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VIRTOPSY: Minimally Invasive, Imaging-guided Virtual Autopsy

¹ From the Institute of Forensic Medicine, University of Bern, Buehlstrasse 20, CH-3012 Bern, Switzerland (R.D., C.J., M.J.T.); the Institute of Diagnostic Radiology, Inselspital, University of Bern, Bern, Switzerland (P.V.); and the Armed Forces Institute of Pathology, MRM Facility, Washington, DC (K.P.). Presented as an education exhibit at the 2003 RSNA Annual Meeting. Received January 3, 2006; revision requested January 30 and received March 23; accepted March 24. All authors have no financial relationships to disclose. Address correspondence to M.J.T. (e-mail: michael.thali{at}irm.unibe.ch).

	Abstract

Top Abstract Introduction Clinical Experience Results Conclusions References

 
Invasive "body-opening" autopsy represents the traditional means of postmortem investigation in humans. However, modern cross-sectional imaging techniques can supplement and may even partially replace traditional autopsy. Computed tomography (CT) is the imaging modality of choice for two- and three-dimensional documentation and analysis of autopsy findings including fracture systems, pathologic gas collections (eg, air embolism, subcutaneous emphysema after trauma, hyperbaric trauma, decomposition effects), and gross tissue injury. Various postprocessing techniques can provide strong forensic evidence for use in legal proceedings. Magnetic resonance (MR) imaging has had a greater impact in demonstrating soft-tissue injury, organ trauma, and nontraumatic conditions. However, the differences in morphologic features and signal intensity characteristics seen at antemortem versus postmortem MR imaging have not yet been studied systematically. The documentation and analysis of postmortem findings with CT and MR imaging and postprocessing techniques ("virtopsy") is investigator independent, objective, and noninvasive and will lead to qualitative improvements in forensic pathologic investigation. Future applications of this approach include the assessment of morbidity and mortality in the general population and, perhaps, routine screening of bodies prior to burial.

© RSNA, 2006

	Introduction

Top Abstract Introduction Clinical Experience Results Conclusions References

 
The main objectives of forensic medicine are to document, analyze, and elucidate scientific medical findings in both living and deceased persons in a comprehensible way for courtroom presentation. In deceased persons, the main goals are to determine the cause and manner of death, to evaluate the vitality of the sustained injuries, and to develop a forensic reconstruction based on the findings. Other than in forensic genetics (in which DNA is used) and forensic toxicology—areas in which "high-tech" methods have already been incorporated into the daily routine—the documentation of forensic pathologic findings is still predominantly based on the same autopsy techniques and protocols that have been used for centuries. The most commonly used tools are a scalpel, verbal description, and conventional two-dimensional photography (1). Forensic findings are thereby documented in an unintentionally subjective (observer-dependent) way, and findings that have not been documented are irrevocably destroyed if the body has been sent to the crematory. For many years, the application of imaging methods for objective nondestructive documentation of relevant forensic findings has lagged far behind the technical development of the imaging methods themselves. There are only a few textbooks available that deal with forensic radiology, most of which concentrate on conventional radiography and do not discuss newer sectional imaging techniques such as computed tomography (CT) and magnetic resonance (MR) imaging in detail. Brogdon (2), in his book Forensic Radiology, makes the following statement: "The sad truth is that a century after the first x-ray was introduced as evidence in a law court, there is no general appreciation of the extent of the radiology potential in the forensic sciences." In principle, all clinical applications of radiologic methods can also be used for forensic purposes (Table). Diagnostic imaging is still underused in forensics, mainly due to unawareness of its potential and the lack of teaching and experience (2–4).

The use of full-body postmortem MR imaging in nonforensic cases for the detection of gross cranial, thoracic, and abdominal disease has been described by a number of different groups (11–22). Limited single-organ studies have been performed by some forensic groups, mainly for the visualization of gunshot wound tracks in the brain (17,23,24). None of these groups performed systematic whole-body examinations using a combination of multisection CT and MR imaging.

It was suggested that conventional autopsy, nowadays often rejected by family members or not tolerated by religions in a multicultural society, might be replaced by noninvasive imaging documentation and, when required, by minimally invasive imaging-guided tissue sampling and by angiography to address vascular questions. The digitally acquired data could be reconsulted whenever new questions arose or could be sent to other experts for a second opinion.

The concept of objective, noninvasive documentation of the body surface for forensic purposes arose in the early 1990s with the development of forensic photogrammetry (25). As is usual in forensic science, this idea was born of and stimulated by a pressing need—in this case, a very high-profile homicide in Switzerland. The case required that a possible murder weapon be compared with an impression on the skull of the victim to identify the weapon with a high degree of certainty. In 2000, it was suggested that observer-independent documentation of the body surface be combined with observer-independent documentation of the interior of the body.

The Virtopsy project of the Institutes of Forensic Medicine, Diagnostic Radiology, and Neuroradiology at the University of Bern, Switzerland, attempts to achieve this combined documentation. Through close collaboration between these institutes, modern cross-sectional techniques were performed for forensic purposes. The term "virtopsy" was created from the terms "virtual" and "autopsy." The former term is derived from the Latin word virtus, which means "useful, efficient, and good." The term "autopsy" is a combination of the classical Greek terms autos ("self") and opsomei ("I will see"). Thus, autopsy means "to see with one’s own eyes." Because our goal was to eliminate the subjectivity implied by autos, we merged the terms "virtual" and "autopsy"—deleting autos—to create the term "virtopsy" (26).

Virtopsy basically consists of (a) body volume documentation and analysis using CT, MR imaging, and microradiology; and (b) 3D body surface documentation using forensic photogrammetry and 3D optical scanning. The resulting data set contains high-resolution 3D color-encoded documentation of the body surface and 3D volume documentation of the interior of the body (Fig 1). By manipulating the data set with volume-rendering (VR) tools at a workstation, one can perform a virtual autopsy anytime, in any place. No forensic findings are disturbed, as they would be by the destructive techniques used in traditional autopsy. The aim of the Virtopsy project is to validate this new approach by systematically comparing the radiologic and surface scanning findings with those obtained at traditional autopsy.

View larger version (15K): [in this window] [in a new window] [Download PPT slide]   Figure 1.  Chart illustrates the Virtopsy project, in which forensic information is acquired with various radiologic methods.

In this article, we discuss and illustrate the use of 3D optical and photogrammetric surface scanning combined with CT and MR imaging for postmortem investigation. We also discuss the correlation of these imaging findings with the forensic findings obtained at traditional autopsy.

	Clinical Experience

Top Abstract Introduction Clinical Experience Results Conclusions References

 
Case Samples
The study was approved by the local department of justice and the Ethics Committee of the University of Bern and, as of this writing, includes 120 forensic cases involving persons whose age at death ranged from 22 weeks gestation to 94 years.

Each body was wrapped in two artifact-free body bags to avoid contaminating the radiology equipment and to protect the identity of the deceased person during clinical scanning. Because the Institute of Forensic Medicine owns a six–detector row scanner (Emotion 6; Siemens Medical Systems, Erlangen, Germany), only contaminated or putrefied bodies are wrapped for CT.

Imaging Considerations
Multisection CT.— CT was performed on a four– or six–detector row scanner. Whole-body scans were performed with a collimation of 1 or 1.25 mm. Up to 1200 axial images were obtained, with a section thickness of 1.25 mm and an increment of 0.7 mm in soft-tissue and osseous kernels. For areas of special forensic importance (special fracture systems, teeth, foreign bodies), additional raw data were acquired with a collimation of 0.5 mm and 0.625-mm-thick sections were calculated. Acquisition time was approximately 10 minutes.

MR Imaging.— MR imaging of the head, thorax, and abdomen was performed on a 1.5-T system (Signa v5.8; GE Medical Systems, Milwaukee, Wis), and further areas of interest (eg, the neck in cases of strangulation, extremities when injured) were added. We acquired coronal, sagittal, and axial images with different contrast weighting (T1-weighted spin-echo and T2-weighted fast spin-echo sequences with and without fat saturation, turbo inversion recovery sequences, gradient-echo sequences). Occasionally, when cardiac findings were expected or observed on axial images, short-axis, horizontal long-axis, and vertical long-axis images were acquired. Acquisition time ranged from 1.5 to 3.5 hours.

Data analysis and postprocessing of CT and MR imaging data were performed on a Leonardo (Siemens) workstation.

Micro-CT.— In special situations, bone-tissue specimens were examined on a micro-CT system developed and built at the Institute of Medical Physics in Erlangen, Germany. This scanner can image a 3D volume with an isotropic resolution ranging from 10 to 100 µm (28). The system allows the examination of samples with diameters ranging from 4 to 40 mm.

MR Microscopy.— MR microscopic studies were performed at room temperature on a Bruker DMX spectrometer (Bruker Biospin MRI, Billerica, Mass) coupled to a wide-bore magnet operating at 9.4 T (400 MHz for protons). Formalin-fixed eyeballs were washed in phosphate-buffered saline solution, blotted dry, and placed in a 25-mm glass tube filled with Fluorinert (Oakwood Products, West Columbia, SC) prior to imaging. Three-dimensional anatomic images were acquired with a fat-suppressed rapid acquisition with relaxation enhancement (RARE) T1-weighted imaging sequence (repetition time msec/echo time msec = 200/8, number of signals acquired = 16, acquisition time = 9.5 hours). Voxels were typically 78 µm in size (3). After imaging was completed, the eyeballs were cut in half and prepared for paraffin embedding. Histologic sections 6 µm thick were cut and then stained with hematoxylin-eosin (H-E) stain to help distinguish hemorrhage from eye tissue.

Photogrammetry-based 3D Optical Scanning.— At present, the standard for the documentation of injuries in forensic medicine is still photography with exact measurements. However, like conventional radiography, the photographic process displays a 3D wound in only two dimensions.

With the TRITOP/ATOS II system (GOM, Braunschweig, Germany), the 3D color-encoded surface can be documented by means of detection of the distortion of light stripes projected onto the surface. In this way, the system can recalculate the 3D surface that caused the distortion. This system is usually used when high precision is required, since it is accurate to less than 20 µm. This accuracy allows more detailed surface documentation compared with 3D reconstructed images from high-resolution CT data.

The color information is acquired using TRI-TOP software, which combines digital photographs of the surface taken from many different angles to create a single 3D color image of the object that can be matched up with the digital 3D surface image of the object with use of coded and uncoded markers placed on the object. With this technology, documentation ranging from that of fine details (eg, skin lesion) to overview documentation (whole body or entire vehicle) is possible.

Logistics
Most of the cross-sectional imaging of bodies performed on the clinical scanners at the Institutes of Diagnostic Radiology and Neuroradiology was performed during evening hours or weekends. A local mortician worked out the necessary logistics between the two institutes.

Correlation of Cross-Sectional with Traditional Autopsy Findings
After forensic autopsy had been performed by board-certified forensic pathologists with detailed digital photographic documentation of all findings, a correlation was performed according to the Armed Forces Institute of Pathology (AFIP) design (29,30).

	Results

Top Abstract Introduction Clinical Experience Results Conclusions References

 
The cases illustrated in this article are predominantly of special interest in the forensic domain. The postmortem imaging appearance of trauma and organ disease does not differ markedly from their clinical appearances except for overlying postmortem alterations.

Identification
Prior to any postmortem investigation, the identity of the body must be clarified and proved; otherwise, the postmortem investigation has as one of its goals the reestablishment of the identity of the unidentified body. Multi–detector row CT can be of great help in this regard. Secure postmortem identification is possible only on the basis of dental status, DNA profiles, or fingerprinting. Because DNA is the most expensive and time-consuming method, fingerprinting and dental identification are more commonly used. With cranial CT data obtained in a corpse, it is possible to reconstruct any antemortem radiographic projection for comparison (31). Even panoramic images can be created that are comparable to antemortem orthopantograms (32). In addition, the restoration material that was used can be ascertained on the basis of postmortem CT data and correlated with the antemortem dental records of suspected missing persons (33).

In addition to gross morphologic findings such as an endoprosthesis of the shoulder, hip, or knee—findings that are often already expected on the basis of an efficient external inspection—whole-body CT of the corpse reveals numerous findings that can be used for positive identification as well as for exclusion of an assumed identity, conclusions that could not be reached with routine autopsy (Fig 2) (34,35). These applications of CT technology in the forensic domain suggested that mobile machines could be used for postmortem data acquisition in cases of mass casualties such as airplane crashes or natural disasters (eg, the recent tsunami catastrophe in Asia). In these incidents, identification of bodies is the major issue to be addressed, and CT can be of inestimable value in disaster victim identification.

View larger version (70K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Corpse identification with CT in four different cases. (a) Oblique VR bone image obtained in a completely burned corpse shows a helical wire in the left humerus representing a rare technique of humeral osteosynthesis. (b) Anteroposterior view of the pelvis shows two screws in the left femur. (c) Anteroposterior view of the knees shows replacement of the right anterior cruciate ligament with screws in the femur and tibia. (d) Anteroposterior view of the lumbar spine shows percutaneous vertebroplasty with cement in the vertebral bodies, a finding that can be used for identification. Routine forensic autopsy would be incapable of demonstrating the findings in a–d.

View larger version (68K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Corpse identification with CT in four different cases. (a) Oblique VR bone image obtained in a completely burned corpse shows a helical wire in the left humerus representing a rare technique of humeral osteosynthesis. (b) Anteroposterior view of the pelvis shows two screws in the left femur. (c) Anteroposterior view of the knees shows replacement of the right anterior cruciate ligament with screws in the femur and tibia. (d) Anteroposterior view of the lumbar spine shows percutaneous vertebroplasty with cement in the vertebral bodies, a finding that can be used for identification. Routine forensic autopsy would be incapable of demonstrating the findings in a–d.

View larger version (47K): [in this window] [in a new window] [Download PPT slide]   Figure 2c.  Corpse identification with CT in four different cases. (a) Oblique VR bone image obtained in a completely burned corpse shows a helical wire in the left humerus representing a rare technique of humeral osteosynthesis. (b) Anteroposterior view of the pelvis shows two screws in the left femur. (c) Anteroposterior view of the knees shows replacement of the right anterior cruciate ligament with screws in the femur and tibia. (d) Anteroposterior view of the lumbar spine shows percutaneous vertebroplasty with cement in the vertebral bodies, a finding that can be used for identification. Routine forensic autopsy would be incapable of demonstrating the findings in a–d.

View larger version (57K): [in this window] [in a new window] [Download PPT slide]   Figure 2d.  Corpse identification with CT in four different cases. (a) Oblique VR bone image obtained in a completely burned corpse shows a helical wire in the left humerus representing a rare technique of humeral osteosynthesis. (b) Anteroposterior view of the pelvis shows two screws in the left femur. (c) Anteroposterior view of the knees shows replacement of the right anterior cruciate ligament with screws in the femur and tibia. (d) Anteroposterior view of the lumbar spine shows percutaneous vertebroplasty with cement in the vertebral bodies, a finding that can be used for identification. Routine forensic autopsy would be incapable of demonstrating the findings in a–d.

Cause and Manner of Death
Regardless of the manner of death (ie, natural causes, accident, suicide, homicide, or iatrogenic causes), death can have a variety of causes. Some of these causes are specific to certain organs such as the brain, heart, and lungs. Various systemic findings can also indicate the cause of death.

Brain.— Typical trauma findings at clinical radiology are equally well visualized at postmortem imaging. Increased intracranial pressure as a result of trauma or ischemia typically manifests at autopsy as transtentorial herniation of the temporal lobe or herniation of the cerebellum into the foramen magnum, with impressions at the base of the cerebellum corresponding to the foramen magnum (Fig 3) (39). If there is a gross pathologic finding within the brain responsible for the increased intracranial pressure, postmortem imaging allows detailed visualization (Fig 4). This capacity is especially helpful when advanced stages of putrefaction make impracticable an autopsy investigation of the remaining brain structures when the skull is opened. In such cases, postmortem MR imaging provides an adequate anatomic overview of the brain in situ and allows exclusion of gross pathologic alterations within the brain (40). Recent studies have investigated the sensitivity and significance of postmortem MR imaging for discrete brain alterations. Initial 3-T MR imaging examinations of bodies indicate that the lack of sufficient sensitivity for brain lesions smaller than 5 mm on 1.5-T systems can be overcome by increasing the field strength, with a possible image matrix up to 1024. Furthermore, initial postmortem diffusion tensor imaging studies promise to overcome present cross-sectional imaging limitations in the visualization of small brain lesions within vitally important regions (41).

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  Increased intracranial pressure as the cause of death. (a) Coronal T2-weighted MR image shows herniation of basilar parts of the cerebellum into the foramen magnum. (b) Autopsy photograph shows the cerebellum, with swelling of the tonsils (solid arrows) and a pressure mark caused by the foramen magnum (dashed arrows).

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  Increased intracranial pressure as the cause of death. (a) Coronal T2-weighted MR image shows herniation of basilar parts of the cerebellum into the foramen magnum. (b) Autopsy photograph shows the cerebellum, with swelling of the tonsils (solid arrows) and a pressure mark caused by the foramen magnum (dashed arrows).

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Traumatic intraaxial bleeding. (a) Axial gradient-recalled acquisition in the steady state image shows local hypointense areas (arrow) in the left temporal lobe that reach the subarachnoidal space. These areas represent degenerative products of hemoglobin and indicate trauma. (b) Autopsy photograph of a slice through the temporal lobe of the formalin-fixed brain shows trauma-related bleeding, predominantly in the cortex and subcortex (arrow).

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Traumatic intraaxial bleeding. (a) Axial gradient-recalled acquisition in the steady state image shows local hypointense areas (arrow) in the left temporal lobe that reach the subarachnoidal space. These areas represent degenerative products of hemoglobin and indicate trauma. (b) Autopsy photograph of a slice through the temporal lobe of the formalin-fixed brain shows trauma-related bleeding, predominantly in the cortex and subcortex (arrow).

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  Natural cardiac death. (a) Short-axis T2-weighted MR image shows local hypointense areas (arrow) in the left lateral wall, with areas of hyperintensity in the surrounding myocardial tissue. (b) Photograph of the corresponding autopsy specimen shows hemorrhagic myocardial infarction (arrow) in the lateral wall of the left ventricle. (c) Short-axis T2-weighted MR image obtained in a patient with chronic uremic cardiomyopathy shows massive eccentrically hypertrophic ventricles in a so-called cor bovinum. (d) Photograph of the corresponding autopsy specimen helps confirm biventricular eccentric hypertrophy (heart weight, 1070 g). On all scales shown in the figures, the smallest units are millimeters.

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  Natural cardiac death. (a) Short-axis T2-weighted MR image shows local hypointense areas (arrow) in the left lateral wall, with areas of hyperintensity in the surrounding myocardial tissue. (b) Photograph of the corresponding autopsy specimen shows hemorrhagic myocardial infarction (arrow) in the lateral wall of the left ventricle. (c) Short-axis T2-weighted MR image obtained in a patient with chronic uremic cardiomyopathy shows massive eccentrically hypertrophic ventricles in a so-called cor bovinum. (d) Photograph of the corresponding autopsy specimen helps confirm biventricular eccentric hypertrophy (heart weight, 1070 g). On all scales shown in the figures, the smallest units are millimeters.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 5c.  Natural cardiac death. (a) Short-axis T2-weighted MR image shows local hypointense areas (arrow) in the left lateral wall, with areas of hyperintensity in the surrounding myocardial tissue. (b) Photograph of the corresponding autopsy specimen shows hemorrhagic myocardial infarction (arrow) in the lateral wall of the left ventricle. (c) Short-axis T2-weighted MR image obtained in a patient with chronic uremic cardiomyopathy shows massive eccentrically hypertrophic ventricles in a so-called cor bovinum. (d) Photograph of the corresponding autopsy specimen helps confirm biventricular eccentric hypertrophy (heart weight, 1070 g). On all scales shown in the figures, the smallest units are millimeters.

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 5d.  Natural cardiac death. (a) Short-axis T2-weighted MR image shows local hypointense areas (arrow) in the left lateral wall, with areas of hyperintensity in the surrounding myocardial tissue. (b) Photograph of the corresponding autopsy specimen shows hemorrhagic myocardial infarction (arrow) in the lateral wall of the left ventricle. (c) Short-axis T2-weighted MR image obtained in a patient with chronic uremic cardiomyopathy shows massive eccentrically hypertrophic ventricles in a so-called cor bovinum. (d) Photograph of the corresponding autopsy specimen helps confirm biventricular eccentric hypertrophy (heart weight, 1070 g). On all scales shown in the figures, the smallest units are millimeters.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Cardiac trauma (stab wound to the heart). (a) Short-axis T2-weighted MR image through the cardiac apex shows a myocardial injury (solid white arrow). Subsequent pericardial tamponade manifests as sedimented cellular components (dashed white arrows) with medium signal intensity and an upper layer of serum (black arrows) with increased signal intensity. (b) Photograph of the corresponding autopsy specimen demonstrates transmural laceration of the left ventricle in the apical region (arrow).

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Cardiac trauma (stab wound to the heart). (a) Short-axis T2-weighted MR image through the cardiac apex shows a myocardial injury (solid white arrow). Subsequent pericardial tamponade manifests as sedimented cellular components (dashed white arrows) with medium signal intensity and an upper layer of serum (black arrows) with increased signal intensity. (b) Photograph of the corresponding autopsy specimen demonstrates transmural laceration of the left ventricle in the apical region (arrow).

View larger version (70K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  Lethal air embolism of the pulmonary artery in the victim of a gunshot wound to the head. (a) Anteroposterior 3D VR image shows the air-filled right ventricle and pulmonary artery. CT-based volumetry showed 59 mL of gas within these two structures. 1 = cranial veins, 2 = trachea, 3 = main pulmonary artery, 4 = right ventricular outflow tract, 5 = intrahepatic veins. (b) Autopsy photograph demonstrates the procedure used to confirm the presence of an air embolism. After the pericardium has been opened, the pericardial space is filled with clear water to totally cover the heart. The right ventricle is then punctured with a scalpel, and turning the scalpel produces ascending air bubbles (arrow).

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  Lethal air embolism of the pulmonary artery in the victim of a gunshot wound to the head. (a) Anteroposterior 3D VR image shows the air-filled right ventricle and pulmonary artery. CT-based volumetry showed 59 mL of gas within these two structures. 1 = cranial veins, 2 = trachea, 3 = main pulmonary artery, 4 = right ventricular outflow tract, 5 = intrahepatic veins. (b) Autopsy photograph demonstrates the procedure used to confirm the presence of an air embolism. After the pericardium has been opened, the pericardial space is filled with clear water to totally cover the heart. The right ventricle is then punctured with a scalpel, and turning the scalpel produces ascending air bubbles (arrow).

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Pulmonary edema. (a) Coronal T2-weighted MR image of the thorax shows a global increase in signal intensity throughout the lungs caused by an increased fraction of intrapulmonary water. (b) Photograph of the corresponding autopsy specimen shows the loss of tissue water after sectioning. Note the accumulation of the drained edema (arrows) surrounding the thumbs of the forensic pathologist.

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Pulmonary edema. (a) Coronal T2-weighted MR image of the thorax shows a global increase in signal intensity throughout the lungs caused by an increased fraction of intrapulmonary water. (b) Photograph of the corresponding autopsy specimen shows the loss of tissue water after sectioning. Note the accumulation of the drained edema (arrows) surrounding the thumbs of the forensic pathologist.

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Severe postmortem broncho-pneumonia. (a) CT scan shows complete air displacement in the right lung. Only parts of the left lung are ventilated. (b) Coronal T2-weighted MR image demonstrates increased signal intensity throughout the right lung and in parts of the left lung. Note also the ascites below the diaphragm. (c) Photomicrograph (original magnification, x100; H-E stain) shows purulent bronchitis with massive intraalveolar edema.

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Severe postmortem broncho-pneumonia. (a) CT scan shows complete air displacement in the right lung. Only parts of the left lung are ventilated. (b) Coronal T2-weighted MR image demonstrates increased signal intensity throughout the right lung and in parts of the left lung. Note also the ascites below the diaphragm. (c) Photomicrograph (original magnification, x100; H-E stain) shows purulent bronchitis with massive intraalveolar edema.

View larger version (214K): [in this window] [in a new window] [Download PPT slide]   Figure 9c.  Severe postmortem broncho-pneumonia. (a) CT scan shows complete air displacement in the right lung. Only parts of the left lung are ventilated. (b) Coronal T2-weighted MR image demonstrates increased signal intensity throughout the right lung and in parts of the left lung. Note also the ascites below the diaphragm. (c) Photomicrograph (original magnification, x100; H-E stain) shows purulent bronchitis with massive intraalveolar edema.

View larger version (66K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  Emphysema aquosum. (a) Thoracic CT scan (lung windowing) demonstrates emphysema aquosum caused by drowning, with anterior contact between the lungs. Note the postmortem sedimentation phenomenon with an increase in attenuation from ventral to dorsal, a finding that is especially visible in the right upper lobe. (b) Anteroposterior 3D VR lung image allows correlation with the traditional autopsy findings (cf c). (c) On an autopsy photograph, the ventral parts of the lungs overlap retrosternally. (d) Anteroposterior maximum-intensity-projection (MIP) image from coronal T2-weighted MR imaging data shows hyperintense contents in the stomach (solid arrow) and duodenum (dashed arrow), findings that indicate active swallowing of drowning fluid. (e) Autopsy photograph shows a distinctively fluid-filled stomach (solid arrow) and duodenum (dashed arrow). The organs were opened to sample the fluid.

View larger version (99K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  Emphysema aquosum. (a) Thoracic CT scan (lung windowing) demonstrates emphysema aquosum caused by drowning, with anterior contact between the lungs. Note the postmortem sedimentation phenomenon with an increase in attenuation from ventral to dorsal, a finding that is especially visible in the right upper lobe. (b) Anteroposterior 3D VR lung image allows correlation with the traditional autopsy findings (cf c). (c) On an autopsy photograph, the ventral parts of the lungs overlap retrosternally. (d) Anteroposterior maximum-intensity-projection (MIP) image from coronal T2-weighted MR imaging data shows hyperintense contents in the stomach (solid arrow) and duodenum (dashed arrow), findings that indicate active swallowing of drowning fluid. (e) Autopsy photograph shows a distinctively fluid-filled stomach (solid arrow) and duodenum (dashed arrow). The organs were opened to sample the fluid.

View larger version (158K): [in this window] [in a new window] [Download PPT slide]   Figure 10c.  Emphysema aquosum. (a) Thoracic CT scan (lung windowing) demonstrates emphysema aquosum caused by drowning, with anterior contact between the lungs. Note the postmortem sedimentation phenomenon with an increase in attenuation from ventral to dorsal, a finding that is especially visible in the right upper lobe. (b) Anteroposterior 3D VR lung image allows correlation with the traditional autopsy findings (cf c). (c) On an autopsy photograph, the ventral parts of the lungs overlap retrosternally. (d) Anteroposterior maximum-intensity-projection (MIP) image from coronal T2-weighted MR imaging data shows hyperintense contents in the stomach (solid arrow) and duodenum (dashed arrow), findings that indicate active swallowing of drowning fluid. (e) Autopsy photograph shows a distinctively fluid-filled stomach (solid arrow) and duodenum (dashed arrow). The organs were opened to sample the fluid.

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 10d.  Emphysema aquosum. (a) Thoracic CT scan (lung windowing) demonstrates emphysema aquosum caused by drowning, with anterior contact between the lungs. Note the postmortem sedimentation phenomenon with an increase in attenuation from ventral to dorsal, a finding that is especially visible in the right upper lobe. (b) Anteroposterior 3D VR lung image allows correlation with the traditional autopsy findings (cf c). (c) On an autopsy photograph, the ventral parts of the lungs overlap retrosternally. (d) Anteroposterior maximum-intensity-projection (MIP) image from coronal T2-weighted MR imaging data shows hyperintense contents in the stomach (solid arrow) and duodenum (dashed arrow), findings that indicate active swallowing of drowning fluid. (e) Autopsy photograph shows a distinctively fluid-filled stomach (solid arrow) and duodenum (dashed arrow). The organs were opened to sample the fluid.

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 10e.  Emphysema aquosum. (a) Thoracic CT scan (lung windowing) demonstrates emphysema aquosum caused by drowning, with anterior contact between the lungs. Note the postmortem sedimentation phenomenon with an increase in attenuation from ventral to dorsal, a finding that is especially visible in the right upper lobe. (b) Anteroposterior 3D VR lung image allows correlation with the traditional autopsy findings (cf c). (c) On an autopsy photograph, the ventral parts of the lungs overlap retrosternally. (d) Anteroposterior maximum-intensity-projection (MIP) image from coronal T2-weighted MR imaging data shows hyperintense contents in the stomach (solid arrow) and duodenum (dashed arrow), findings that indicate active swallowing of drowning fluid. (e) Autopsy photograph shows a distinctively fluid-filled stomach (solid arrow) and duodenum (dashed arrow). The organs were opened to sample the fluid.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.  Hypothermia. (a) Coronal reformatted short inversion time inversion-recovery image of the lower abdomen shows areas of bleeding (arrow) within the body core (left psoas muscle) with no causative trauma. (b) Autopsy photograph shows the left psoas muscle with a local intramuscular hematoma (arrow) and no injury to the surrounding tissue.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.  Hypothermia. (a) Coronal reformatted short inversion time inversion-recovery image of the lower abdomen shows areas of bleeding (arrow) within the body core (left psoas muscle) with no causative trauma. (b) Autopsy photograph shows the left psoas muscle with a local intramuscular hematoma (arrow) and no injury to the surrounding tissue.

View larger version (94K): [in this window] [in a new window] [Download PPT slide]   Figure 12a.  Fatal hemorrhage. 1 = superior vena cava, 2 = ascending aorta, 3 = main pulmonary artery. (a) Postmortem CT scan obtained at the level of the right pulmonary artery in a case in which elevated intracranial pressure was the cause of death shows normal vessel dimensions. (b) Postmortem CT scan obtained at the level of the right pulmonary artery in a different case demonstrates fatal hemorrhage with collapsed thoracic vessels.

View larger version (85K): [in this window] [in a new window] [Download PPT slide]   Figure 12b.  Fatal hemorrhage. 1 = superior vena cava, 2 = ascending aorta, 3 = main pulmonary artery. (a) Postmortem CT scan obtained at the level of the right pulmonary artery in a case in which elevated intracranial pressure was the cause of death shows normal vessel dimensions. (b) Postmortem CT scan obtained at the level of the right pulmonary artery in a different case demonstrates fatal hemorrhage with collapsed thoracic vessels.

Vitality of Sustained Injuries
Vital reactions elucidate the sequence of injury and death in forensic pathologic investigations. The question of whether an injury was sustained before or after death can be an important forensic matter. The answer is provided by forensic findings that occur only with intact circulation (eg, fatal hemorrhage, air and fat embolism), respiration (eg, aspiration, cutaneous emphysema), metabolism, or consciousness. These findings are known as forensic vital reactions.

Trauma.— Aspirated material, whether blood, gastric contents, or soot, reveals ongoing ventilation after trauma (Fig 13), just as extensive soft-tissue emphysema does in blunt trauma (Fig 14). After soft-tissue emphysema is palpated, it is hardly visible at autopsy because the air disappears when the overlying skin is incised. Active swallowing of foreign material can also demonstrate that the victim was still alive when the incident happened (Figs 10, 15).

View larger version (60K): [in this window] [in a new window] [Download PPT slide]   Figure 13a.  Aspiration as a postmortem sign of vitality of sustained injuries in a man who was killed in an airplane crash. (a) Thoracic CT scan shows a local hyperattenuating area (arrow) in the right lower lobe. (b) Autopsy photograph of a lung specimen reveals aspirated blood (arrows), a finding that indicates that the victim was still alive when he sustained the injuries.

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 13b.  Aspiration as a postmortem sign of vitality of sustained injuries in a man who was killed in an airplane crash. (a) Thoracic CT scan shows a local hyperattenuating area (arrow) in the right lower lobe. (b) Autopsy photograph of a lung specimen reveals aspirated blood (arrows), a finding that indicates that the victim was still alive when he sustained the injuries.

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 14.  Soft-tissue emphysema as a vital sign of trauma in a pedestrian who had been rolled over by a car. Abdominal CT scan demonstrates massive soft-tissue emphysema (arrowheads). Distinctive air collections between the subcutis and the muscle as well as within the soft tissues indicate that ventilation continued for some time after the accident.

View larger version (170K): [in this window] [in a new window] [Download PPT slide]   Figure 15a.  Swallowed foreign bodies as a vital sign in a person who died in an automobile accident. (a) Thoracic CT scan shows a foreign body (arrow) in the esophagus. The image fails to demonstrate any traumatic injury to the esophagus that might represent an entry wound, a finding that indicates active swallowing of the foreign body. (b) Autopsy photograph of the opened esophagus shows multiple small pieces of windshield (arrows) that have partly lacerated the mucosa.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 15b.  Swallowed foreign bodies as a vital sign in a person who died in an automobile accident. (a) Thoracic CT scan shows a foreign body (arrow) in the esophagus. The image fails to demonstrate any traumatic injury to the esophagus that might represent an entry wound, a finding that indicates active swallowing of the foreign body. (b) Autopsy photograph of the opened esophagus shows multiple small pieces of windshield (arrows) that have partly lacerated the mucosa.

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 16a.  Vital signs in a case of suicide by hanging. (a) Sagittal T2-weighted MR image shows areas of hyperintensity (arrow) around the sternoclavicular insertions of the sternocleidomastoid muscle. (b) Autopsy photograph reveals areas of bleeding (arrow) around the insertions of the sternocleidomastoid muscle, findings that indicate ongoing circulation at the onset of strangulation. (c) CT scan of the neck demonstrates massive soft-tissue emphysema below the strangulation mark. The air ascends from a pneumomediastinum that was caused by a rupture of alveoles during breathing attempts against occluded airways, thereby serving as a vital sign. Demonstration at autopsy is nearly impossible because the first incision allows the air to escape; therefore, the air must be palpated at autopsy. (d) Coronal T2-weighted MR image demonstrates a hyperintense lymph node (arrow) on the left side of the neck. (e) Autopsy photograph of the formalin-fixed specimen shows the lymph node with hemorrhage.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 16b.  Vital signs in a case of suicide by hanging. (a) Sagittal T2-weighted MR image shows areas of hyperintensity (arrow) around the sternoclavicular insertions of the sternocleidomastoid muscle. (b) Autopsy photograph reveals areas of bleeding (arrow) around the insertions of the sternocleidomastoid muscle, findings that indicate ongoing circulation at the onset of strangulation. (c) CT scan of the neck demonstrates massive soft-tissue emphysema below the strangulation mark. The air ascends from a pneumomediastinum that was caused by a rupture of alveoles during breathing attempts against occluded airways, thereby serving as a vital sign. Demonstration at autopsy is nearly impossible because the first incision allows the air to escape; therefore, the air must be palpated at autopsy. (d) Coronal T2-weighted MR image demonstrates a hyperintense lymph node (arrow) on the left side of the neck. (e) Autopsy photograph of the formalin-fixed specimen shows the lymph node with hemorrhage.

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 16c.  Vital signs in a case of suicide by hanging. (a) Sagittal T2-weighted MR image shows areas of hyperintensity (arrow) around the sternoclavicular insertions of the sternocleidomastoid muscle. (b) Autopsy photograph reveals areas of bleeding (arrow) around the insertions of the sternocleidomastoid muscle, findings that indicate ongoing circulation at the onset of strangulation. (c) CT scan of the neck demonstrates massive soft-tissue emphysema below the strangulation mark. The air ascends from a pneumomediastinum that was caused by a rupture of alveoles during breathing attempts against occluded airways, thereby serving as a vital sign. Demonstration at autopsy is nearly impossible because the first incision allows the air to escape; therefore, the air must be palpated at autopsy. (d) Coronal T2-weighted MR image demonstrates a hyperintense lymph node (arrow) on the left side of the neck. (e) Autopsy photograph of the formalin-fixed specimen shows the lymph node with hemorrhage.

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 16d.  Vital signs in a case of suicide by hanging. (a) Sagittal T2-weighted MR image shows areas of hyperintensity (arrow) around the sternoclavicular insertions of the sternocleidomastoid muscle. (b) Autopsy photograph reveals areas of bleeding (arrow) around the insertions of the sternocleidomastoid muscle, findings that indicate ongoing circulation at the onset of strangulation. (c) CT scan of the neck demonstrates massive soft-tissue emphysema below the strangulation mark. The air ascends from a pneumomediastinum that was caused by a rupture of alveoles during breathing attempts against occluded airways, thereby serving as a vital sign. Demonstration at autopsy is nearly impossible because the first incision allows the air to escape; therefore, the air must be palpated at autopsy. (d) Coronal T2-weighted MR image demonstrates a hyperintense lymph node (arrow) on the left side of the neck. (e) Autopsy photograph of the formalin-fixed specimen shows the lymph node with hemorrhage.

View larger version (55K): [in this window] [in a new window] [Download PPT slide]   Figure 16e.  Vital signs in a case of suicide by hanging. (a) Sagittal T2-weighted MR image shows areas of hyperintensity (arrow) around the sternoclavicular insertions of the sternocleidomastoid muscle. (b) Autopsy photograph reveals areas of bleeding (arrow) around the insertions of the sternocleidomastoid muscle, findings that indicate ongoing circulation at the onset of strangulation. (c) CT scan of the neck demonstrates massive soft-tissue emphysema below the strangulation mark. The air ascends from a pneumomediastinum that was caused by a rupture of alveoles during breathing attempts against occluded airways, thereby serving as a vital sign. Demonstration at autopsy is nearly impossible because the first incision allows the air to escape; therefore, the air must be palpated at autopsy. (d) Coronal T2-weighted MR image demonstrates a hyperintense lymph node (arrow) on the left side of the neck. (e) Autopsy photograph of the formalin-fixed specimen shows the lymph node with hemorrhage.

View larger version (60K): [in this window] [in a new window] [Download PPT slide]   Figure 17.  Assessment of impact direction in a pedestrian who was struck by an automobile. Anteroposterior 3D VR image shows fractures of the left tibia and fibula, with a wedge-shaped fracture piece (white arrow). The base of the wedge indicates the direction of the force that caused the fracture (red arrow).

View larger version (102K): [in this window] [in a new window] [Download PPT slide]   Figure 18a.  Fat contusion with formation of a subcutaneous cavity in a person who was rolled over by a car. (a) Coronal fat-saturated MR image of the thigh displays high-signal-intensity areas (arrow) within the subcutaneous tissue, findings that represent a fat contusion at the site of impact. (b) Axial T2-weighted MR image of the left lateral gluteal area shows contusion and disconnection between the muscle fascia and the subcutaneous fat (décollement injury) (arrow). The formed wound cavity is filled with liquefied fat and blood, and the sedimentation of the cellular blood components has resulted in an upper layer of hyperintense serum. (c) Autopsy photograph shows a typical décollement injury, with subcutaneous fat disconnected from the fascia.

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 18b.  Fat contusion with formation of a subcutaneous cavity in a person who was rolled over by a car. (a) Coronal fat-saturated MR image of the thigh displays high-signal-intensity areas (arrow) within the subcutaneous tissue, findings that represent a fat contusion at the site of impact. (b) Axial T2-weighted MR image of the left lateral gluteal area shows contusion and disconnection between the muscle fascia and the subcutaneous fat (décollement injury) (arrow). The formed wound cavity is filled with liquefied fat and blood, and the sedimentation of the cellular blood components has resulted in an upper layer of hyperintense serum. (c) Autopsy photograph shows a typical décollement injury, with subcutaneous fat disconnected from the fascia.

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 18c.  Fat contusion with formation of a subcutaneous cavity in a person who was rolled over by a car. (a) Coronal fat-saturated MR image of the thigh displays high-signal-intensity areas (arrow) within the subcutaneous tissue, findings that represent a fat contusion at the site of impact. (b) Axial T2-weighted MR image of the left lateral gluteal area shows contusion and disconnection between the muscle fascia and the subcutaneous fat (décollement injury) (arrow). The formed wound cavity is filled with liquefied fat and blood, and the sedimentation of the cellular blood components has resulted in an upper layer of hyperintense serum. (c) Autopsy photograph shows a typical décollement injury, with subcutaneous fat disconnected from the fascia.

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 19a.  (a) Injury caused by blows to the head. Oblique left lateral 3D VR CT image shows a typical local impression and ring fracture of the occipital skull due to blows with a hammer. (b) Head injury due to a fall from a great height. Oblique left lateral 3D VR CT image shows comminuted burst fractures starting at the posterior prominent part of the skull (point of impact).

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 19b.  (a) Injury caused by blows to the head. Oblique left lateral 3D VR CT image shows a typical local impression and ring fracture of the occipital skull due to blows with a hammer. (b) Head injury due to a fall from a great height. Oblique left lateral 3D VR CT image shows comminuted burst fractures starting at the posterior prominent part of the skull (point of impact).

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 20a.  Direction of the creation of a gunshot wound to the head. (a) Anteroposterior 3D VR CT image shows an entrance wound with sharp external margins and a cone-shaped bone defect that enlarges from external to internal. (b) Autopsy photograph shows findings similar to those seen in a. (c) Left posterior oblique 3D VR CT image shows the exit wound and a cone-shaped defect that enlarges from internal to external. The formed fracture lines can also help determine the order in which the wounds occurred. From the entrance wound, large fracture lines course along the skull, the result of increased pressure within the water-filled (incompressible) skull caused by the projectile. The short fracture lines from the exit wound stop at the previously formed entrance wound fractures (Puppe’s rule). (d) Autopsy photograph reveals findings similar to those seen in c.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 20b.  Direction of the creation of a gunshot wound to the head. (a) Anteroposterior 3D VR CT image shows an entrance wound with sharp external margins and a cone-shaped bone defect that enlarges from external to internal. (b) Autopsy photograph shows findings similar to those seen in a. (c) Left posterior oblique 3D VR CT image shows the exit wound and a cone-shaped defect that enlarges from internal to external. The formed fracture lines can also help determine the order in which the wounds occurred. From the entrance wound, large fracture lines course along the skull, the result of increased pressure within the water-filled (incompressible) skull caused by the projectile. The short fracture lines from the exit wound stop at the previously formed entrance wound fractures (Puppe’s rule). (d) Autopsy photograph reveals findings similar to those seen in c.

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 20c.  Direction of the creation of a gunshot wound to the head. (a) Anteroposterior 3D VR CT image shows an entrance wound with sharp external margins and a cone-shaped bone defect that enlarges from external to internal. (b) Autopsy photograph shows findings similar to those seen in a. (c) Left posterior oblique 3D VR CT image shows the exit wound and a cone-shaped defect that enlarges from internal to external. The formed fracture lines can also help determine the order in which the wounds occurred. From the entrance wound, large fracture lines course along the skull, the result of increased pressure within the water-filled (incompressible) skull caused by the projectile. The short fracture lines from the exit wound stop at the previously formed entrance wound fractures (Puppe’s rule). (d) Autopsy photograph reveals findings similar to those seen in c.

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 20d.  Direction of the creation of a gunshot wound to the head. (a) Anteroposterior 3D VR CT image shows an entrance wound with sharp external margins and a cone-shaped bone defect that enlarges from external to internal. (b) Autopsy photograph shows findings similar to those seen in a. (c) Left posterior oblique 3D VR CT image shows the exit wound and a cone-shaped defect that enlarges from internal to external. The formed fracture lines can also help determine the order in which the wounds occurred. From the entrance wound, large fracture lines course along the skull, the result of increased pressure within the water-filled (incompressible) skull caused by the projectile. The short fracture lines from the exit wound stop at the previously formed entrance wound fractures (Puppe’s rule). (d) Autopsy photograph reveals findings similar to those seen in c.

View larger version (159K): [in this window] [in a new window] [Download PPT slide]   Figure 21a.  Pilot injury sustained in a plane crash. (a) Coronal T2-weighted MR image of the hand and forearm demonstrates local hyperintense palmar regions (solid arrow). Note also the fracture hematoma (dashed arrow) resulting from fracture of the ulna. (b) Autopsy photograph reveals palmar soft-tissue bleeding (arrow) caused by the control lever of the plane. This and other hemorrhages indicated that the blood circulation of the pilot was ongoing when the plane crashed.

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 21b.  Pilot injury sustained in a plane crash. (a) Coronal T2-weighted MR image of the hand and forearm demonstrates local hyperintense palmar regions (solid arrow). Note also the fracture hematoma (dashed arrow) resulting from fracture of the ulna. (b) Autopsy photograph reveals palmar soft-tissue bleeding (arrow) caused by the control lever of the plane. This and other hemorrhages indicated that the blood circulation of the pilot was ongoing when the plane crashed.

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 22a.  Use of postmortem imaging to address medical-legal issues. (a) Anteroposterior MIP image displays vertebroplasty cement in the inferior vena cava (IVC) (solid arrows) and pulmonary artery branches (dashed arrows). (b) Coronal reformatted CT image shows foreign body embolism of the right pulmonary artery (arrow) as the cause of death. (c) Autopsy photograph shows cement in the IVC (arrows). The cement reached the IVC via lumbar veins into which the cement had been injected as part of the minimally invasive treatment.

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 22b.  Use of postmortem imaging to address medical-legal issues. (a) Anteroposterior MIP image displays vertebroplasty cement in the inferior vena cava (IVC) (solid arrows) and pulmonary artery branches (dashed arrows). (b) Coronal reformatted CT image shows foreign body embolism of the right pulmonary artery (arrow) as the cause of death. (c) Autopsy photograph shows cement in the IVC (arrows). The cement reached the IVC via lumbar veins into which the cement had been injected as part of the minimally invasive treatment.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 22c.  Use of postmortem imaging to address medical-legal issues. (a) Anteroposterior MIP image displays vertebroplasty cement in the inferior vena cava (IVC) (solid arrows) and pulmonary artery branches (dashed arrows). (b) Coronal reformatted CT image shows foreign body embolism of the right pulmonary artery (arrow) as the cause of death. (c) Autopsy photograph shows cement in the IVC (arrows). The cement reached the IVC via lumbar veins into which the cement had been injected as part of the minimally invasive treatment.

View larger version (53K): [in this window] [in a new window] [Download PPT slide]   Figure 23a.  Heat epidural in a burned corpse. (a) CT scan shows a soft-tissue-attenuation epidural mass (arrows). (b) Autopsy photograph reveals coagulated blood masses (arrows) in the epidural space, an unimportant but common finding in burned corpses.

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 23b.  Heat epidural in a burned corpse. (a) CT scan shows a soft-tissue-attenuation epidural mass (arrows). (b) Autopsy photograph reveals coagulated blood masses (arrows) in the epidural space, an unimportant but common finding in burned corpses.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 24a.  Putrefaction. (a) Preautopsy photograph shows the gross appearance of the body, which was in an advanced state of putrefaction. Red lines indicate the section planes of the CT scans shown in b (top line), c (middle line), and d (bottom line). (b) Thoracic CT scan shows putrefaction gas within the heart, the vascular system, and the interstitial spaces of the soft tissues. Note also the bilateral pleural putrefaction fluid. (c) CT scan shows intraluminal and peritoneal gaseous ballooning of the abdomen as well as putrefaction gas within the intrahepatic vessels, liver, and spleen. (d) CT scan shows gaseous ballooning of the scrotum, gas accumulation within the testicles, and massive gas accumulation within the soft tissues.

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 24b.  Putrefaction. (a) Preautopsy photograph shows the gross appearance of the body, which was in an advanced state of putrefaction. Red lines indicate the section planes of the CT scans shown in b (top line), c (middle line), and d (bottom line). (b) Thoracic CT scan shows putrefaction gas within the heart, the vascular system, and the interstitial spaces of the soft tissues. Note also the bilateral pleural putrefaction fluid. (c) CT scan shows intraluminal and peritoneal gaseous ballooning of the abdomen as well as putrefaction gas within the intrahepatic vessels, liver, and spleen. (d) CT scan shows gaseous ballooning of the scrotum, gas accumulation within the testicles, and massive gas accumulation within the soft tissues.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 24c.  Putrefaction. (a) Preautopsy photograph shows the gross appearance of the body, which was in an advanced state of putrefaction. Red lines indicate the section planes of the CT scans shown in b (top line), c (middle line), and d (bottom line). (b) Thoracic CT scan shows putrefaction gas within the heart, the vascular system, and the interstitial spaces of the soft tissues. Note also the bilateral pleural putrefaction fluid. (c) CT scan shows intraluminal and peritoneal gaseous ballooning of the abdomen as well as putrefaction gas within the intrahepatic vessels, liver, and spleen. (d) CT scan shows gaseous ballooning of the scrotum, gas accumulation within the testicles, and massive gas accumulation within the soft tissues.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 24d.  Putrefaction. (a) Preautopsy photograph shows the gross appearance of the body, which was in an advanced state of putrefaction. Red lines indicate the section planes of the CT scans shown in b (top line), c (middle line), and d (bottom line). (b) Thoracic CT scan shows putrefaction gas within the heart, the vascular system, and the interstitial spaces of the soft tissues. Note also the bilateral pleural putrefaction fluid. (c) CT scan shows intraluminal and peritoneal gaseous ballooning of the abdomen as well as putrefaction gas within the intrahepatic vessels, liver, and spleen. (d) CT scan shows gaseous ballooning of the scrotum, gas accumulation within the testicles, and massive gas accumulation within the soft tissues.

View larger version (99K): [in this window] [in a new window] [Download PPT slide]   Figure 25a.  Putrefaction at postmortem MR imaging in a body that had been underwater for more than 1 year. (a) Sagittal T2-weighted MR image depicts intracerebral structures in the putrefied brain, thereby allowing cross-sectional exclusion of gross pathologic cerebral findings. (b) Autopsy photograph fails to allow cerebral assessment, since the liquefied intracranial structures became indistinguishable when the skull was opened. A further sectional preparation was not possible.

View larger version (158K): [in this window] [in a new window] [Download PPT slide]   Figure 25b.  Putrefaction at postmortem MR imaging in a body that had been underwater for more than 1 year. (a) Sagittal T2-weighted MR image depicts intracerebral structures in the putrefied brain, thereby allowing cross-sectional exclusion of gross pathologic cerebral findings. (b) Autopsy photograph fails to allow cerebral assessment, since the liquefied intracranial structures became indistinguishable when the skull was opened. A further sectional preparation was not possible.

View larger version (53K): [in this window] [in a new window] [Download PPT slide]   Figure 26.  Experimental postmortem angiography in a dog that had died 2 days earlier. Lateral 3D reconstructed whole-body multisection CT angiographic image shows the aorta (solid yellow arrow), arteries of the head and neck (carotid arteries) (solid red arrow), the hepatic vasculature (dashed red arrow), and the mesenteric vasculature (dashed yellow arrow).

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 27.  Minimally invasive postmortem CT angiography in a human corpse. Oblique posterior 3D VR image shows the cranial arterial system, including both vertebral arteries, the basilar artery, the circle of Willis, the middle cerebral arteries, the anterior cerebral arteries, and parts of the left temporal artery. The image represents the cranial portion of a whole-body angiographic study performed using a right femoral artery approach.

View larger version (83K): [in this window] [in a new window] [Download PPT slide]   Figure 28a.  Postmortem imaging-guided biopsy. (a) Left lateral 3D CT image clearly depicts a biopsy needle that was inserted into the brain through a hole bored into the skull. The linear blue object on the left side of the image represents a metallic part of a denture. (b) Photograph shows extracted brain specimens that were used for histologic staining.

View larger version (95K): [in this window] [in a new window] [Download PPT slide]   Figure 28b.  Postmortem imaging-guided biopsy. (a) Left lateral 3D CT image clearly depicts a biopsy needle that was inserted into the brain through a hole bored into the skull. The linear blue object on the left side of the image represents a metallic part of a denture. (b) Photograph shows extracted brain specimens that were used for histologic staining.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 29a.  Forensic micro-CT in a case of sharp-force injury. (a) Photograph shows a bone defect that was to be investigated and compared with a knife that was suspected to have caused the injury. (b) Photograph shows the knife. (c) On a micro-CT scan obtained orthogonal to the bone lesion, the knife’s dimensions are superimposed, allowing inclusion of the knife in the group of possible injury-causing instruments.

View larger version (42K): [in this window] [in a new window] [Download PPT slide]   Figure 29b.  Forensic micro-CT in a case of sharp-force injury. (a) Photograph shows a bone defect that was to be investigated and compared with a knife that was suspected to have caused the injury. (b) Photograph shows the knife. (c) On a micro-CT scan obtained orthogonal to the bone lesion, the knife’s dimensions are superimposed, allowing inclusion of the knife in the group of possible injury-causing instruments.

View larger version (162K): [in this window] [in a new window] [Download PPT slide]   Figure 29c.  Forensic micro-CT in a case of sharp-force injury. (a) Photograph shows a bone defect that was to be investigated and compared with a knife that was suspected to have caused the injury. (b) Photograph shows the knife. (c) On a micro-CT scan obtained orthogonal to the bone lesion, the knife’s dimensions are superimposed, allowing inclusion of the knife in the group of possible injury-causing instruments.

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 30a.  Forensic MR microscopy in a case of suspected shaken baby syndrome. (a) RARE T1-weighted MR image (9.4 T) of an isolated eyeball shows retinal hemorrhages (arrows) that are dark compared with the bright subjacent choroid layer. Retinal detachment is also seen. (b) Photograph of a section through the eyeball shows no distinctive alterations. (c) Photomicrograph (H-E stain) shows areas of hemorrhage (arrow and box) containing deposits of the breakdown products of hemoglobin (cf a). (d) Photomicrograph (original magnification, x10; H-E stain) of the area indicated by the box in c more clearly depicts the hemorrhage (arrows). The observed retinal detachment (cf a) was an artifact that may have been introduced upon removal of the eyeball from the skull and exacerbated during the dehydration of the eyeball prior to paraffin embedding.

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 30b.  Forensic MR microscopy in a case of suspected shaken baby syndrome. (a) RARE T1-weighted MR image (9.4 T) of an isolated eyeball shows retinal hemorrhages (arrows) that are dark compared with the bright subjacent choroid layer. Retinal detachment is also seen. (b) Photograph of a section through the eyeball shows no distinctive alterations. (c) Photomicrograph (H-E stain) shows areas of hemorrhage (arrow and box) containing deposits of the breakdown products of hemoglobin (cf a). (d) Photomicrograph (original magnification, x10; H-E stain) of the area indicated by the box in c more clearly depicts the hemorrhage (arrows). The observed retinal detachment (cf a) was an artifact that may have been introduced upon removal of the eyeball from the skull and exacerbated during the dehydration of the eyeball prior to paraffin embedding.

View larger version (50K): [in this window] [in a new window] [Download PPT slide]   Figure 30c.  Forensic MR microscopy in a case of suspected shaken baby syndrome. (a) RARE T1-weighted MR image (9.4 T) of an isolated eyeball shows retinal hemorrhages (arrows) that are dark compared with the bright subjacent choroid layer. Retinal detachment is also seen. (b) Photograph of a section through the eyeball shows no distinctive alterations. (c) Photomicrograph (H-E stain) shows areas of hemorrhage (arrow and box) containing deposits of the breakdown products of hemoglobin (cf a). (d) Photomicrograph (original magnification, x10; H-E stain) of the area indicated by the box in c more clearly depicts the hemorrhage (arrows). The observed retinal detachment (cf a) was an artifact that may have been introduced upon removal of the eyeball from the skull and exacerbated during the dehydration of the eyeball prior to paraffin embedding.

View larger version (44K): [in this window] [in a new window] [Download PPT slide]   Figure 30d.  Forensic MR microscopy in a case of suspected shaken baby syndrome. (a) RARE T1-weighted MR image (9.4 T) of an isolated eyeball shows retinal hemorrhages (arrows) that are dark compared with the bright subjacent choroid layer. Retinal detachment is also seen. (b) Photograph of a section through the eyeball shows no distinctive alterations. (c) Photomicrograph (H-E stain) shows areas of hemorrhage (arrow and box) containing deposits of the breakdown products of hemoglobin (cf a). (d) Photomicrograph (original magnification, x10; H-E stain) of the area indicated by the box in c more clearly depicts the hemorrhage (arrows). The observed retinal detachment (cf a) was an artifact that may have been introduced upon removal of the eyeball from the skull and exacerbated during the dehydration of the eyeball prior to paraffin embedding.

3D Color-encoded Surface Scanning
Skin and bone injuries are 3D. With conventional documentation methods like photography, 3D objects are unfortunately displayed in only two dimensions, which can sometimes be insufficient for forensic and scientific analysis. The forensic application of the TRITOP/ATOS II system (GOM) consists of 3D documentation of the formed injury on the body (skin, bone) and of the weapon (injury-causing instrument) that was presumably used (63). This 3D data set is a so-called patterned injury or "morphologic fingerprint" (Fig 31b). This kind of documentation is independent of the perishability of the wound findings (eg, healing in living persons, natural biologic decomposition in deceased persons). The suspected weapon can be documented three dimensionally in the same way. Both 3D models are real databased, and their sizes and dimensions are calibrated. Subsequently, the use of the suspected weapon can be confirmed or excluded on the basis of the correspondence between the weapon and the formed injury. Thus, a weapon that turns up months or even years after autopsy has been performed can be linked to patterned injuries on the body (63). After the weapon is scanned, attempts at correlation are made in a virtual 3D space. Possible morphologic correlations range from that between small bite wounds and the dentition of possible offenders (Fig 32) to that between patterned injuries on the body of a traffic accident victim and the possible involved vehicle (63).

View larger version (101K): [in this window] [in a new window] [Download PPT slide]   Figure 31a.  Color-encoded 3D surface scanning of a corpse. (a) Photograph shows the scanning arrangement in the autopsy room. Multimodality markers on the body allow the fusion of 3D surface data with cross-sectional volume data. (b) Lateral color-encoded 3D surface image clearly depicts the entrance wound and the "face imprint" or "muzzle imprint" of the weapon that was used.

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 31b.  Color-encoded 3D surface scanning of a corpse. (a) Photograph shows the scanning arrangement in the autopsy room. Multimodality markers on the body allow the fusion of 3D surface data with cross-sectional volume data. (b) Lateral color-encoded 3D surface image clearly depicts the entrance wound and the "face imprint" or "muzzle imprint" of the weapon that was used.

View larger version (74K): [in this window] [in a new window] [Download PPT slide]   Figure 32.  Three-dimensional analysis of a bite wound. Color-encoded 3D surface image of a bite mark on the victim’s skin is correlated with a 3D surface image of the dentition of the suspected offender. The analysis in this case allowed a positive match between the bite mark and the injury-causing dentition based on the specific positions of several teeth.

View larger version (95K): [in this window] [in a new window] [Download PPT slide]   Figure 33a.  Fusion of 3D surface data with cross-sectional body volume data. (a) Thoracic CT scan demonstrates a gunshot channel. The CT data set has been fused with the surface data obtained at the entrance wound. (b) Image demonstrates how a virtual autopsy can be performed with 3D postprocessing tools on a surface–cross-sectional data set even years after the death of the victim.

View larger version (85K): [in this window] [in a new window] [Download PPT slide]   Figure 33b.  Fusion of 3D surface data with cross-sectional body volume data. (a) Thoracic CT scan demonstrates a gunshot channel. The CT data set has been fused with the surface data obtained at the entrance wound. (b) Image demonstrates how a virtual autopsy can be performed with 3D postprocessing tools on a surface–cross-sectional data set even years after the death of the victim.

1. The photogrammetric data set for a smaller injury can be merged with the radiologic 3D reconstructed image of the skin or soft tissue. Visible radiologic landmarks are useful for correlating the data sets. If the wound is located in an anatomically stable region, a fusion process based on geometric anatomic fusion is possible even without radiologic markers.
   
2. The 3D optical surface scan, acquired with the TRITOP/ATOS II system (GOM), can be matched (merged) with the radiologic data set. This new approach holds promise for the analysis of large, widespread, or complex injuries on the body surface or for cases in which whole-body documentation is necessary (63,64).
   

Real Data–based 3D Forensic Reconstruction of Incidents
With CT data concerning skeletal joints and fractures in the deceased person, it becomes possible to rearrange the position of the extremities and, indeed, of the entire body. Thus, an incident can be investigated on the basis of real data and reconstructed with animation to address various questions (Fig 34). With these data fusion possibilities, it is possible to answer questions regarding the dynamic development of patterned injuries (morphologic fingerprints) and to evaluate their matchability with or linkability to suspected injury-causing instruments even years after the body has been interred.

View larger version (88K): [in this window] [in a new window] [Download PPT slide]   Figure 34a.  Real data–based forensic reconstruction in a pedestrian who was struck by a car. (a) Three-dimensional CT images show how information about joints can be used to define movable extremity models with surface details. (b) Image illustrates how correlation of the 3D surface image of the car (including the damage to the car) with the injuries of the victim allows forensic reconstruction of the accident. In this case, the victim was working with his left knee on the ground when the car hit him.

 

View larger version (86K): [in this window] [in a new window] [Download PPT slide]   Figure 34b.  Real data–based forensic reconstruction in a pedestrian who was struck by a car. (a) Three-dimensional CT images show how information about joints can be used to define movable extremity models with surface details. (b) Image illustrates how correlation of the 3D surface image of the car (including the damage to the car) with the injuries of the victim allows forensic reconstruction of the accident. In this case, the victim was working with his left knee on the ground when the car hit him.

 

Real 3D data–based documentation opens up new vistas for scientific reconstruction and dynamic animation. It improves the quality of forensic science in terms of accuracy, precision, variability, and objectivity. In contrast to computer-generated animations in computer games and the film industry, which are not based on real data, the added value of virtopsy may qualify it as the visualization method of choice for courtroom proceedings.

Forensic Assessment of Living Persons
Forensic medicine is used not only in the investigation of deceased persons; surviving victims of any kind of assault may also undergo forensic assessment. Thus, the severity of an assault can be medically determined, thereby facilitating adequate sentencing of the offender. Especially in survivors of strangulation, the knowledge gleaned from postmortem MR imaging of the neck (65) can help assess whether the assault was life threatening. This is why in Bern, forensically indicated MR imaging of the head and neck is performed in the surviving victims of a strangulation assault to look for findings seen in known lethal strangulation cases. This imaging allows assessment of the mortal danger of the strangulation attempt when internal findings such as major bleeding into the muscles of the neck, the salivary glands, or the lymph nodes are present (Fig 35). Until we started performing forensically indicated MR imaging in living persons, the term "life threatening" was predominantly based on subjective anamnestic information about temporary loss of consciousness, unconscious urination, or an increased pressure sensitivity of the neck. The only objective finding considered to indicate a life-threatening situation was the presence of petechial hemorrhages within the conjunctiva or oral mucosa due to congestion.

View larger version (78K): [in this window] [in a new window] [Download PPT slide]   Figure 35a.  Forensic MR imaging in a survivor of manual strangulation. (a) Axial T2-weighted MR image demonstrates a hyperintense left sternocleidoid muscle (box), a finding that reflects traumatic hemorrhage in the muscle tissue. (b) Axial T2-weighted MR image shows subcutaneous hemorrhage on the left side (box).

View larger version (78K): [in this window] [in a new window] [Download PPT slide]   Figure 35b.  Forensic MR imaging in a survivor of manual strangulation. (a) Axial T2-weighted MR image demonstrates a hyperintense left sternocleidoid muscle (box), a finding that reflects traumatic hemorrhage in the muscle tissue. (b) Axial T2-weighted MR image shows subcutaneous hemorrhage on the left side (box).

An "all-in-one" machine called Virtobot (Fig 36) will allow the forensic use of all the techniques discussed in this article. This machine will allow combined surface and body volume data acquisition within a single 3D space, making present-day data fusion techniques dispensable. Robotic arms will allow precise and automatic placement of injection tools (for minimally invasive angiography) or biopsy needles (for imaging-guided biopsy). A version mounted on a trailer ("Virtomobile") can be envisioned that could be used to conduct investigations near the crime scene or to facilitate the work of disaster victim identification teams at the disaster site.

View larger version (85K): [in this window] [in a new window] [Download PPT slide]   Figure 36a.  (a) Drawing illustrates how Virtobot will combine all currently implemented technologies in a single investigative unit. The machine will allow 3D color-encoded surface documentation, CT- and MR imaging–based body volume documentation, tissue and body fluid extraction (using robotic arm guidance with the CT or MR imaging data), and, when necessary, microradiologic investigations. (b) Photograph shows forensic equipment that is currently in use at our institution: a new six–detector row CT scanner (Emotion 6, Siemens), a 3D surface scanner (TRITOP/ATOS II, GOM), a navigation system for imaging guidance, and an angiographic perfusion unit.

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 36b.  (a) Drawing illustrates how Virtobot will combine all currently implemented technologies in a single investigative unit. The machine will allow 3D color-encoded surface documentation, CT- and MR imaging–based body volume documentation, tissue and body fluid extraction (using robotic arm guidance with the CT or MR imaging data), and, when necessary, microradiologic investigations. (b) Photograph shows forensic equipment that is currently in use at our institution: a new six–detector row CT scanner (Emotion 6, Siemens), a 3D surface scanner (TRITOP/ATOS II, GOM), a navigation system for imaging guidance, and an angiographic perfusion unit.

	Conclusions

Top Abstract Introduction Clinical Experience Results Conclusions References

 
CT is the tool of choice for two-dimensional and 3D documentation and analysis of fracture systems, pathologic gas collections (air embolism, subcutaneous emphysema after trauma, hyperbaric trauma, decomposition effects), and gross tissue injury. The CT scanning times are short (whole-body documentation takes 5–10 minutes), depending on the section thickness and the volume to be covered. Postprocessing techniques such as multiplanar reformation, MIP, and 3D VR can provide strong visual evidence for use in courtroom proceedings.

MR imaging has clearly had a greater impact in demonstrating soft-tissue injury, neurologic as well as nonneurologic organ trauma, and non-traumatic conditions. However, the differences in morphologic features and signal intensity characteristics seen at antemortem versus postmortem MR imaging have yet to be studied systematically. If the results of clinical MR imaging can increasingly be transferred to postmortem analysis, there is the real possibility of more diagnostic power for nondestructive analysis of visceral disease, such as cardiac and coronary disease.

The method of documenting forensic findings presented in this article is investigator independent, objective, and noninvasive and will lead to qualitative improvements in forensic pathologic investigation, since the digitally stored data may be recalled at any time to provide fresh, intact topographic and anatomic-clinical information.

Greater degrees of quality control and expert supervision become possible, as do image transmission and forensic "telemedicine" consultation. The two-dimensional–3D methods of reconstruction are superior to the older descriptive and photographic techniques in comprehensively demonstrating findings to laypersons in a courtroom setting.

With the expansion of data acquisition, the data and the resulting information can be used as an epidemiologic basis for assessing morbidity and mortality in the general population, thereby aiding in the planning of further research projects. A virtopsy screening procedure prior to burial is conceivable. Traditional autopsy rates are decreasing for several reasons, so that autopsy provides only limited data. Virtual autopsy provide an alternative means of acquiring relevant postmortem data for further research.

	Acknowledgments

 
The authors are grateful to the entire Virtopsy team and their research partners (see www.virtopsy.com), who made this study possible due to their exceptional commitment. Special thanks go to Urs Koenigsdorfer, Roland Dorn, and Therese Périnat (Institute of Forensic Medicine, Bern, Switzerland) for their expertise and support during autopsy and histologic analysis. Furthermore, we thank the team of highly motivated radiology technicians—Karin Zwygart, Verena Beutler, Elke Spielvogel, Christoph Laeser, and Carolina Dobrowolska (Inselspital, University of Bern, Switzerland)—for performing scans during the evening and at night. We also thank William R. Oliver, MD (AFIP, Bethesda, Md), for his assistance in interpreting MR microscopic images, and Marcel Braun (Scientific Service, Zurich City Police, Zurich, Switzerland) for his ongoing support over the past 10 years.

	Footnotes

 

Abbreviations: AFIP = Armed Forces Institute of Pathology, H-E = hematoxylin-eosin, IVC = inferior vena cava, MIP = maximum intensity projection, RARE = rapid acquisition with relaxation enhancement, 3D = three-dimensional, VR = volume rendered

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