Representation of cerebral bridging veins in infants by postmortem computed tomography

The postmortem diagnosis of shaken baby syndrome, a severe form of child abuse, may be difficult, especially when no other visible signs of significant trauma are obvious. An important finding in shaken baby syndrome is subdural haemorrhage, typically originating from ruptured cerebral bridging veins. Since these are difficult to detect at autopsy, we have developed a special postmortem computed tomographic (PMCT) method to demonstrate the intracranial vein system in infants. This method is minimally invasive and can be carried out conveniently and quickly on clinical computed tomography (CT) systems. Firstly, a precontrast CT is made of the infant's head, to document the original state. Secondly, contrast fluid is injected manually via fontanel puncture into the superior sagittal sinus, followed by a repeat CT scan. This allows the depiction of even very small vessels of the deep and superficial cerebral veins, especially the bridging veins, without damaging them. Ruptures appear as extravasation of contrast medium, which helps to locate them at autopsy and examine them histologically, whenever necessary.     

Post-mortem radiological examination in infants:: Evidence of child abuse?

We examined the value of post-mortem radiological examination of infants who were brought in for medico–legal autopsy. Twenty children between the age of 1 month and 15 months died under the picture of SIDS. No radiological or other signs of previous child abuse were seen in our autopsy material. A fatal case of child abuse with several metaphyseal fractures is reported. Some fractures were not visible on gross examination, but could be demonstrated by radiography and histology. In our material no association between SIDS and child abuse was found. In suspected cases of child abuse, particularly rib fractures and metaphyseal fractures should be sought. We recommend that post-mortem radiography is performed in such cases. If fractures are demonstrated, they should be verified by histologic examination.     

Child abuse: practical application of autopsy, radiological, and microscopic studies

A 17-month-old male infant died at home. The infant's right arm was immobilized because of a humeral fracture 1 month earlier. The circumstances of death appeared unclear to the police investigators and a medicolegal autopsy was carried out. External examination revealed diffuse ecchymoses of varying color. Postmortem imaging was performed prior to autopsy (X-rays, multislice computed tomography [MSCT], and focused brain magnetic resonance imaging [MRI]). These investigations revealed four rib fractures of varying ages, one of which was posterior. Cerebral and pericerebral traumatic lesions were also diagnosed: bilateral subdural hematomas, intraventricular, meningeal, and interpedoncular hemorrhages. In the abdomen, fresh blood was visible within the anterior abdominal wall and the mesenteric root. Autopsy and microscopic study confirmed these lesions. This case report illustrates the valuable assistance rendered by MSCT and MRI to diagnose abuse when a child has died in unclear circumstances.     

Pneumomediastinum and Soft Tissue Emphysema in Pediatric Hanging

Postmortem computed tomography (CT) is increasingly being used as a tool in forensic pathology. The exact value of postmortem imaging in detecting specific conditions has not yet been established, but in specific cases, it can be used as a diagnostic tool demonstrating findings that remain undetected during autopsy, as in this case. Pneumomediastinum and soft tissue emphysema were detected with postmortem CT in a 3‐year‐old girl after hanging. It was not found during autopsy. This radiological finding matches 3 adult cases previously described. It is assumed that in this case, the first reported in a child, hanging was the most likely cause as well. In the adult cases, it was interpreted as a vital sign; the person must have been alive to create a pressure gradient causing rupture of the alveoli. This case demonstrates one of the added values of postmortem imaging, the possibility of demonstrating findings that remain undetected during autopsy.     

Dural hemorrhage of the tentorium on postmortem cranial computed tomographic scans in children

We analyzed four children with increased density of the tentorium on postmortem computed tomographic (CT) scans that suggested traumatic subarachnoid hemorrhage; but in which followup autopsy demonstrated an absence of subarachnoid hemorrhage. All cases had neither head injuries nor distinct intracranial abnormalities. Histological examinations showed extensive hemorrhage within the tentorium. These findings indicate that increased density of the tentorium on postmortem CT scan reflects 'dural hemorrhage' that may occur in children without intracranial abnormalities. Pediatricians and forensic pathologists should be aware of this phenomenon when using postmortem preautopsy CT scanning for diagnosis of child abuse.     

Reversal sign on ante- and postmortem brain imaging in a newborn: report of one case

A 16-day-old female newborn was admitted to the emergency department after cardiopulmonary arrest. Total-body radiographs and non-enhanced CT of the brain showed fracture of the right clavicle, pericerebral hemorrhage and brain damage with reversal sign. The infant died on the day of her hospital admission. Because child abuse was suspected, a medicolegal autopsy was ordered by the legal authorities. Prior to autopsy, total-body MRI and CT were performed. Results of the ante- and postmortem investigations were compared with each other and then with the autopsy findings. Postmortem brain imaging showed persistence of the reversal sign. To the best of our knowledge, this is the first case describing hypoxic ischemic damage of the brain parenchyma on antemortem CT and persisting on postmortem imaging in a child abuse case.     

The Role of Postmortem Computed Tomography in the Evaluation of Strangulation Deaths

We explored the value of postmortem computed tomography (PMCT) to augment autopsy in evaluating strangulation fatalities. A literature search identified 16 studies describing autopsy findings in 576 deaths and two studies describing autopsy and PMCT findings in six deaths. Similar cases were identified from our institution, yielding 130 deaths with autopsy findings and 14 deaths with both autopsy and PMCT findings. The presence of laryngohyoid fracture and soft tissue hemorrhage was compared from autopsy and autopsy+PMCT cases. The detection rates of fractures in autopsy and autopsy+PMCT cases were not significantly different. PMCT identified all fractures observed at autopsy and five fractures not identified. While PMCT may not detect soft tissue injuries in decomposed remains or subtle internal hemorrhages in neck injury, it is equally able to detect bony injuries as autopsy and might surpass autopsy in detecting subtle fractures. We conclude PMCT is useful to supplement autopsy in strangulation cases.     

CT技术在尸体检验中的应用

自1990年CT首次应用于死后尸体检验以来,不断有学者对其在全身尸体检验中的价值和优势进行探讨。CT用于解剖前的系统检验,对解剖有指导作用,可以与解剖所见互相印证,有时还能弥补解剖检验的不足。本文综述了CT技术在尸体检验中对死因分析、致伤方式推断和个体识别等方面的主要应用价值及其发展趋势,提示CT技术与其他学科联合应用将在法医病理学领域发挥更大的作用。     

Inadvertent clavicular fractures caused by "chiropractic" manipulations in an infant: an unusual form of pseudoabuse

A nine-month-old child was found unresponsive in his crib, five hours after his last feeding. At autopsy, there were no external or internal signs of abuse or neglect, and a few visceral pleural and epicardial petechiae were consistent with the sudden infant death syndrome (SIDS). However, postmortem total body radiographs revealed healing, symmetrical clavicular fractures and a healing left medial humeral epicondyle fracture. The parents had no explanation for these injuries and denied causing any harm to the child. The location and nature of the fractures strongly suggested abusive origin, and the case was reported to the police and the district attorney's office as child abuse. During the investigation, information from the parents indicated that the child had undergone "chiropractic" manipulations by an unlicensed therapist, between three and four weeks prior to death, to correct supposed "shoulder dislocations." This time interval correlated with the histologic age of the injuries, and the history explained their unusual bilateral location and appearance. The parents were exonerated of abuse charges, and the death was ascribed to SIDS.     

A Unique Type of Birth Trauma Mistaken for Abuse

Pediatric abusive head trauma is a challenging subject across many disciplines. Of particular importance is the identification of mimics of abuse, so cause and manner of death can be properly assigned. We present the case of suspected child abuse involving an infant who presented unresponsive to the hospital with hypoglycemia, hypothermia, and bilateral parietal fractures. An autopsy revealed fractures associated with organizing scalp hemorrhage and gross leptomeningeal congestion and hemorrhage. The fractures were circular with external displacement, rounded margins, and subperiosteal new bone formation indicative of healing. Birth records revealed vacuum assist and cesarean section delivery. Although vacuum extraction‐related injuries are typically cephalohematomas and/or linear fractures, the outbending and circular morphology of the fractures are consistent with vacuum extraction. Moreover, microscopic neuropathological examination revealed hemorrhagic purulent leptomeningitis. This unique case demonstrates the importance of considering birth trauma in the determination of cause and manner of death of an infant.     

Anthropological measurement of lower limb and foot bones using multi-detector computed tomography

Anthropological examination of defleshed bones is the gold standard for osteological measurement in forensic practice. However, multi-detector computed tomography (MDCT) offers the opportunity of three-dimensional imaging of skeletal elements, allowing measurement of bones in any plane without defleshing. We present our experiences of the examination of 15 human lower limbs in different states of decomposition using MDCT. We present our method of imaging and radiological measurement of the bones including sex assessment. The radiological measurements were undertaken by three professional groups--anthropology, radiology, and forensic pathology--both at the site of scanning and at a remote site. The results were compared to anthropological oestological assessment of the defleshed bones. We discuss the limitations of this technique and the potential applications of our observations. We introduce the concept of remote radiological anthropological measurement of bones, so-called tele-anthro-radiology and the role that this could play in providing the facility for standardization of protocols, international peer review and quality assurance schemes.     

Massive parallel sequencing and osteogenesis imperfecta: An essential tool for forensic investigation over child abuse

Osteogenesis imperfecta (OI) is a rare disease of collagen synthesis causing bone fragility. Also called “glass bone disease” since it manifests as spontaneous fractures, it is classified into nine types, both with dominant and recessive transmission. In 95% of cases OI is caused by mutations in COL1A1 and COL1A2 genes encoding the alpha1 and alpha2 chains of type 1 collagen, mainly null variants caused by frame-shift/nonsense mutations or splicing defects. In infants the differential diagnosis include not-accidental trauma, so child abuse. Families suspected of abuse often provide an unverified history of frequent fractures; conversely, the family history of individuals with OI often does not reveal any other affected individuals because of a de novo pathogenic variant in the proband or the presence of a mild phenotype in relatives. Therefore, legal medicine unit with DNA lab is crucial in these cases since it could early collect living or autopsy samples when a child abuse is suspected and then test DNA. We set up a MPS (massively parallel sequencing) panel including the coding regions of COL1A1 and COL1A2 and other 11 genes known to cause OI. We presented a case of suspected abuses in 2-month-old baby. MPS libraries were sequenced by Ion Torrent PGM platform; pathogenic variants and VUS (variants of uncertain significance) were confirmed by Sanger sequencing and familial segregation study was performed to better characterize the clinical significance of the mutation. This study remarks that MPS could help not only for identification, ancestry/phenotyping or molecular autopsy applications but also for forensic investigation over child abuse. The usefulness of this assay for diagnostic projects on victims of abuse together with post-mortem cases is discussed.     

Image-guided virtual autopsy findings of gunshot victims performed with multi-slice computed tomography and magnetic resonance imaging and subsequent correlation between radiology and autopsy findings

Because the use of radiology in modern forensic medicine has been, until today, mostly restricted to conventional X-rays, which reduces a 3D body to a 2D projection, a detailed 3D documentation of a gunshot's wound ballistic effects was not possible. The aim of our study was to evaluate whether the progress in imaging techniques over the last years has made it possible to establish an observer-independent and reproducible forensic assessment using multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) technologies for the documentation and analysis of gunshot wounds. The bodies of eight gunshot victims were scanned by MSCT and by MRI; the data of these imaging techniques were post-processed on a workstation, interpreted and subsequently correlated with the findings of classical autopsy. With the spiral CT and MRI examinations and the subsequent 2D multi-planar reformation (MPR) and 3D shaded surface display (SSD) reconstruction, the entire gunshot-created complex skull fractures and brain injuries (such as wound channels and deeply-driven bone splinters) could be documented in complete and graphic detail. CT and MRI also documented vital reaction to the gunshot by demonstrating air emboli in the heart and blood vessels and the classic pattern of blood aspiration to the lung. Gunshot residues deposited within and under the skin were visible. In conclusion, we think that the radiological methods of MSCT and MRI have the potential to become a routine "virtual autopsy" tool in the future. Bullets and relevant histological samples from specific sites then might be won in image-guided minimally invasive fashion via percutaneous biopsy. The rapid application of developing radiological methods may lead to new horizons in forensic documentation and intravital as well as postmortem examination.     

Can computed tomography replace or supplement autopsy?

Postmortem computed tomography (PMCT) has been integrated into the practice of many forensic pathologists. To evaluate the utility of PMCT in supplementing and/or supplanting medicolegal autopsy, we conducted a prospective double-blind comparison of abnormal findings reported by the autopsy pathologist with those reported by a radiologist reviewing the PMCT. We reviewed 890 cases: 167 with blunt force injury (BFI), 63 with pediatric trauma (under 5 years), 203 firearm injuries, and 457 drug poisoning deaths. Autopsy and radiology reports were coded using the Abbreviated Injury Scale and abnormal findings and cause of death (COD) were compared for congruence in consensus conferences with novel pathologists and radiologists. Overall sensitivity for recognizing abnormal findings was 71% for PMCT and 74.6% for autopsy. Sensitivities for PMCT/autopsy were 74%/73.1% for BFI, 61.5%/71.4% for pediatric trauma, 84.9%/83.7% for firearm injuries, and 56.5%/66.4% for drug poisoning deaths. COD assigned by reviewing PMCT/autopsy was correct in 88%/95.8% of BFI cases, 99%/99.5% of firearm fatalities, 82.5%/98.5% of pediatric trauma deaths, and 84%/100% of drug poisoning deaths of individuals younger than 50. Both autopsy and PMCT were imperfect in recognizing injuries. However, both methods identified the most important findings and are sufficient to establish COD in cases of BFI, pediatric trauma, firearm injuries and drug poisoning in individuals younger than 50. Ideally, all forensic pathologists would have access to a CT scanner and a consulting radiologist. This would allow a flexible approach that meets the diagnostic needs of each case and best serves decedents' families and other stakeholders.     

Pitfalls of Computed Tomography 3D Reconstruction Models in Cranial Nonmetric Analysis*

Many studies in the literature have highlighted the utility of virtual 3D databanks as a substitute for real skeletal collections and the important application of radiological records in personal identification. However, none have investigated the accuracy of virtual material compared to skeletal remains in nonmetric variant analysis using 3D models. The present study investigates the accuracy of 20 computed tomography (CT) 3D reconstruction models compared to the real crania, focusing on the quality of the reproduction of the real crania and the possibility to detect 29 dental/cranial morphological variations in 3D images. An interobserver analysis was performed to evaluate trait identification, number, position, and shape. Results demonstrate a false bone loss in 3D models in some cranial regions, specifically the maxillary and occipital bones in 85% and 20% of the samples. Additional analyses revealed several difficulties in the detection of cranial nonmetric traits in 3D models, resulting in incorrect identification in circa 70% of the traits. In particular, pitfalls included the detection of erroneous position, error in presence/absence rates, in number, and in shape. The lowest percentages of correct evaluations were found in traits localized in the lateral side of the cranium and for the infraorbital suture, mastoid foramen, and crenulation. The present study highlights important pitfalls in CT scan when compared with the real crania for nonmetric analysis. This may have crucial consequences in cases where 3D databanks are used as a source of reference population data for nonmetric traits and pathologies and during bone-CT comparisons for identification purposes.     

Commotio cordis: A case report of a fatal blow

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.     

Blood aspiration as a vital sign detected by postmortem computed tomography imaging

Blood aspiration is a significant forensic finding. In this study, we examined the value of postmortem computed tomography (CT) imaging in evaluating findings of blood aspiration. We selected 37 cases with autopsy evidence of blood in the lungs and/or in the airways previously submitted to total-body CT scanning. The CT-images were retrospectively analyzed. In one case with pulmonary blood aspiration, biopsy specimens were obtained under CT guide for histological examination. In six cases, CT detected pulmonary abnormalities suggestive of blood aspiration, not mentioned in the autopsy reports. CT reconstructions provided additional data about the distribution and extent of aspiration. In one needle-biopsied case, the pulmonary specimens showed blood in the alveoli. We suggest the use of CT imaging as a tool complementary to traditional techniques in cases of blood aspiration to avoid misdiagnosis, to guide the investigation of lung tissue, and to allow for more evidence-based inferences on the cause of death.     

Observational Case Series: An Algorithm Incorporating Multidetector Computed Tomography in the Medicolegal Investigation of Human Remains after a Natural Disaster

An algorithm incorporating multidetector computed tomography (MDCT), digital radiographs, and external examination was used to triage cases for noninvasive or complete autopsy after a natural disaster. The algorithm was applied to 27 individuals who died during or soon after the earthquake that struck the Republic of Haiti on January 12, 2010. Of the 27 cases reviewed, 7 (26%) required a complete autopsy to determine cause and manner of death. In the remaining 20 (74%), cause and manner of death were determined with a reasonable degree of medical certainty after review of circumstances, an external examination, and postmortem imaging by MDCT and digital radiography (noninvasive autopsy). MDCT was particularly useful in detecting skeletal fractures caused by blunt force injury which were not evident on digital radiographs. The algorithm incorporating postmortem MDCT can be useful in the triage of human remains for autopsy after a natural disaster.     

鼻骨骨折螺旋CT3D成像与X线片对比研究

目的 评价螺旋CT扫描三维重建成像与X线摄片对比对鼻骨骨折法医学鉴定的价值。方法 使用SOMATOM BALANCE 1s螺旋CT机，对32例复杂鼻部外伤者2mm／2mm扫描，常规进行最大密度投影法(MIP)、多平面重建(MPR)、表面覆盖法(SSD)、容积成像(VR)方式。全貌显示受伤鼻骨骨折影像，并与常规鼻骨摄片比较。结果 螺旋CT三维成像纠正3例X线照片的假阳性和6例诊断骨折类型不准确。结论 螺旋CT三维重建对诊断复杂鼻骨骨折块数目、移位，以及骨折类型优于X线摄片。