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.     

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.     

A baby, a virus, and a rat

The authors present a case initially thought to be a child abuse homicide that, after complete autopsy and thorough investigation, was determined to be caused by a viral infection and complicated by postmortem animal activity. Neonatal herpes simplex infection and postmortem skin defects are discussed.     

Fatal paradoxical air embolism diagnosed by postmortem imaging and autopsy

The recognition and visualization of an arterial gas embolism are difficult. We report a case of sudden death caused by paradoxical air embolism of coronary and cerebral arteries, diagnosed by the pre autopsy computed tomography (CT) scanning. A 54-year-old woman suddenly died after the self-removal of the jugular vein catheter. Postmortem imaging examination using CT scanning showed multiple gas embolisms in the cerebral arteries, pulmonary artery, right atrium and ventricle, left ventricle, aorta, and coronary arteries. These findings suggested that the occurrence of acute ischemia of the brain and heart caused by massive air inflow to the artery. Conventional autopsy revealed a patent foramen ovale of the heart. These results indicated that the patient died of paradoxical air embolization of the coronary and cerebral arteries through a patent foramen ovale because of right-to-left shunting. The use of postmortem imaging as an aid for conventional autopsy has proved to be of advantage in the case of gas embolism.     

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.     

Massive systemic fat embolism detected by postmortem imaging and biopsy*

Postmortem computed tomography (pmCT) and pmCT angiography (pmCTA) provide a minimally invasive method to determine the cause of death. Postmortem image-guided biopsy allows for precise sampling of histological specimens. This case study describes the findings of lethal systemic fat embolism (FE) on whole-body unenhanced pmCT, pmCTA, and image-guided biopsy, with autopsy and histopathologic correlation. Unenhanced pmCT revealed a distinct fat level on top of sedimented layers of corpuscular blood particles and serum in the arterial system and pulmonary trunk. Subsequent pmCTA showed reproducible results, and image-guided biopsy confirmed fatal FE. pm CT/pmCTA combined with image-guided biopsy established the cause of death as right heart failure as a result of systemic fatal FE prior to autopsy. All imaging findings were consistent with traditional autopsy and histological specimens. This unique case demonstrates new imaging findings in massive, fatal FE and highlights that postmortem imaging, supplemented by image-guided biopsy, may detect the cause of death prior to traditional autopsy.     

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 forensic neuroimaging: correlation of MSCT and MRI findings with autopsy results

Multislice-computed tomography (MSCT) and magnetic resonance imaging (MRI) are increasingly used for forensic purposes. Based on broad experience in clinical neuroimaging, post-mortem MSCT and MRI were performed in 57 forensic cases with the goal to evaluate the radiological methods concerning their usability for forensic head and brain examination. An experienced clinical radiologist evaluated the imaging data. The results were compared to the autopsy findings that served as the gold standard with regard to common forensic neurotrauma findings such as skull fractures, soft tissue lesions of the scalp, various forms of intracranial hemorrhage or signs of increased brain pressure. The sensitivity of the imaging methods ranged from 100% (e.g., heat-induced alterations, intracranial gas) to zero (e.g., mediobasal impression marks as a sign of increased brain pressure, plaques jaunes). The agreement between MRI and CT was 69%. The radiological methods prevalently failed in the detection of lesions smaller than 3mm of size, whereas they were generally satisfactory concerning the evaluation of intracranial hemorrhage. Due to its advanced 2D and 3D post-processing possibilities, CT in particular possessed certain advantages in comparison with autopsy with regard to forensic reconstruction. MRI showed forensically relevant findings not seen during autopsy in several cases. The partly limited sensitivity of imaging that was observed in this retrospective study was based on several factors: besides general technical limitations it became apparent that clinical radiologists require a sound basic forensic background in order to detect specific signs. Focused teaching sessions will be essential to improve the outcome in future examinations. On the other hand, the autopsy protocols should be further standardized to allow an exact comparison of imaging and autopsy data. In consideration of these facts, MRI and CT have the power to play an important role in future forensic neuropathological examination.     

An Incidental Diffuse Midline Glioma Found at Autopsy

This case shows an unexpected midline glioma found at autopsy. Two siblings were riding on a single bicycle on the side of a road. The 13‐year‐old brother was seated and steering the bicycle, while the 14‐year‐old sister held onto the back. The bicycle veered left into traffic and was struck by a vehicle. The siblings were admitted to the local Level 1 trauma center, but both later succumbed to injuries. Autopsies were performed on the children, including brains for neuropathologic evaluation. The brother was found to have an infiltrating astrocytoma located in the left middle cerebellar peduncle, with extension to the pons and medulla. His hospital course included several imaging studies using CT and MRI modalities. However, this lesion was not identified until the postmortem neuropathologic examination. This rare case shows the continued need for postmortem autopsy and the current limitations of medical imaging.     

Spectrophotometric and tristimulus analysis of the colors of subcutaneous bleeding in living persons

Skeletal injuries are often strong indicators of child abuse and their detection is therefore crucial. The aim of this study was to compare the sensitivity of three diagnostic approaches, namely autopsy, traditional (conventional) radiology, and computed tomography on "battered" piglets, in order to verify the sensitivity of each method, with respect to the true number of bone fractures assessed once the piglet was skeletonised (osteological control). Four newborn cadaver piglets who had died from natural causes were severely beaten post-mortem in every district of the body. Traditional radiography, computed tomography (CT) and autopsy were performed. The piglet was then macerated until skeletonised and the number of all fractures present recorded (osteological control). On the cranium, traditional radiology revealed only 35% circa of actual fractures, autopsy detected only 31% (P<0.01 for both comparisons versus osteological control), whereas CT imaging detected all fractures actually present. For ribs, radiology detected only 47% of all fractures present, and autopsy 65% circa (P>0.05 for both comparisons versus osteological control), while CT scans detected 34% (P<0.01). In suspected cases of fatal child abuse, we suggest that the bones of specific districts be directly analysed either at autopsy or by collecting specific diagnostic sites, such as parts of the rib cage, and subjecting them to maceration. The removed areas could be replaced with artificial material for cosmetic purposes. The authors stress the importance of combined radiological, CT scan, autopsy and osteological survey in the detection of perimortem bone fractures.     

Childhood panhypopituitarism presenting as child abuse: a case report and review of the literature

Childhood panhypopituitarism may be acquired or congenital. Children with panhypopituitarism can present clinically with diabetes, growth failure, decreased bone density, and morbid obesity. In the forensic setting without the proper history, it can be misdiagnosed as child abuse or neglect. We report a case of a 3-year-old black girl who was admitted to the emergency room with apnea and subsequently died. While at the emergency department, it was discovered that the child had a fractured left hip and was severely growth retarded for age. The coroner wanted to rule out child abuse and/or neglect and requested an autopsy based on the physical findings identified by hospital staff. Significant findings at autopsy included small for age (15th percentile for age), hypoplastic brain/pituitary gland/adrenal gland/thyroid gland, abnormally formed skull with an occipital protuberance, a fractured left hip with decreased bone density, and central adiposity. Subsequent to the autopsy, it was discovered that at 6 weeks of age the child suffered from group B streptococci meningitis that resulted in panhypopituitarism. The panhypopituitarism then resulted in seizure activity, diabetes insipidus, and growth retardation. The authors hope this case report and review of the literature will assist investigators, pathologists, and clinicians in making a distinction between neglect or inflicted injury of child abuse and panhypopituitarism that can present with similar signs and symptoms.     

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.     

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.     

Virtopsy: postmortem imaging of the human heart in situ using MSCT and MRI

The rapid further development of computed tomography (CT) and magnetic resonance imaging (MRI) induced the idea to use these techniques for postmortem documentation of forensic findings. Until now, only a few institutes of forensic medicine have acquired experience in postmortem cross-sectional imaging. Protocols, image interpretation and visualization have to be adapted to the postmortem conditions. Especially, postmortem alterations, such as putrefaction and livores, different temperature of the corpse and the loss of the circulation are a challenge for the imaging process and interpretation. Advantages of postmortem imaging are the higher exposure and resolution available in CT when there is no concern for biologic effects of ionizing radiation, and the lack of cardiac motion artifacts during scanning. CT and MRI may become useful tools for postmortem documentation in forensic medicine. In Bern, 80 human corpses underwent postmortem imaging by CT and MRI prior to traditional autopsy until the month of August 2003. Here, we describe the imaging appearance of postmortem alterations--internal livores, putrefaction, postmortem clotting--and distinguish them from the forensic findings of the heart, such as calcification, endocarditis, myocardial infarction, myocardial scarring, injury and other morphological alterations.     

Undiagnosed, untreated acute lymphoblastic leukemia presenting as suspected child abuse

Natural disease being mistaken for child abuse is rare. A two-year-old child was found unresponsive at home and transported to a local hospital, where she expired in the emergency room. Several cutaneous contusions were observed. Prior to the autopsy it was learned that an anonymous report of "child abuse" had been previously filed concerning this child. At autopsy there were multiple metasynchronous cutaneous contusions, but no radiologic or gross evidence of other injuries. A pericardial effusion, massive hepatosplenomegaly and generalized lymphadenopathy were apparent. The bone marrow, liver, spleen, lymph nodes, kidneys, pancreas, heart, stomach, and dura mater showed a monotonous lymphocytic infiltrate. Immunocytochemical studies confirmed the diagnosis of acute lymphoblastic leukemia of childhood. This case reaffirms the need for an objective examination of all cases by a forensic pathologist.     

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.     

Spontaneous intracerebral hemorrhage related to methamphetamine abuse: autopsy findings and clinical correlation

A healthy 31-year-old male abstinent from drug abuse during his recent incarceration developed slurred speech, a severe headache, and left-sided hemiparesis prior to his eventual death 9.5 hours after inhalation of methamphetamine. On postmortem examination, inspection of the brain revealed bilateral subarachnoid hemorrhage, with a prominent intralobar hemorrhage centered within the right frontal cerebral hemisphere. No evidence of vasculitis, infarction, intraventricular hemorrhage, or ruptured aneurysm could be observed. While this is not the first report of a methamphetamine-related stroke, this report describes the autopsy findings of an intracerebral hemorrhage secondary to methamphetamine abuse on autopsy and compares the findings and antemortem history to previously reported methamphetamine cerebral vascular deaths.     

Brain amino acid abnormalities in kidney disease and diabetes mellitus

The present postmortem study examines whether specific amino acid abnormalities associated with renal diseases or diabetes mellitus in animal experiments and on clinical examination may also be found in human brain samples obtained at clinical autopsies. The material includes 12 deceased with renal insufficiency, 23 deceased with diabetes mellitus and 26 control cases with lethal cardiovascular diseases (without a history of hepatic, renal or metabolic disturbances). The autopsy and clinical records were retrospectively analyzed for age, sex, postmortem delay, cause of death, substantial preexisting diseases and histological findings. The analysis of free amino acid concentrations in human brain specimens was performed applying a Beckman amino acid analyzer. The results were evaluated using the U-test according to Mann, Willcox and Whitney. A P-value less than 0.05 was considered to be significantly different. Differences of amino acid concentrations attributable to sex, age and postmortem delay were not significant. The comparison of postmortem amino acid concentrations in the brains of patients with diabetes mellitus and controls did not reveal relevant changes. However, the patients with renal diseases, as compared to controls, showed a significant cerebral increase of urea, phenylethanolamine and gamma-aminobutyric acid. Thus, the postmortem amino acid analysis may contribute to the understanding of pathophysiological mechanisms of uremic encephalopathy and may supplement the conventional postmortem morphological diagnosis in kidney diseases by indication of functional impairment.     

Postmortem diagnostics using MSCT and MRI of a lethal streptococcus group A infection at infancy: a case report

Postmortem cross-sectional imaging using multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) was considered as a base for a minimal invasive postmortem investigation in forensic medicine such as within the Virtopsy approach. We present the case of a 3-year-old girl with a lethal streptococcus group A infection and the findings of postmortem imaging in this kind of natural death. Postmortem MSCT and MRI revealed an edematous occlusion of the larynx at the level of the vocal cords, severe pneumonia with atelectatic parts of both upper lobes and complete atelectasis of both lower lobes, purulent fluid-filled right main bronchus, enlargement of cervical lymph nodes and pharyngeal tonsils, and additionally, a remaining glossopharyngeal cyst as well as an ureter fissus of the right kidney. All relevant autopsy findings could be obtained and visualized by postmortem imaging and confirmed by histological and microbiological investigations supporting the idea of a minimal invasive autopsy technique.