Review article

Forensic radiology: The role of cross-sectional imaging in virtual

post-mortem examinations
Joshua Higginbotham-Jones
a,
*
, Anthony Ward
b
a
Burton Hospitals NHS Foundation Trust, Staffordshire, United Kingdom
b
The University of Liverpool, School of Health Sciences, Johnston Building, Liverpool L69 3GB, United Kingdom
a r t i c l e i n f o
Article history:
Received 9 July 2013
Received in revised form
17 September 2013
Accepted 7 October 2013
Available online 1 November 2013
Keywords:
Multi slice computed tomography
Magnetic resonance imaging
a b s t r a c t
Aim: The aim of this review is to assess the benets and limitations of using Multi Slice Computed
Tomography and Magnetic Resonance as non-invasive post-mortem imaging methods.
Method: The author utilised SciVerse (Science Direct), Scopus, PubMed and Discover to search for
relevant articles. The following search terms were used: virtopsy, minimally invasive post-mortem im-
aging, autopsy, Multi Slice Computed Tomography, Magnetic Resonance. Articles which discussed the use
of non-invasive imaging techniques for post-mortem examinations were included in the review. Any
articles published before 2003 were excluded with a few exceptions.
Findings: The decline in use of the conventional post-mortem method has led to the need for an alter-
native method of investigation which increases both sensitivity and specicity, and also is more
acceptable to the family of the deceased.
Discussion/conclusion: There are numerous factors affecting the usability of these non-invasive post-
mortem options including cost and availability. With the price of non-invasive post-mortem examina-
tions often rising above 1000, it is considered to be less economically viable than the conventional
method. Therefore, further research into this method and its implementation in hospitals has been
delayed.
2013 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Introduction
Forensic Medicine can be described as the application of medical
knowledge to law. Radiology is widely used in forensic medicine to
visualise and document ndings, in the living as well as the
deceased. Although radiology alone cannot provide certain infor-
mation such as tumour types and other subtle pathological pro-
cesses, radiographical techniques have a rmly established position
in aiding forensic investigations.
1
General radiography has a number of different applications
throughout the forensic medical eld as it is an integral part of the
actions that occur during associated enquiries and legal in-
vestigations. These include investigating paediatric non-accidental
injuries, corpse identication and the cause of death, both singular
and in mass fatality disasters.
2
Imaging may also be used in esti-
mating age, detecting foreign bodies and visualising difcult areas
to reach during a conventional post-mortem, such as the upper
neck which is shrouded in soft tissue and bony anatomy.
3
This review will focus primarily on the roles of cross-sectional
imaging. The rationale for this is that there has been an increase
in demand for a more non-invasive post-mortemtechnique.
4
In the
literature it has been suggested that there is some discrepancy in
the results found when using cross-sectional imaging for post-
mortem investigations when compared to conventional post-
mortem techniques.
The burgeoning use of Multi Slice Computed Tomography
(MSCT) and Magnetic Resonance Imaging (MRI), when imaging
corpses forensically, has given rise to the term Virtopsy. The re-
sults of these virtopsies have proved somewhat speculative in that
they have helped bring to light certain ndings which the con-
ventional post-mortem has failed to identify.
5,6
This review will
consider the indications, benets, sensitivity, specicity and eco-
nomic viability of this method of post-mortem examination.
Method
The authors utilised SciVerse (Science Direct), Scopus, PubMed
and Discover to search for relevant articles. The following search
terms were used: virtopsy, minimally invasive post-mortem im-
aging, autopsy, Multi Slice Computed Tomography, Magnetic
* Corresponding author. Tel.: 44 7534729258.
E-mail addresses: joshhiggyjones@aol.com, joshua75@hotmail.co.uk
(J. Higginbotham-Jones).
Contents lists available at ScienceDirect
Radiography
j ournal homepage: www. el sevi er. com/ l ocat e/ radi
1078-8174/$ e see front matter 2013 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.radi.2013.10.003
Radiography 20 (2014) 87e90
Resonance Imaging. A range of articles which discussed both the
benets and limitations as well as the ethical and legal impact of
non-invasive post-mortem methods were included. Any articles
published before 2003 were excluded with a few exceptions leav-
ing a total of 29 papers meeting the inclusion criteria for this
literature review.
Literature review
Rationale for cross-sectional imaging in post-mortem examinations
The reasons for implementing imaging techniques such as
MSCT and MRI in post-mortem settings become more apparent
when the advantages of such are brought to light. It is felt that
cross-sectional imaging may become an option where consent for
a conventional post-mortem is withheld by the relatives or next of
kin of the deceased.
7
While there is no absolute prohibition of
post-mortems in any of the major religions, within some Jewish
and Islamic teachings a conventional post-mortem is seen as a
violation of human dignity and may hold serious spiritual impli-
cations.
8
Other benets are also apparent and these include a
decreased risk of transmission of diseases such as hepatitis and
CreutzfeldteJakob disease (CJD)
9
and the improved aesthetic
appearance of the corpse for the benet of the family and loved
ones.
7
Aside from the ethical rationale behind the use of virtual post-
mortem techniques, there are also some considerable scientic
arguments for the use of this method. The three dimensional (3D)
reconstruction available with this form of imaging provides
remarkable investigatory potential. An application of this is in road
trafc accidents, where 3D post-mortem reconstructions of a
corpse can be compared to the corresponding structures within the
vehicle helping to map out the course of events that unfolded
which may have led to the victims death. Another major advantage
of this method, which conventional documentation lacks, is that it
allows for the reconstructions of the corpse to be re-investigated
years later, and without the demolishing nature of decomposi-
tion. 3D reconstructions are also extremely useful when demon-
strating medical technicalities to a court of law as they are more
easily interpreted by the lay person.
10
The application of MSCT in post-mortem examinations
The use of MSCT in virtual post-mortem reconstruction is a
valuable tool to augment conventional methods when used to
forensically investigate a body as it aids in providing supple-
mentary information when traditional techniques are used. It can
also be split into a number of different categories in which it is
advantageous. This form of imaging within forensic radiology is
excellent at detecting and demonstrating fractures or other bony
pathology, foreign bodies and the presence of gas or air embo-
lism.
11
It has been suggested that this approach is as good as or
even better than post-mortem at detecting bone fracture and gas
(sensitivity of 100%).
12
A widely reviewed topic in the sub-category of foreign bodies is
the use of MSCT in investigating gunshot victims. This modality is
utilised to investigate many different aspects of the victims injuries
in order to evaluate a cause of death. These include the number and
location of entrance and exit wounds, the detection of bullets and
bullet fragments, the bullet tracks, associated injuries and nally,
the cause of death.
13
Although MSCT is less sensitive to soft tissue than MRI, it is
possible to acquire images demonstrating bullet tracks through soft
tissue structures. Gunshot tracks through the cerebrum, neck and
visceral abdomen can be demonstrated on the 2D cross-sections as
linear areas of gas and metallic fragments along the path of the
bullet.
14
This is also evident in pulmonary gunshot trauma as the
vascular mediastinal and luminal structures are highly vulnerable
to trauma.
15
Damage to these structures, identied by cross-
sectional imaging, can therefore convey information regarding
the direction of the bullet track and so inuence the cause of death
stated.
Post-mortem CT (PMCT) also has signicant advantages for
detecting gas accumulations. Whether traumatic or putrefactive
gas, the implementation of PMCT helps determine its origin, the
importance of which can ultimately decipher a cause of death.
For example, gas accumulation has a strong association with
traumatic events as they introduce internal anatomy to the at-
mospheric air, and so any gas accumulation evident would have
to be accounted for in the post-mortem investigation.
16
MSCT
would therefore play a role in detecting this gas within the body
and an experienced forensic pathologist or radiologist would be
able to interpret the acquired images in order to gauge whether
the gas is putrefactive or as a result of a traumatic event leading
to the persons death.
Contrary to the convincing results MSCT has to offer when
investigating bony injuries and bullet trauma, there are major dif-
culties when there is the need for vascular demonstration.
5
After
death, soft tissue anatomy changes dramatically in shape due to the
lack of blood pressure and also certain blood elements sediment
out.
17
So in order to adequately demonstrate vasculature in the
deceased using MSCT there are techniques involving the use of
contrast material, such as a radio-opaque barium sulphate sus-
pension liquid, that can be injected into a vascular site shortly prior
to imaging. Studies have demonstrated that minimally invasive
post-mortemangiography can be performed via access through the
iliac arteries where a catheter is inserted which can be manoeuvred
up the abdominal aorta to the aortic arch.
18
Conventional injection
of the contrast medium at this point under a certain pressure can
then be used to demonstrate the cerebral vascular system, the
coronary arteries and the peripheral vascular system of both the
upper and lower limbs.
19
With the help of MSCT post-mortem examinations can be much
less invasive, with the exception of minimal vascular incisions, and
the images acquired can lead to more accurate and specic results
than conventional examinations which can consequently provide
A MSCT 3D bone reconstruction who suffered multiple stab wounds to the left side of
her chest (arrows). This image shows the effect of the knife on the ribs and can be used
to demonstrate the injuries sustained for instance of court.
10
J. Higginbotham-Jones, A. Ward / Radiography 20 (2014) 87e90 88
useful visualisation for court trial.
5
Furthermore, the digital nature
of this method of post-mortem not only allows for the archive of
the images but also gives the ndings chance to appear at a later
date should the need for it arise.
10
The application of MRI in post-mortem examinations
Due to the rapid development of MRI over recent decades the
domain of this modality within radiology has extended from the
brain, chest and abdomen to the heart and articular regions of the
body. However, contrary to the rapid development of clinical MRI,
the application of this method of imaging in forensic radiology has
trailed far behind its technical developments.
6
The sensitivity of post-mortem MRI is much the same as in-
vestigations in the clinical setting. In demonstrating soft tissue
injury, organ trauma and other pathology, MRI has a high sensi-
tivity and accuracy.
5
However the specicity can often be deemed
as relatively low for such an advanced form of imaging, leading to
the need for biopsy to provide the diagnosis in many types of
neoplasms.
20
The literature suggests that there is also a signicant use of this
modality for neurological imaging and foetal (perinatal and
neonatal) imaging in post-mortem examinations. Although the
specicity of this modality is questioned, in the second trimester
foetus, most abnormalities are developmental and often manifest
themselves in a macroscopic nature. However, the third trimester
and stillborn child, in some cases, present more complicated issues
because of a higher prevalence of acquired diseases which are, for
example, haemorrhagic, ischaemic or hypoxic in nature.
20
Unfor-
tunately there is a paucity of large scale comparative studies on the
accuracy of conventional post-mortem examinations when
compared to MRI. However, a systematic review of small scale
studies on the accuracy of MRI in detecting the cause of foetal death
reported a sensitivity of 69% and a specicity of 95%.
21
Given the
diagnostic potential and minimally invasive nature of this modality,
this post-mortem technique has been suggested as an alternative
for conventional post-mortems. This becomes increasingly signi-
cant in light of the decline in consented conventional post-mor-
tems especially in foetus and neonatal deaths.
22
Post-mortem MRI can provide high resolution, archival and re-
sliceable images of neurological specimens as opposed to perma-
nent, irreversible and invasive conventional sectioning. This, much
the same as CT imaging, dramatically reduces the risk of contrac-
tion of neurological diseases and improves the aesthetic appear-
ances of the corpses for the benet of the loved ones, with less of
the emotional stress attached to the conventional post-mortem
method.
23
Whitby et al. (2005)
24
examined the central nervous system
(CNS) of 37 in-utero and neonatal post-mortem specimens
facilitating MRI in this study. CNS abnormalities account for 20
per cent of congenital deformations and the CNS is one of the
more difcult areas to examine in the conventional setting as
parents are more inclined to refuse post-mortem examinations
once given full disclosure of what the examination entails. The
results of this study proved that in some cases, where the results
of the post-mortem MRI (PMMRI) were compared to conven-
tional post-mortems, PMMRI provided additional information
regarding cause of death.
The usability of MRI in investigating soft tissue traumatology is a
well-established subject and has been successfully adopted into
forensic investigations. It has been reported that MRI has a sensi-
tivity of 100% when detecting subcutaneous uid/haemorrhage and
a sensitivity of 89% when detecting intramuscular bleeding.
12
Given
its high sensitivity to soft tissue anatomy and its 3D rendering ca-
pabilities, accurate and precise images can be obtained and
displayed in such a fashion as to help the reporting radiologist in
reducing any limitations brought about prior to image viewing.
Other advantages of using certain digitally programmed techniques
include road-mapping and layering whereby certain tissue struc-
tures can be either included or excluded when the images are being
interpreted depending on which region of the body they are
investigating.
25
MRI has sufcient diagnostic accuracy to be used in conjunction
with conventional post-mortem methods, and has a high potential
to develop into a more commonly used method of the least invasive
virtual post-mortems. However, there are some limitations of using
MRI as a diagnostic tool on corpses, which in some cases reduces
the continuity of the results found when compared to the con-
ventional post-mortemndings. For example, while imaging of the
CNS is very accurate when using MRI, body imaging, especially of
the heart, proves to be potentially problematic due to the small
vascular coronary structures not being well visualised.
21
Another
limitation of using MRI as a post-mortem service is the cost effec-
tiveness. In comparison to the traditional post-mortem, the cost (in
Manchester, UK, 2012) of a post-mortem MRI scan can climb to a
considerable amount more than that of the traditional method.
Depending on the relative regions of the body being investigated
costs range between 995 and 1350 for a PMMRI scan. Compared
to the cost of a conventional post-mortem ranging between 177
and 342, PMMRI alone can prove to be quite costly.
26
Discussion
The comparison of PMCT and PMMRI results has been a widely
reviewed topic. It is evident that PMCT or PMMRI in conjunction
with conventional post-mortem examinations provides more in-
formation than either examination alone
3,5,25
leaving the topic of
whether cross-sectional post-mortem imaging will replace con-
ventional methods up for debate.
Reecting on the results of the many studies undertaken
involving these two minimally invasive post-mortem imaging
methods, there seems to be a realistic potential that they can be
utilised as a helpful adjunct to the conventional method. There is
little in the literature that suggests these virtual post-mortem re-
constructions have replaced the routine job of the forensic pa-
thologists; however there is overwhelming evidence available that
would suggest these methods of obtaining a cause of death could be
evermore utilised. The topic of replacing traditional post-mortem
methods with cross-sectional methods has already been discussed
within the National Health Service (NHS UK). Professor Guy Rutty
had made the recommendations in late October 2012. He outlined
the need for funded research to produce an evidence base to
expand the types of death amenable to the use of a non-invasive
post-mortem method. He also agrees that this method of exami-
nation is important for the benet of religious, cultural and hu-
manitarian groups as there may no longer be the need to undertake
invasive post mortems in certain types of death.
26
With the increasing use of cross-sectional imaging techniques in
post-mortem examinations comes the need to further educate and
train medical personnel in order to accommodate the needs of this
extremely difcult and specialised eld. The interpretation of cross-
sectional post-mortem images can vary, to some degree, to the
evaluation of clinical images as a result of chemical and morpho-
logical changes that affect the body after death.
17
Therefore, the
training of radiologists and radiographers in this eld would give
thema sound knowledge base for ndings that should be expected,
which are essential to the forensic expert.
27
Regarding the economic evaluation of PMCT and PMMRI in the
forensic setting, the cost of minimally invasive post-mortem ex-
aminations varies from around 950 to over 1000 in 2009, which
J. Higginbotham-Jones, A. Ward / Radiography 20 (2014) 87e90 89
in some countries is not too dissimilar to the cost of a conventional
post-mortem.
21,25
However, when using the more time and energy
consuming virtual MRI technique more extensively, the cost can
rise to well above 1000.
28
Another study by Yen et al. (2004)
29
concluded that virtual post-mortem examinations can take up to
a maximum of 5 with a cost double that of the conventional
method, when MRI is used depending on accessory regions of in-
terest or special protocols.
A review of the advantages and disadvantages of MRI and MSCT
virtopsy
Conclusion
While the conventional post-mortem examination remains the
gold standard in most hospitals around the world, the decline in
conventional post-mortem rates due to a lack of informed consent
suggests that this important examination is in considerable need of
either an alternative or supplementary methods. If cross-sectional
imaging is to provide this then, besides the general technical lim-
itations, in order to improve the outcome of cross-sectional forensic
investigations, there is a need for more direct training of either
forensic pathologists or clinical radiologists to provide themwith a
sound forensic background.
With regards to the authenticity of the cross-sectional imaging
methods in post-mortems and the results they convey, it has been
made clear that there is no other modality with such investigatory
potential similar to that of the conventional method. Both modal-
ities 3D rendering, digital nature and non-invasiveness increase
the chance of further bettering their own sensitivities and speci-
cities as the dimensions and exploratory potential of the virtual
post-mortem continue to expand far beyond that of the conven-
tional post-mortem. This is evidence of a promising facilitation to
the post-mortem, meaning this priceless asset may no longer
become bereft of a method in years to come.
Conict of interest statement
None.
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Advantages Disadvantages
Precise, objective and clear
documentation of forensic
ndings for the court
MRI more expensive than conventional
post-mortem
3D demonstration and archive
of ndings
MRI is more time consuming than
conventional post-mortem
Helpful adjunct to the conventional
method
Further training needed in
the acquisition and interpretation
of images
Reduction of psychological trauma
for the family and friends of
the deceased
Within MSCT vascular demonstration
requires the introduction of
vascular material
Approval in cultures with low
autopsy acceptance
Availability of technology
Decreased risk of transmission
of disease
J. Higginbotham-Jones, A. Ward / Radiography 20 (2014) 87e90 90