distinction between ante-
mortem embolism and post-mortem
clotting is an important issue. Per-
forming the CT scan as soon as
possible may reduce the risk of post-
mortem clotting [6]. Extensive con-
trast defect of the pulmonary trunk,
right atrium and ventricle may argue
for post-mortem clotting rather than
for pulmonary embolism.
In conclusion, we report an effi-
cient, easy to perform and minimally
invasive protocol for post-mortem CT
angiography of the pulmonary
arteries.
Conflicts of interest On behalf of all
authors, the corresponding author states that 5. Landefeld CS, Chren MM, Myers A et al
there is no conflict of interest.
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C. Pichereau
E. Maury ())

J.-L. Baudel
H. Ait Oufella
B. Guidet
Réanimation Médicale, Hôpital Saint-
Antoine, Assistance Publique-Hôpitaux de
Paris, 184 rue du Faubourg Saint-Antoine,
e-mail: eric.maury@sat.aphp.fr
Tel.: 33149282322
L. Monnier-Cholley
L. Arrivé
Radiologie, Hôpital Saint-Antoine,
Assistance Publique-Hôpitaux de Paris,
75571 Paris Cedex 12, France