Distinction between salt water drowning and freshwater

drowning by assessment of the sinus fluid on post-mortem

computed tomography.
Poster No.:

C-0370

Congress:

ECR 2014

Type:

Scientific Exhibit

Authors:

Y. Kawasumi, A. Usui, Y. Hosokai, M. Sato, Y. Hayashizaki, H.

Saito, T. Ishibashi, M. Funayama; Sendai/JP

Keywords:

Forensics, Diagnostic procedure, CT, Forensic / Necropsy studies

DOI:

10.1594/ecr2014/C-0370

Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org

Page 1 of 9

Aims and objectives

The utility of post-mortem computed tomography (CT) has become widely recognized
and is commonly used in forensic medicine [1,2]. Previous studies have reported that fluid
accumulation in the maxillary or sphenoid sinuses is one of the most notable CT findings
in drowning victims [3-5]. Furthermore, we previously demonstrated that the volume and
density of fluid accumulation in the maxillary or sphenoid sinuses differed significantly
between drowning and non-drowning cases [6]. These results prompted the question as
to whether fluid volume and density in the sinuses was different between drowning cases,
e.g. saltwater drowning vs. freshwater drowning. In the present study, we analysed the
sinus fluid volume and density of drowning victims and evaluated the difference between
drowning in the sea and drowning in a river.

Methods and materials

Study cases
We retrospectively reviewed 641 cases that had undergone post-mortem CT and
a forensic autopsy between May 2009 and January 2013 at our institution. Each
cause of death was diagnosed at autopsy. We excluded infant cases and pronounced
decomposition cases. Finally, we selected 22 cases of drowning in the sea: 10 females,
12 males; median age 59.5 (range 35-87) years, and 26 cases of drowning in a river:
8 females, 18 males; median age 67.5 (range 19-87) years. All drowning cases were
diagnosed as wet drowning at autopsy and had fluid accumulation in either the maxillary
or sphenoid sinuses. Typical CT images of drowning victims are shown in Figure 1. The
interval between death and CT was less than 2 days in all cases.

CT and autopsy
An eight-channel multi-detector row CT (MDCT) scanner (Aquilion 8; Toshiba Medical
Systems, Tokyo, Japan) was used. All cases were scanned in a body bag while fully
clothed and no contrast material was administered. CT was performed with two scans.
First, the head was subject to conventional CT; the tube voltage was 120 kVp and the
tube current was changed arbitrarily based on the installed mode. The rotation time was
1.5 s. The field of view was S-size, and matrix size was 512 512 pixels. The collimation
was 4.0 and 8.0 mm. The reconstruction filter was FC27, and the reconstruction interval
was 0. The second scan was from the head to the pelvis using the helical mode; the tube
voltage was 120 kVp, and the tube current was arbitrarily changed based on the installed
mode. The rotation time was 0.75 s. The field of view was S-size, and matrix size was
512 512 pixels. The table speed was 14 mm per rotation, and the helical beam pitch

Page 2 of 9

was 0.875. The reconstruction filter was FC10, and the reconstruction interval was 0. The
reconstructed slice thickness of the images was 2.0 mm.
In all cases, a conventional autopsy was performed shortly after forensic CT. A forensic
pathologist who had more than 30 years of experience performing forensic autopsies
carried out all post-mortem examinations.

Image assessment
All CT images were sent to a three-dimensional DICOM workstation (ziostation2; Ziosoft,
Tokyo, Japan). Regions of fluid in the maxillary and sphenoid sinuses on axial images
were extracted manually for each slice. The workstation automatically built volume data
from the extracted regions and calculated the volume and average density.

Statistical analysis
Differences in volume and density between sea drowning and river drowning cases were
evaluated using the Mann-Whitney U test. Additionally, receiver operating characteristic
(ROC) analysis was performed to determine the cut-off value and evaluate diagnostic
performance.
Images for this section:

Fig. 1: A typical drowning case showing fluid accumulation in the maxillary and sphenoid
sinuses (arrows).
Page 3 of 9

Results
There was no significant difference in the age or the interval time between sea drowning
and river drowning cases (p = 0.3385 and p = 0.8294, respectively).
Figure 2 shows a Tukey boxplot of the volume distribution of fluid accumulation in the
maxillary or sphenoid sinuses. The median volume in sea drowning cases was 5.675
(range 0.08-37.55) mL and that in river drowning cases was 4.795 (0.05-19.62) mL. There
was no significant difference in volume between sea drowning and river drowning cases
(p = 0.7879).
Figure 3 shows a Tukey boxplot of the density distribution of fluid accumulation. The
median density was 46.89 (14.26-75.98) HU and 27.47 (7.41-62.51) HU, respectively.
The fluid density in sea drowning cases was significantly higher than that in river drowning
cases (p = 0.0003). Figure 4 shows the ROC curve when diagnosing saltwater drowning.
ROC analysis determined the cut-off value as 33.77 HU for the point closest to (0,1) and
the Youden's index, with sensitivity 77.3%, specificity 76.9%, positive predictive value
(PPV) 73.9%, and negative predictive value (NPV) 80.0%.
Images for this section:

Page 4 of 9

Fig. 2: Tukey boxplot of volume distribution of fluid accumulation in the maxillary

or sphenoid sinuses. The median volume in sea drowning cases was 5.675 (range
0.08-37.55) mL and that in river drowning cases was 4.795 (0.05-19.62) mL. There was

Page 5 of 9

no significant difference in volume between sea drowning and river drowning cases (p
= 0.7879, Mann-Whitney U test).

Page 6 of 9

Fig. 3: Tukey boxplot of density distribution of fluid accumulation in the maxillary or

sphenoid sinuses. The median density in sea drowning cases was 46.89 (14.26-75.98)
HU and that in river drowning cases was 27.47 (7.41-62.51) HU. The density in sea
drowning cases was significantly higher than that in river drowning cases (p = 0.0003,
Mann-Whitney U test).

Fig. 4: The ROC curve when diagnosing saltwater drowning. ROC analysis determined
the cut-off value as being 33.77 HU for the point closest to (0,1) and the Youden's index,
with sensitivity being 77.3%, specificity 76.9%, positive predictive value (PPV) 73.9%,
and negative predictive value (NPV) 80.0%.

Page 7 of 9

Conclusion
The sinus fluid density in saltwater drowning cases was significantly higher than that in
freshwater drowning cases. ROC analysis determined the cut-off value as 33.77 HU,
sensitivity as 77.3%, specificity as 76.9%, PPV as 73.9%, and NPV as 80.0%. The
observed difference may help forensic pathologists better diagnose the specific cause
of death in drowning cases.

Personal information
Yusuke KAWASUMI, M.D., Ph.D.
Tohoku University Graduate School of Medicine
Course of Radiological Technology
Clinical Imaging

References
1.
2.

3.
4.

5.

6.

Dirnhofer R, Fackowski C, Vock P, et al. VIRTOPSY: Minimally invasive,

imaging-guided virtual autopsy. RadioGraphics 2006;26:1305-1333
Bolliger SA, Thali MJ, Ross S, et al. Virtual autopsy using imaging: bridging
radiologic and forensic sciences. A review of the Virtopsy and similar
projects. Eur Radiol 2008;18:273-282
Christe A, Aghayev E, Jackowski C, et al. Drowning-post-mortem imaging
findings by computed tomography. Eur Radiol 2008;18:283-290
Levy AD, Harcke HT, Getz JM et al. Virtual Autopsy: Two- and threedimensional multidetector CT findings in drowning with autopsy comparison.
Radiology 2007;243(3):862-868
Kawasumi Y, Kawabata T, Sugai Y, et al. Assessment of the relationship
between drowning and fluid accumulation in the paranasal sinuses on
post-mortem computed tomography. European Journal of Radiology
2012;81:3953-3955
Kawasumi Y, Kawabata T, Sugai Y, et al. Diagnosis of drowning using postmortem computed tomography based on the volume and density of fluid
accumulation in the maxillary and sphenoid sinuses. European journal of
radiology. 2013 Oct;82(10):e562-6. PubMed PMID: 23891140.

Page 8 of 9

Page 9 of 9