Post-Mortem Imaging FIX

Post-mortem imaging as an alternative to autopsy in the
diagnosis of adult deaths: a validation study
Dede Yusuf Fahma Razi

Dewi Elkha Maisarah
Ngafif Muzaqin
Yudi Pratama
Department of Forensic and Medicolegal Medicine Faculty of Medicine, University of Syiah Kuala
January, 2015
Background
Traditional autopsy has changed little in the past century, consisting of external examination
and evisceration, dissection of the major organs with identification of macroscopic
pathologies
A post-mortem MRI service for selected non-suspicious deaths was introduced in
Manchester, UK, in the 1990s
In post mortem MRI, it showed important weaknesses of imaging notably, an inability to
detect arterial occlusions and to differentiate between pulmonary oedema and pneumonia
We aimed to identify the accuracy of post-mortem CT and MRI compared with full autopsy in
a large series of adult deaths
www.themegallery.com
Methods
Date and time
Manchester and Oxford
April 2006 and November 2008
Sample
Whole-body CT and MRI followed by full autopsy to investigate a
series of adult deaths that were reported to the coroner
Post Mortem Changes and Pathologies

(A)Axial CT image through the upper abdomen
showing extensive intravascular gas, in
keeping with decomposition. Free
intraperitoneal gas is due to decomposition
in this patient, but creates difficulty
forexclusion of a perforated intraabdominal
viscus.
(B) Axial CT image through the brain showing
extensive intracranial gas due to
decomposition. Diff erentiation between grey
and white matter is poor.
(C) Axial CT image showing rupture of an
abdominal aortic aneurysm with extensive
retroperitoneal haemorrhage on the left
(D)Oblique axial T2-weighted MRI image

showing a haemopericardium due to rupture
of a myocardial infarct.
The most common indication for coronial referral is sudden death

of unknown cause, as such, the most common cause of death was
cardiovascular disease.
Circumstances of death and indications for coronial referral
Found dead in community, unknown
cause
Witnessed
sudden death
in 1%
drug-related
death;
Post-trauma; 2% Suspected industrial disease; 1% Suspected
community, unknown cause
Postoperative; 6%
Died in hospital,
unknown
case;
14%
Found
dead in
community,
unknown cause;
Died54%
in hospital, unknown case
Witnessed sudden death in community, unknown cause; 21%
Postoperative
Post-trauma
Suspected industrial disease

Suspected drug-related death
Autopsy causes of death by type of pathology and organs

involved
Type of pathology
Organ/system involved
Heart and coronary arteries
7%
7%
8%
3% 2% 1%
51%
Vascular (eg, thrombosis /

infarct / atheroma)
Respiratory (larynx, airways,

lungs)
Infection
CNS
12%
Anatomical (eg, obstruction

/ perforation)
Neoplasm
Toxic
Trauma*
Asphyxia
2% 1% 1% 1% 0%
Inflammation / fibrosis
Biochemical / metabolic
9%
Gastrointestinal
Aorta and peripheral arteries
Hepatobiliary and pancreatic
4%
5%
40%
4%
6%
7%
9%
Endocrine
Pulmonary arteries
Urinary
20%
Multisystem disorder
Musculoskeletal
Lymphoreticular
Oropharynx
Results
The major discrepancy rate between cause of death identified by radiology and autopsy
70%
60%
50%
40%
30%
20%
10%
0%
68%
CT - Scan
32%
43% 57%
MRI
Match Non Match
30% 70%
Consensus
Table: Major discrepancy rate between autopsy & radiology

cause of death
CT
MRI
Consensus CT
and MRI
Major discrepancy rate with autopsy cause of

32% (2640) 43% (3650) 30 % (2437)
death, all cases (%)
Proportion of cases with definite radiological
34% (2841) 42% (3549) 48 % (4156)
cause of death, no autopsy needed (%)
Major discrepancy rate with autopsy when
radiologist confi dence is defi nite (%)
Major discrepancy rate with autopsy when
radiologist confi dence is not defi nite (%)
16% (927)
41% (3350)
21% (1332) 16 % (1025)

59% (4967) 44 % (3454)
Data are % (95% CI) or number (%, 95% CI). Percentages are rounded to nearest
whole number.
Radiologists indicated that autopsy was not

No
needed in :
Autopsy
!
62 of 182
cases
MRI reports
CT reports
76 of 182 88 of 182 consensus reports

cases
cases
Of these cases, the major discrepancy rate compared with autopsy was
16% (CT), 21% (MRI), and 16% (Consensus).
IMAGING
Imaging was sensitive in the detection of
internal haemorrhage, and correctly
identifying all ten cases of haemopericardium
Imaging could be better than autopsy in
detection of some fractures, intracranial
pathologies, and pneumothorax.
Cerebellar infarct evident with

imaging was missed at autopsy.
AUTOPSY
1. Subarachnoid haemorrhage were identified

on CT but not MRI.
2. CT provides visualisation of coronary artery
calcification that is not apparent with MRI
3. Forensic practices use CT because it
provides better spatial resolution than MRI
and is effective for showing fractures and
haemorrhages.
1. Bronchial carcinoma was correctly

reported with MRI but not with CT.
2. Acute myocardial infarcts might be
seen with MRI but not with CT.
3. Non-forensic and paediatric practices

have used MRI because it provides
greater detail of soft tissues than does
CT.
Major Discrepancy
The most common imaging errors in

identification of cause of death were
ischaemic heart disease, pulmonary
embolism, pneumonia, and
intraabdominal lesions.
Other diagnoses missed on imaging were
cases of pancreatitis, perforated
duodenal ulcer, acute asthma, and
overwhelming sepsis with adult
respiratory distress syndrome
Most common sources of major discrepancy between autopsy and

consensus radiology cause of death
Overattributed on imaging
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0%
16% 84%
100%
Missed
14% 86%
Acurate
33% 67%
Interpretation
When radiologists
are confident that
the cause of death
The radiologists
on imaging is
ability to accurately
Compared with
definite, the
identify cases for
autopsy, CT is more
discrepancy rate
which their
accurate than MRI in
between the
diagnosis is correct
determination of
radiological and
is essential for the
cause of death in
autopsy diagnoses is safe introduction of
adults
lower and might be a minimally invasive
acceptable from a
autopsy service.
medicolegal point of
view.
CT has important practical advantages, being more

available, less expensive, and quicker to do than MRI.
widely
CT could also be combined with angiography, increasing the

accuracy of detection of vascular pathologies.
If imaging were to be used as a pre-autopsy screening technique,

the overall diagnostic accuracy is less important than radiologists
being able to identify almost half of the cases without the autopsy.
those cases in which imaging can correctly diagnose the cause of
death.
THANK YOU!
CT
Sp.F
MRI

Post-Mortem Imaging FIX

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Post-mortem imaging as an alternative to autopsy in the

diagnosis of adult deaths: a validation study

Dede Yusuf Fahma Razi

Post Mortem Changes and Pathologies

(D)Oblique axial T2-weighted MRI image

The most common indication for coronial referral is sudden death

Suspected industrial disease

Autopsy causes of death by type of pathology and organs

Vascular (eg, thrombosis /

Respiratory (larynx, airways,

Anatomical (eg, obstruction

Match Non Match

Table: Major discrepancy rate between autopsy & radiology

Major discrepancy rate with autopsy cause of

21% (1332) 16 % (1025)

Radiologists indicated that autopsy was not

76 of 182 88 of 182 consensus reports

Cerebellar infarct evident with

1. Subarachnoid haemorrhage were identified

1. Bronchial carcinoma was correctly

3. Non-forensic and paediatric practices

The most common imaging errors in

Most common sources of major discrepancy between autopsy and

CT has important practical advantages, being more

CT could also be combined with angiography, increasing the

If imaging were to be used as a pre-autopsy screening technique,

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