死后尸体CT在法医学鉴定中的应用价值初探

目的 对不同类型案件中的死者进行死后尸体CT扫描和常规尸体解剖,探索PMCT在法医学鉴定中的应用价值.方法 对7例因不同原因死亡的个体进行全身PMCT扫描,随后进行系统的尸体解剖,通过比较两种方法检测的结果,分析PMCT与传统尸体解剖在不同类型案件中应用的优点和不足.结果 在7个案例中,尸体上总共检出67处阳性发现.其...     

Non-traumatic postmortem computed tomographic (PMCT) findings of the lung

PURPOSE: We attempted to obtain postmortem computed tomographic (PMCT) images of the lung in cases of non-traumatic death and describe the results to distinguish usual postmortem findings from those of specific thoracic causes of death. MATERIALS AND METHODS: Our subjects were a total of 150 consecutive non-traumatic cases with cardiopulmonary arrest on arrival who were examined by CT within 2h after certification of death between January 1993 and December 2001. PMCT images of the lung and the frequency of imaging findings (dependent density, ground glass attenuation (GGA), consolidation, pleural effusion, and endotracheal (or endobronchial) air defect) were retrospectively reviewed. Autopsy had been conducted in 16 of the cases. RESULTS: The causes of death and frequency percentages of dependent density, GGA, consolidation, pleural effusion, and endotracheal (or endobronchial) air defect were: 91 cases of acute heart failure (AHF) (69, 66, 24, 11, 14%), 23 cases of aortic dissection (57, 39, 4, 52, 0%), 11 cases of pneumonia (18, 82, 100, 45, 27%), 23 other specified cases (52, 30, 13, 17, 9%), and two unspecified cases (0, 0, 0, 50, 0%), [total respective frequency percentages were (60, 57, 25, 21, 12%)]. Autopsy confirmed that GGA on PMCT in AHF cases corresponded to pulmonary edema. CONCLUSION: When PMCT of the lung shows no other shadows than dependent density, further analysis is necessary to detect the cause of death.     

Postmortem Computed Tomography in Firearm Homicides: A Retrospective Case Series,

Postmortem computed tomography (PMCT) is integrated into the evaluation of decedents in several American medical examiner offices and medicolegal death investigative centers in many other countries. We retrospectively investigated the value of PMCT in a series of firearm homicide cases from a statewide centralized medical examiner’s office that occurred during 2016. Autopsies were performed or supervised by board-certified forensic pathologists who reviewed the PMCT scans prior to autopsy. PMCT scans were re-evaluated by a forensic radiologist blinded to the autopsy findings and scored by body region (head–neck, thoracoabdominal, and extremities). Injury discrepancies were scored using a modified Goldman classification and analyzed with McNemar’s test. We included 60 males and 20 females (median age 31 years, range 3–73). Based on PMCT, 56 (79.1%) cases had injuries relevant to the cause of death in a single body region (24 head–neck region, 32 thoracoabdominal region). Out of these 56 cases, 9 had a missed major diagnosis by PMCT outside that region, including 6 extremity injuries visible during standard external examination. Yet all had evident lethal firearm injury. We showed that PMCT identifies major firearm injuries in homicide victims and excludes injuries related to the cause of death in other regions when a single body region is injured. Although PMCT has a known limited sensitivity for soft tissue and vascular pathology, it can be combined with external examination to potentially reduce or focus dissections in some of these cases depending on the circumstances and medicolegal needs.     

Abdominal Stab Wounds with Tension Pneumopericardium Confirmed by Autopsy and Postmortem Computed Tomography

We present the first report of pneumopericardium observed by autopsy and on postmortem computed tomography (PMCT) images. The subject was a woman who died of self‐inflicted stab wounds to the abdomen. The PMCT scan revealed air in the pericardial sac, a “flattened heart” sign, and retroperitoneal hemorrhage. Medicolegal autopsy revealed two abdominal stab wounds near the xiphoid process that had cut the apical pericardium and adjacent diaphragm and liver. Examination of the open thorax confirmed that the pericardial sac was distended with air. The wound extended to the abdominal aorta, causing retroperitoneal hemorrhage. PMCT images showed that the pneumopericardial volume was 133 mL. We believe that cardiac tamponade occurred resulting from the tension pneumopericardium; however, the effects were mitigated by hypovolemia secondary to the retroperitoneal hemorrhage as well as obstructive shock. Therefore, the cause of death appears to have been low‐pressure cardiac tamponade.     

Technical and interpretive pitfalls of postmortem CT: Five examples of errors revealed by autopsy

Image acquisition of dead bodies, particularly using postmortem computed tomography (PMCT), has become common in forensic investigations worldwide. Meanwhile, in countries such as Japan which have an extremely low rate of autopsy, PMCT is being increasingly used in the clinical field to certify the cause of death (COD) without performing an autopsy or toxicological tests, even in cases of unnatural death. Additionally, these PMCT images are predominantly interpreted by clinical personnel such as emergency physicians or clinicians who are not trained in PMCT interpretation and who work for the police, that is, the so-called police doctors. Many potential pitfalls associated with the use of PMCT have been previously described in textbooks and published papers, including the pitfalls of not performing a complete forensic pathology investigation, and the use of physicians without appropriate PMCT training to interpret PMCT and direct death investigation and certification. We describe five examples in which apparent misdiagnosis of COD based on PMCT misinterpretation was revealed by autopsy. Here are the five examples of errors: (1) Postmortem changes were misinterpreted as COD, (2) resuscitation effects were misinterpreted as COD, (3) COD was determined after an incomplete examination, (4) fatal findings caused by external origin were wrongly interpreted as ‘of internal origin’ based on PMCT, and (5) non-fatal findings on PMCT were wrongly interpreted as fatal. Interpretation of PMCT by appropriately trained physicians and an accompanying complete forensic investigation, including autopsy when indicated, is necessary to prevent significant errors in COD determination and related potential adverse medicolegal consequences.     

Pregnancy-associated deaths: a 15-year retrospective study and overall review of maternal pathophysiology

Pregnancy-related death is defined by the International Classification of Diseases, Tenth Revision (ICD-10) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In the year 2000, a collaborative effort involving World Health Organization (WHO), UNICEF, and UNFPA estimated 660 maternal deaths in the United States. This averages 11 maternal deaths per 100,000 live births reported. Many pregnancy-associated deaths are not easily identified as such since the presence of a recent or current pregnancy may not be listed on the death certificate. Thus, the WHO estimates that in the United States, the maternal mortality is approximately 17/100,000 pregnancies. This is significantly higher than the goal set by the US Department of Health and Human Services in Healthy People 2010, which sets the target for maternal mortality at less than 3.3/100,000 live births. The most common causes of maternal death vary somewhat from region to region in the United States. They include pulmonary thromboembolism, amniotic fluid embolism, primary postpartum uterine hemorrhage, infection, and complications of hypertension including preeclampsia and eclampsia. Pulmonary disease, complications of anesthesia, and cardiomyopathy also are significant contributors to maternal mortality in some populations. The death of a pregnant or recently pregnant individual poses a wide scope of challenges to the forensic pathologist and investigator. The pathologist must have a broad knowledge of the physiologic and biochemical changes that occur during pregnancy, as well as the clinical and pathological manifestation of these changes. Conditions that may be "benign" in the nonpregnant individual may be lethal in the puerperal period. In addition, it should be kept in mind that deaths during pregnancy may be due to unnatural causes. Accident, homicide, and suicide must be ruled out in each case. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina from January 1989 through December 2003. All decedents listed as pregnant or postpartum were analyzed as to maternal age, race, past medical history, previous pregnancies and outcome, prenatal care, gestational age, fetal or neonatal outcome, location of delivery, placental findings, maternal autopsy findings, toxicology, cause of death, manner of death, and fetal or neonatal autopsy findings. The authors present this retrospective study to better determine the factors leading to maternal demise and discuss the autopsy/ancillary techniques useful in determining the cause of death in this challenging area.     

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.     

Death during immersion in water in childhood.

Drowning is a relatively common cause of accidental death in children. Autopsy records at the Adelaide Children's Hospital over a 27-year period from 1964 to 1990 were examined, and 58 cases were found where the cause of death was listed as drowning. In six cases, however, careful examination of the history and postmortem findings provided important additional information that suggested a more complex antemortem sequence of events. Specifically, four patients aged between 6 years, 10 months and 11 years were known to have had epilepsy. A further patient, an 8-year-old boy, died from a subarachnoid hemorrhage due to a bleeding cerebral arteriovenous malformation while swimming. The final patient, an 11-year-old boy who collapsed in a public swimming pool, was found at autopsy to have marked hypoplasia of the right coronary artery. In this series, six of 58 (10.3%) of the pediatric cases had additional underlying medical problems that could either have initiated the drowning episode or caused death due to alternate mechanisms. We present the clinicopathological findings in detail to demonstrate that a high index of suspicion must be maintained in all cases of pediatric drowning, not only for unnatural causes of death but also for additional natural disease processes that may have contributed significantly to the fatal episode. These findings may have particular relevance in jurisdictions where full postmortem examination is not always required by law.     

Postbariatric surgery deaths, which fall under the jurisdiction of the coroner

Obesity has attained epidemic proportions in the United States, with more than 50% of adults classified as overweight or obese. If untreated, morbidly obese patients have a 1 in 7 chance of reaching normal life expectancy. The surgical treatment of obesity has emerged as the most effective treatment modality in long-term weight control and has become increasingly popular, with attendant postoperative complications and death. We performed a cross-sectional, coroner based, 2-year retrospective review of archival case records for decedents who died following bariatric surgery for the treatment of obesity to identify underlying causes of death and forensic characteristics of this cohort. Fifteen (0.5%) out of 3097 archival cases died following bariatric surgery, with approximately 73% of decedents dying within 6 months of surgery. The underlying causes of death in 80% of decedents were natural comorbidities of obesity, with cardiovascular diseases (33%) being the most frequent causes of death, followed by gastrointestinal diseases (20%), acute pulmonary thromboembolism (13%), and acute bacterial pneumonia (13%). The majority of decedents were white females who remained morbidly obese after bariatric surgery. Only 2 decedents died of direct inadvertent/accidental surgical complications.     

Acute deaths in nonpregnant adults due to invasive streptococcal infections

Streptococcal organisms, part of the normal human bacterial flora, occasionally become infectious pathogens responsible for a wide array of clinical syndromes, ranging from mild pharyngitis to death. Notably, infections due to group A and group B beta-hemolytic strains are well known for causing invasive disease leading to death. These deaths, while often suspected clinically, occasionally are not diagnosed until autopsy. We present 3 rapid deaths, with very different presentations, due to streptococcal infection. Two decedents experienced sudden deaths due to pneumonia and severe meningoencephalitis caused by group B beta-hemolytic streptococcal infection, a common cause of neonatal meningitis but only rarely reported in nonpregnant adults. The final case involves a 69-year-old male who presented to the emergency room with a complaint of shoulder pain but over the next several hours developed signs of necrotizing fasciitis, became septic, and died. While antemortem cultures were negative, owing to antibiotic administration, postmortem cultures of bone and deep soft tissue were positive for group A beta-hemolytic Streptococcus sp. Acute and sudden deaths due to infectious etiology represent an uncommon yet well-documented occurrence. The importance of appropriate postmortem cultures in these situations and a review of the literature will be discussed.     

Sudden death in mitral valve prolapse: Associated accessory atrioventricular pathways

Sudden death in patients with mitral valve prolapse is a rare complication with a possible arrhythmic mechanism. We made a detailed postmortem examination of the conduction system in three patients with MVP who died suddenly. One patient who died in cardiac failure had a normal conduction system. The two other patients with no cardiac symptoms prior to death had both accessory atrioventricular pathways.These findings suggest a higher incidence than hitherto known of accessory bypass tracts in patients with MVP who die suddenly, and support the presumption of an arrhythmic cause of death.     

Histologic findings in the lung in sudden infant death

The lungs of 79 children who had died between the ages of 1 week and 2 years old were histologically examined. 59 of these children could be categorized as cases of Sudden Infant Death because of the history and postmortem findings. In the remaining 20 cases a definite cause of death could be established. This is the same collective on which the histological investigations of the lymphatic tissue has been carried out. Morphological changes which are typical for a virus pneumonia were found in a substantially higher frequency in the cases of Sudden Infant Death than in the control cases. The validity of these findings and their possible significance for the cause of death are discussed.     

Sudden Cardiac Deaths in Adults with Congenital Heart Disease with Structural Abnormalities: A Retrospective Review of Cases in the Cook County Medical Examiner's Office

Sudden cardiac death is a significant cause of mortality in adults with congenital heart disease (CHD). The Cook County Medical Examiner's Office database was queried for cases of CHD as a cause of death in the period between July 2008 and April 2019. Twenty-two cases were identified, including 11 decedents with simple defects and 10 decedents with complex defects. All of the subjects were in apparent good health at the time of death. In the absence of other obvious causes of death, simple defects were considered cases of sudden cardiac death. Significant cardiac morphological changes were common in complex defects. While 16 cases had known, diagnosed/treated CHD, 5 cases had no diagnosis prior to autopsy. In these cases, the ability to recognize CHD (sometimes subtle) helped in determining the causes of death. Therefore, forensic pathologists must be able to properly recognize various forms of CHD and request consultations, when needed.     

Fatal Candida tropicalis infection in an 8-month-old infant with an aplasia of the thymus as a rare cause of death in infancy

Anomalies of the thymus can lead to immunodeficiencies that are often associated with complex syndromes. The clinical relevance of those anomalies varies a lot. Regarding mortality and morbidity, opportunistic infections play a major role in immunocompromised individuals. Case report: An 8-month-old infant died of a sepsis with multi-organ failure after 32 days in intensive care. At autopsy, no thymus gland could be found; toxicological examinations yielded high morphine concentrations. Autopsy findings and the results of further examinations performed postmortem are discussed in view of the clinical findings, the classification and the cause of death.     

Fatal Spontaneous Retropharyngeal Hematoma with Airway Obstruction in the Setting of Treatment with Dipyridamole

We report a fatal case of airway obstruction caused by spontaneous retropharyngeal hematoma (RH) in the setting of treatment with dipyridamole. A 90-year-old woman presented with cervical swelling, neck and chest ecchymoses, and complaints of dyspnea. She suffered cardiopulmonary arrest in the ambulance, and her death was confirmed after transportation to the hospital. The major finding of postmortem computed tomography (PMCT) prior to autopsy was widening of the prevertebral soft tissue. The results of the autopsy indicated that the cause of death was mechanical asphyxia, secondary to pharyngeal and laryngeal compression caused by the RH. There were no evident injuries, medical interventions, or particular diseases, suggesting the spontaneous cause of the RH. To the best of our knowledge, this is the first report of a fatal case secondary to spontaneous RH that was revealed through PMCT imaging.     

The predictive value of history and scene investigation for toxicology results in a medical examiner population

Medical examiner offices vary in the extent to which they pursue postmortem toxicology. Our office routinely tests decedents for ethanol and drugs of abuse, and we decided to evaluate the usefulness of our practice. We reviewed 1180 medical examiner cases examined in 2002-2003. History and scene investigation indicated that alcohol or drugs of abuse were likely to be detected in 369 cases, yet toxicology testing revealed an intoxicating substance in 589 cases, a prevalence of 50%. Screening for toxicology testing based on investigative findings had a sensitivity of 0.47, a specificity of 0.84, and a positive predictive value of 0.74. Moreover, even in the 811 cases where initial investigation did not suggest substance abuse, toxicology testing revealed at least 1 substance that was pertinent to the subsequent investigation in one third of the cases (260), and the intoxicating substance was sufficiently important to merit inclusion as a cause of death or contributing factor in nearly half of those cases (113). We conclude that investigation alone is ineffective at predicting the presence of intoxicating substances within decedents.     

Endothelial cell membrane perforation of aorta and pulmonary artery in the electrocution victims

Some electrocution deaths occur without detectable current marks on the skin, making forensic examination to determine the true cause of death more difficult. Because arterial thrombosis was a frequent finding in victims of electrocution, we investigated injury to the endothelium of the aorta and pulmonary artery with a scanning electron microscope in five cases of death known to be caused by electrocution. We found large pores on the surface of endothelial cells of the aorta and pulmonary artery in those who died of electrocution, but no endothelial membrane perforation was found in those who died of cardiac diseases. These findings were present within 12h after death. Therefore, scanning electron microscopic evidence of endothelial perforation in the aorta and pulmonary artery could be a useful marker to identify electrocution for those victims without detectable current marks on the skin.     

Skeletal identification using the frontal sinus region: a retrospective study of 39 cases

The importance of identification using the frontal sinus has been previously demonstrated in case reports. In this study, 39 cases of identification using frontal sinus comparison from the Ontario Chief Coroner's Office were reviewed and differences between antemortem and postmortem radiographs examined. All cases involved decedents older than twenty years. Three cases were rejected due to poor antemortem and postmortem film quality. One subject had no frontal sinus. Thirty-five cases provided conclusive postmortem to antemortem pattern matches. Sixteen cases also yielded metric (quantitative) matches. Duration between antemortem and postmortem radiographic examinations, age, gender, and cause of death did not affect the ability to obtain a match. This is the largest study undertaken on actual cases and demonstrates the validity of frontal sinus pattern matching for forensic identification.     

Postmortem revelation of sickle cell disease following fatal episode of acute bronchial asthma

A 19-year-old black male with previous history of mild bronchial asthma presented sudden dyspnea and died in a state of respiratory distress in spite of resuscitation attempts. Autopsy showed typical lesions of acute bronchial asthma in a context of long-standing asthma associated with a massive and disseminated intravascular sickling. Hemoglobin electrophoresis diagnosed heterozygous sickle cell disease. This rare case raises the problem of the accuracy of death certificate, especially the difficulties to distinguish postmortem lesions as the underlying cause of death or the contributory cause of death.