Post-Mortem Computed Tomography for high
energetic trauma death – a literature review
University of Amsterdam
Faculty of Science
Institute for Interdisciplinary Studies
Student name: Zhong Wan
Student number: 12191434
Program: Master Forensic Science
Supervisor: Prof. Dr. Rick Van Rijn
Examiner: Prof. Dr. Roelof Jan-Oostra
Number of words: 7871
Abstract
In the field of forensic pathology, radiological methods such as post-mortem computed tomography are being increasingly utilized. Compared to traditional autopsy methods, the speed, efficiency as well as non-invasiveness of post-mortem computed tomography makes it a widely accepted tool in analyzing the condition of deceased body. In traumatic death, post-mortem computed interval is especially useful due to its’ ability of revealing entities that are difficult to demonstrate by autopsy examination. This review outlined the application of post-mortem computed tomography in traumatic death involves in high energetic trauma. Compared mortem computed tomography with autopsy method, revealed the advantages of post-mortem computed tomography when analyzing high energetic traumatic death while also raised possible questions that may encounter in relation to the use of post-mortem computed tomography.
Content
Abstract ... 2 Introduction ... 3 Method ... 4 Traffic accident ... 5Fall from height ... 11
Aviation accident ... 15
Conclusion and Perspectives ... 18
References ... 19
Introduction
Since Wilhelm Roentgen presented the very first human X-ray image in 1895, the value of radiology for medico-legal purpose was notified by forensic scientist. In the same year, radiological image was firstly presented as a forensic evidence on court. Three years later, in 1898, radiological examination was introduced for post-mortem analysis.1 However, with a
relatively long history, modern forensic radiology is still an emerging topic within the field of forensic science.2 In recent decades, despite of the traditional post-mortem X-ray radiological
examination, newly developed digital radiology methods are also applied such as post-mortem multi-slice/multi-detector computed tomography (PMMSCT/PMMDCT), post-post-mortem multi-detector computed tomography (PMMDCT), and post-mortem computed tomography angiography (PMCTA). In every case, the most significant and perhaps the ultimate question that needs to be addressed is to answer: who involves in the case, when and where the case was happened as well as how did the case happened. Forensic radiology along with
conventional autopsy are mainly utilized for the identification of an unknown individual and diagnosing their cause of death, to answer the “who” and “how” question. Simultaneously, forensic scientists are developing standards for estimating the time since death, giving an insight on solving the “where” and “when” question. 3
As the pioneer of modern forensic radiology method, the concept of PMCT was firstly proposed on 1994 in order to address the increasing trend of post-mortems examinations. At the beginning, the method provoked opposition from pathologist on its’ validity. Yet with forensic scientists around the world applying PMCT on field while improving the methodology, it has become one of the most important supplementary tools for autopsy. 3 PMCT applies
X-ray, of which has different degrees of attenuation in different tissues. The detector receives the attenuated X-rays, transmits the data to the computer and generate tomographic images with appropriate algorithms.4 Comparing to autopsy and traditional radiological analysis,
PMCT has multiple general advantages including: (1).Non-invasive and non-destructive, cause minimum damage to the body; (2). Excellent visualization method for identifying features on bones, locating foreign objects and observing post-mortem changes; (3). Able to produce high solution images, ideal for reconstructing 3-D models; (4). Relatively easy to operate; (5). The data is preserved digitally, which is accessible to any radiologist for re-evaluation despite of their location. However, limitations on the cost and interpretation strategy of PMCT also exists.4 Beside of these general advantages and limitations, different
PMCT methods have their own characteristics, for the information obtain from them varies. 3
So far, the importance of PMCT in forensic analysis as a tool for qualitative improvement is shown by most of the published research. PMCT also has an important role as an adjunct to the conventional autopsy.
Clinically, there is a trend on applying PMCT on assessing cases involve in traumatic injuries.
5 In the cases involving fatal high energic polytrauma, PMCT is especially useful due to its’
ability of revealing entities that are difficult to demonstrate by autopsy examination. 3 This
article will critically discuss the application of PMCT on the cases involves in high energetic trauma. With the preliminary definition on high energetic trauma, an up-to-date literature review will be produced. The hypothesis of this literature review are as follows:
(1). PMCT is an ideal tool to diagnose high energetic trauma in related cases.
cases.
(3). Limitations exists when applying PMCT on cases involves in high energetic trauma. With appropriate methods, we will be able to avoid some of the limitations in real practice.
Method
High energetic trauma (HET) is a type of trauma that commonly seen in the cases that require in-depth forensic examination. They are always polytrauma, with complex fracture
surrounding long bone, periarticular bone and abdominal bone. Hemorrhage, bruise and lesion can also be observed in a patient suffered with HET. Most frequently, they present in traffic accident and fall from a significant height.6 Such trauma may also occur in the victims of
war, disaster or atypical accidents such as aviation accidents.7 This review applies the
Mechanism-of-injuries criteria defined by CDC8as the selecting criteria for literature. The
criteria are as follows:
--- In case of accidental falls:
Adults: the height of fall > 20 feet (≈6m).
Children under the age of 15: The height of fall >10 feet (≈3m); Or two to three times of child's height. --- In case of Traffic accident:
Intrusion: >12 inches (≈0.3m) to the occupant site; Or >18 inches (≈0.4m) to any site. Ejection from the automobile.
Death in same passenger compartment.
Vehicle telemetry data consistent with high risk of trauma. Automobile versus pedestrian or bicyclist: Thrown; Run over.
Or with significant impact: >20 mph (≈32km/h). Motorcycle crash: >20 mph (≈32km/h).
The cases that fulfill the criteria are documented; the physical trauma that involves in the documented cases are considered as high energetic trauma. The literature search of this review was performed on the PubMed with different indexing terms. An additional search was performed on Google scholar with similar terms. The last search was conducted on
December 20, 2019. For the details of indexing terms please see appendix ‘Searching strategy’. With such searching strategy, a total of 28 articles were retrieved. (Table 1)
Table 1. Literatures involves in high-energetic trauma Mechanism of
trauma
Type of research Analytical
techniques
Literature
Traffic accident Single case report PMCT^ 9,10,11,12,13,14,15,16,17
Unknown*, # 18, 19
Case series overview PMCT 20,21,22,23,24,25
Accidental fall Single case report PMCT 26
Case series overview PMCT 14,25,27,28,29,30
PMCTA 31
Aviation accident Single case report PMCT 32,33,34
Case series overview PMCT 35,36
Abbreviation: PMCT, Post-Mortem Computed Tomography;; PMCTA: Post-Mortem Computed Tomography Angiography.
^ PMCT refers to the studies with methods of Multi-Slice Computed Tomography/Multi-Detector Computed Tomography.
*The literatures didn’t indicate the specific PMCT techniques that was used in the research.
#The case in the literature involves in a multiple vehicle pile-up accident, of which is
categorized as disaster according to the researcher.
Traffic accident
PMCT is widely used in case of fatal traffic accident involves high-energetic trauma. The purpose of performing PMCT in traffic accident including: Detecting bruise and hemorrhage, diagnosing fractures and assessing the severity of the trauma. 12,20 Furthermore, PMCT may
also contributing to the ultimate purposes of forensic investigation: Reconstruction of the event, revealing the cause and manner of death, determining the responsibility of the accident.12,24
In many cases, PMCT significantly showed the ability of revealing several types of high-energetic trauma. Multi-Slice Computed Tomography, the conventional PMCT technique that appeared to be able to demonstrate fractures on head (cranium and face), neck, scapula, long bones (humerus, fibula, tibia, femur) extremities (scapula, humerus, fibula, tibia, femur), vertebra (thoracic, lumbar), chest (sternum, pelvis, rib) and pelvis. 9,10,11,12,13,15,16,23,24,25
Furthermore, despite of the fracture, other damage in skeletal system may also be detected by PMCT such as bone lesion, luxation, pubic symphysis diastasis as well as sign of hyper pressure.10 It is noticeable that conventional PMCT techniques also showed the ability of
revealing rare fractures yet frequently be observed in fatal traffic accidents that involves in HET. Occipital condylar fractures (OCF), which considered as a ‘rare’ fracture previously, was revealed by PMCT that it is quite common to have OCF in high-energetic trauma victims, especially in cyclists and pedestrians hit by cars.14 Similarly, bilateral fractures, a typical type
of fracture of transverse processus that are considered as a sign for overrun, was specifically examined by PMCT. The analytic result revealed all the fractures in deceased body including bilateral fractures, provided the evidence that bilateral fractures are a possible sign for the cases involve overrun. Likewise, PMCT was also applied to detect atlas fracture, a type of ‘horizontal fracture’ that only accounts for 2% of all fractures and only occurred limited times in youth victims of traffic accidents. By detecting spinal cord injury, one of the signs for atlas fracture, PMCT played an important role in identifying the trauma and considering the mechanism of the accident.17 However, it is worth to mention that the atlas fracture was only
reported in one case. It is possible that the experiment result is unique, which is somehow not applicable for other HET induced by traffic accident.
Figure 1. An axial PMCT image of horizontal atlas fracture, the anterior arch moved onto the fracture plane (arrow). 17
Regarding the organs, PMCT is able to demonstrate various brain injury (i.e. subarachnoid hemorrhage); Laceration, effusion and rupture in multiple organs including liver, lung and spleen. 9,10,21,24 The detection of gastric context aspiration by PMCT were also reported in a
case.25 Air-related injuries such as pneumopericardium, pneumomediastinum and
pneumothorax are also frequently observed in the examination result of PMCT.13,21,23,24,25
Similarly with skeletal injuries, PMCT were also applied to investigate rare trauma on organ. Cardiac blunt force trauma, with a range of lesion from banal to severe injury, can be found only in 0.8% of forensic cases with conventional autopsy. The diagnosing of such trauma was reported to be challenging. Nevertheless, as several studies suggested of applying Magnetic Resonance Imaging (MRI) to collaborate with PMCT to improve the performance of
examination, the analysis of the case was performed with the collaboration between these two techniques. With such cross-sectional imaging method, dislocation of the heart was revealed and myocardial rupture was successfully diagnosed without contrast media.10
Correspondingly, PMCT were applied to diagnosing Traumatic Axonal Injury (TAI), a typical type of diffuse axonal injury that can be caused by high energy acceleration-deacceleration process. It is reported that some TAIs can be diagnosed by PMCT, while in the research, the lesions on axonal bulb and swallow axon that could indicate the TAI were difficult to find with
only PMCT examination. A collaboration experiment between PMCT and MRI would be a better solution to identify high energy induced TAI.17 Similarly with atlas fracture research, this
research of applicating PMCT for TAI diagnosing is also a single case report, of which the possibility of misinterpretation on diagnosing sensitivity still exist.
Figure 2. An axial PMCT image of myocardium rupture. The arrow indicated a hyperdense area formed within the left ventricle. 10
Internal bleeding, for example hemorrhage and hematoma, is one of the consequences of vascular trauma. Aside from skeletal and organ trauma, internal bleeding can also diagnose by PMCT. The hemorrhage surrounding head and chest area was reported mostly. The fatal hemorrhage that helps indicating true cause of death, for instance, subarachnoid
hemorrhage, was successfully diagnosed by PMCT in numerous studies. 10,11,13,21,22,24,25
PMCT’s ability of diagnosing rare hemorrhage caused by HET in traffic accident was also highlighted. The earliest research that included in this review, by Bollinger et al. on 2007, detected extrapleural hemorrhage caused by high energetic blunt chest trauma with PMCT. The well-known apical cap sign, which in indicative of extrapleural hemorrhage could be clearly observed and distinguished in PMCT image. The findings by autopsy were also verified and visualized by PMCT image. On 2012, Miyamori et al. applied PMCT in an overrun case. The primary finding in the CT image immediately taken after death is small amount of intra-abdominal hemorrhage. The researcher thus determined the cause of death as hemorrhagic shock. However secondary CT was performed 54 hours later, and
intra-abdominal hemorrhage extent had substantially increased. Therefore, the cause of death was amended as exsanguination.18 Interestingly, in another case with similar overrun victim,
forensic experts also adjusted their estimation on cause of death but to a different side. The adjustment in this case is not based on the comparison of PMCT image overtime, but the uncommon lacking of hemorrhage on the image. PMCT applied revealed only minor hemorrhage around the lacerated liver. Multiple fracture was detected around the body, yet surprisingly, no relevant hemorrhage was detected. This result indicated that, typical cause of death for traffic accident such as hemorrhage may not applicable to this case. The PMCT
image also revealed a round radiopaque material located in the duodenum of the victim. It caught the attention of forensic scientist and later was confirmed as Zopiclone. Further pathological examination revealed the nature of material as well as the reason why no major hemorrhage was detected: the material was a tablet of Zopiclone, and the victim was suffering alcohol intoxication. It was also the cause of death of this ‘high energetic traumatic’ case.13
Figure 3. The axial PMCT images of intra-abdominal hemorrhage overtime. (a) The PMCT imaging taken immediately after death. (b) The PMCT image taken 54 h after death. The hyperdense intra-abdominal hemorrhage area was significantly increased. 18
Despite of conventional PMCT procedures, other occasional PMCT techniques are also involving in cases with high energetic trauma. For instance, Post-Mortem Computed Tomography Angiography (PMCTA). 11,23 As first PMCTA was performed only couple years
after the first X-ray, this technique remained a rare phenomenon in the last centuries. However, with the enhanced equipment developed these years, PMCTA was proved to be a powerful tool for vascular and soft-tissue imaging.11A case report in 2010 applied PMCTA to
visualize vascular rupture in a fatal traffic accident. Allied with conventional PMCT, PMCTA successfully revealed multiple vascular rupture on carotid and subclavian arteries, of which are difficult to reach and perform pathological analysis.11 Another interesting trend of PMCT is
to applied the image obtained by the technique to rebuild the deceased body or the scenario with 3-D models. With routine PMCT images, Benali et al. exploited the 3-D model of cutaneous tissue, bone and skin surface. The HET in the case, including multiple bone fracture and cutaneous lesion, were clearly expressed on the model and the relevant
information on the trauma as well as the case was given. 12 3-D model were also constructed
with both PMCT and MRI imaging technique by Buck et al. PMCT was responsible for the generation of 3-D model of osseous system and the skin surface, the fractures were expressed on the model and helped forensic examiners to determine the mechanism of formation of such fractures.20 Aside from newest techniques, PMCT were also reported to
be applied in a very specific traffic accident case, of which was categorized as ‘disaster’ due to its’ severity. On 2011, a multiple vehicle pile-up happened on a highway. Eight burnt bodies were recovered from the scene. Different from other studies, specifically designed ‘Disaster Victim Identification’ (DVI) procedure of which including PMCT diagnosing was performed on the deceased bodies. The report showed that the cause of death was high energetic
polytrauma caused by traffic accident in at least half of the burnt bodies. Despite of
this ’typical’ diagnosing function, researchers also emphasized another ability of PMCT that is specifically valuable for severe traffic accident: distinguishing between human remains and other materials.19
The performance of PMCT comparing to traditional autopsy method is a common topic when analyzing the high energetic traumatic death. Several studies critically compared the
performance of PMCT and autopsy when applying them on high-energetic trauma death. The utility of PMCT for analysis of motor vehicle crush trauma were firstly studied by Sochor et al. on 2008. Whole body PMCT and autopsy were performed on six deceased body and all the injuries discovered by PMCT or autopsy were coded by Abbreviated Injury Scale (AIS). Severe injuries categorized to AIS were documented for the comparison of the performance of PMCT and autopsy. The comparison results suggested that PMCT provide more 28% additional information on skeletal injury compared with autopsy.21 On 2009, Leth and Ibsen
evaluated the value of PMCT and compared it with autopsy with similar method for traffic accident cases. AIS of all the traffic accident cases were given independently by both PMCT and autopsy and compared. And the κ value that describe the agreement of PMCT and autopsy were calculated. The performance of PMCT is fascinating: 90% of the scoring result were same between PMCT and autopsy. κ value for validity of AIS also confirmed that the agreement between two methods were good.22 The first investigation of interobserver
variation in the evaluation of PMCT image between forensic pathologist and radiologist was given by Leth et al. after the AIS comparing research. The research also used victims in traffic accident as the dataset, and PMCT diagnosed 21% of the injuries alone. Furthermore, in this research, κ value were applied to indicate the validity of examination method. When examine the injuries with higher AIS score (3+), of which are considered as the most important target for injury diagnosing process, κ value of PMCT is the highest (0.87 out of 1).23 The
comparison of PMCT and autopsy for pedestrian cases were also conducted by Chatzaraki et al. PMCT and autopsy methods were characterized by their ability of finding morphological changes with two scoring system, one for changes with reconstructive relevance and another for changes that are relevant to the cause of death. Similar with previous studies, PMCT was proved to have better performance then autopsy in skeletal trauma that have reconstructive relevance. The skeletal trauma that relevant to the cause of death can also be diagnosed by PMCT while autopsy presented same diagnosing sensitivity with PMCT. 24 Other than the
comparison between conventional PMCT techniques and autopsy, 3-D PMCT were compared with the autopsy for its performance on accidental high energetic traumatic death. Although the research also involves in cases of accidental fall from height cases, the overall effect suggested that 3-D PMCT detected more skeletal trauma than autopsy. Regarding the soft tissue trauma, PMCT diagnosed equivalent amount to autopsy. 25 Overall, we can conclude
from all the comparison studies as well as case reports that, not only conventional PMCT but also collaborating techniques based on, or as a extend of PMCT imaging such as 3-D model reconstruction, have a great value on diagnosing high energetic skeletal trauma in traffic accident cases. What’s more, regarding those most severe traumas that could help
determining the cause of death, PMCT will be a powerful and efficient tool to diagnose them. However, flaws exist in these studies, they didn’t threat the reliability of the argumentation, yet the result still need to be verified by further studies. Firstly, the amount of cases involves in
the research is relatively small. There is no research involved in more than one hundred cases for analysis, which means the statistical evaluation may only have limited strength. Secondly, these studies selected case that fulfill their criteria, but lacks of verification process on attracted autopsy and radiological reports. It is possible that in several selected cases, some findings in autopsy report were correlated by pre-autopsy PMCT report, vice versa PMCT report may also be drafted with the influence of autopsy report. Thus the comparison of these studies would be more reliable if the sample size getting larger, or perform a selection that exclude studies with too much noise and artifacts.
Although previous studies suggested many advantages of PMCT, limitations for such
technique is still inevitable. The ability of PMCT assessing skeletal trauma in traffic accidents is emphasized in various studies, by contrast, PMCT’s limitation of diagnosing soft tissue trauma is also critically be discussed by many studies. Among all the forensic examination methods, the ability of detecting soft tissue injuries is always important. For such injuries (i.e. aortic tears) are also common causes of death for the HET victims of traffic accident. 21 The
most critical comments were from the studies comparing PMCT with autopsy: According to the pilot study by Sochor et al., although PMCT showed a high sensitivity on AIS 3+ skeletal trauma, the performance of PMCT is worse than autopsy for the detection of AIS 3+ soft tissue trauma. Leth and Gibson have found similar differences in their study, yet gave more information on the agreement between PMCT and autopsy: The lowest κ values were found for facial skeleton and multiple organs including cerebellum, meninges, lung, kidneys and gastrointestinal tract.22 If the PMCT and autopsy are performed on these organs, the
comparison may confuse the forensic experts and cause a wrongful judgement on the severity of HET or cause of death. Simultaneously, Daly et al. indicated in their research that PMCT didn’t perform well when diagnosing soft tissue trauma.25 The comparison with the
dataset of pedestrian victims by Chatzaraki et al. also implied the shortcoming of PMCT on identifying trauma that related to the cause of death, comparing to autopsy.24 PMCT also
lacks the ability of detecting some specific type of trauma. It is reported that aortic rupture, a common type of trauma that is considered as common cause of death in victims of traffic accidents, especially motor vehicle accidents, can be hardly detected by PMCT technique.22
Similarly, although extrapleural hemorrhage can be diagnosed by PMCT, the source of such phenomenon can be hardly determined by non-contrast enhanced PMCT images.9 Although
PMCTA can somehow amend the weakness of conventional PMCT techniques on identifying vascular injuries, it is still imperfect for such duty. Due to the existence of venous valves, PMCTA lacks the ability of contrasting peripheral veins in hands and lower extremities. 11
Which means the vascular injuries in these areas will be hard to be diagnosed by only PMCTA technique.
How can we minimize the limitations and make maximum use of PMCT when identifying HET in traffic accidents? Overall, the limitations that discovered by various studies are mostly due to the nature of PMCT: it reduces 3-D body information onto 2-D plain, digital images. However, the consequence of traffic accident induced HET always include multiple injuries and systematic damage in whole body. This means that PMCT may sometimes not be able to give sufficient information for the diagnosing process. Thus, we can either improve current techniques to make it more feasible for analyzing HET induced by traffic accident, or combine it with other conventional forensic techniques. With the development of technology, we can
expect improved CT techniques that are specifically designed for post-mortem analysis purpose, or even simply for analyzing HET induced by traffic accident. The algorithm for the generation of PMCT image for HET in traffic accident can also be improved by the
collaboration of forensic radiologists and computer scientists. It is expected that the
developed algorithms may speed up the post-processing step by highlighting some abnormal findings on PMCT image before assessing by forensic radiologists. Besides, since PMCT’s ability of diagnosing rare HET which are consequences of traffic accident was outlined in many articles, and these rare traumas are, obviously, the critical evidence for defining the cause of death or reconstructing the scenario, we can also concentrate on these rare HETs. The customized PMCT procedure for diagnosing these traumas could be expected to be made by forensic radiologists. As comparison studies implied that both autopsy and PMCT have their own advantages on defining specific type of trauma, the combination of PMCT with autopsy should be considered as the standard procedure for examining HET in traffic
accident. Although different perspectives on the adjunctive relationship between PMCT and autopsy were outlined (i.e. autopsy should be adjunct to PMCT, PMCT could assist autopsy), the best solution will still be: when analyzing HET in traffic accident, PMCT and autopsy should both be performed independently, the final examination report is based on the agreement on the result of two examination method. Despite of the collaboration between PMCT and autopsy, we can also expect cross-sectional imaging between regular PMCT techniques and newly invented imaging techniques, for instance, MRI. The collaboration between PMCT and 3-D modelling technique is also a promising research direction. The high solution digital dataset of the body may help forensic experts diagnosing even the smallest trauma in traffic accident. With more information on the trauma, more precise description on the case or the mechanism behind the trauma will be given by the forensic radiologists.
Fall from height
Fall from height, or accidental fall, is a frequently encountered type of case that may induce HET in forensic practice. The high energy vertical deceleration of body may easily result in fatality, while create several types of identical HET. PMCT were also widely applied in
analyzing HET induced by accidental fall cases to assess the trauma and revealing the cause of death. Comparing to traffic accident cases, the requests of scenario reconstruction and revealing the cause and manner of death still exists.
The ability of PMCT to diagnose HET is verified by several studies. Regarding the diagnosing and assessment of fracture, the ability of PMCT identifying fractures in head, neck, thorax, pelvis area as well as extremities were outlined. 26,27,28 Moreover, with more complexity of
fractures happened in these different body areas, PMCT was proved to have more commensurate reliability on diagnosing them.25 It is notable that in most of the retrieved
literature applied PMCT in case of fall from height, diagnosing and assessing fracture is the goal of the research. The correlation between skeletal trauma and energy in fall from height cases were firstly analyzed by Weilemann et al. on 2008. The fractures of each corpse were determined by the image obtained by PMCT and categorized by the body region they belong. In the meantime, the impact energy inflicted to each corpse were calculated. The result is somehow interesting: thorax area always tends to represent most severe fractures regardless
of impact site or amount of energy. Meanwhile, fractures in cranial area have a biphasic distribution: they tend to occur in the falling when impacting energy is less than 10kJ or 20kJ, but in the intermediate status, namely 10 to 20 kJ, cranial fracture is relatively rare. After this study, on 2019, two studies that discuss the relationship between fracture and fall from height cases were published by Rowbotham et al. The examination of the types of fractures resulting from fall from considerable height (>3m) was conducted, PMCT images were acquired and 3-D model were constructed. With the observation from PMCT images, several questions were answered such as: The anatomical locations of fractures; How diverse and extensive these fractures are; The variation in the fracture and the subtle differences between the fracture types. Based on PMCT image, a total of 339 fracture types were classified while 16 of the fracture types at skull, thoracic vertebrae, ribs, extremities and pelvic girdle were found to be significantly associated with accidental fall from considerable height scenarios.29 A deeper
research then correlated these fracture with the specific type of accidental fall cases. For instance, postcranial fracture was likely to occur when the height falling is great (over 25m), which means it has a positive correlation with the energy generated by hitting the ground. Regarding the rare fracture assessment, the occipital condylar fractures literature discussed in the traffic accident chapter also involved in the cases of fall from height. It is revealed by PMCT that, followed after cyclists and pedestrians hit by car, which can be both categorized as traffic accident, accidental fall are the second biggest reason that can cause HET induced OCF.14.
The correlation between OCT and HET thus is proved by PMCT, and the cause and manner of death can be evaluated with the presence of OCT. The ability of detecting organ injuries in HET caused by fall from height cases is emphasized by Heimer et al. Pneumopericardium (PPC), refers to the gas collection in the pericardial sac, was referred to two main modalities: falling from great height and motorcycle accidents. PMCT, with its’ natural superiority of detecting air ,correctly detected PPC in all the accidental fall cases. As PMCT clearly displayed aortic tears and myocardial rupture, these organ injuries were correlated to the presence of PPC trauma. 30. PMCTA were also applied in accidental fall cases, and it showed a great capability
of diagnosing hemorrhage. Mokrane et al. performed PMCTA on three cases of falling from considerable height. In conclusion, PMCTA was able to diagnose typical hematoma and hemorrhage (i.e. subarachnoid hemorrhage) as well as laceration in multiple organs including heart, lungs and aorta. It is noticeable that the diagnoses made only with PMCTA were hemopneumatocele, a special type of trauma that involves both hematoma and organ injuries. PMCTA also detected some fractures, including metacarpal bone and the head of the fibula. 31
Although there are barely no articles comparing the performance of PMCT with conventional autopsy for analyzing HET induced by fall from height cases, the advantages of PMCT were still emphasized in various aspects. On 2017, Rowbotham et al reported a case which applied both PMCT and autopsy to examine a victim of extreme sport. Comparing to other cases in this review, the height of this accidental fall in considerably height, which up to 425m. The victim was expected to suffer multiple, severe fractures after impacting the ground. The full body PMCT were performed and 3-D model were constructed based on the image. It is emphasized by studies that, the application of PMCT in this case provided them an
opportunity to clarify the types, severity and biomechanics of all the fractures. PMCT, in this case, added value to the trauma interpretation due to its advantage of producing high resolution, multi-angle images of specific body parts.26 Several cases in the PPC diagnosing
research also included autopsy examination. Interestingly, although autopsy indicated all the injuries correlated to the PPC such as myocardial rupture, none of the PPC were mentioned in the autopsy reports while PMCT indicated them all. According to the research, the ability of PMCT detecting gas, of which is a critical sign for PPC, capacitate PMCT’s advantage on diagnosing PPC.30 PMCTA, when applying on accidental fall cases, showed a remarkable
advantage comparing to conventional autopsy method. As previously mentioned, both of the autopsy and PMCT indicated most of the lesions in all the examined cases while certain diagnoses were given only be PMCTA. Since the nature of PMCTA is to diagnosing vascular system related injuries, its’ ability of diagnosing hemopneumatocele can surely be guaranteed and be seen as a technical advantage when assessing high energetic accidental fall case. However, it is interesting that PMCTA also diagnosed some fractures, of which never mentioned in other studies involve in this review. Besides, several injuries were
underestimated by autopsy, including posterior curvatures of the ribs and lesions related to rapid deacceleration. Thus, it is possible that comparing to autopsy, PMCTA has some advantages on diagnosing certain types of injuries that are formed in specific high energetic traumatic accidents. But this hypothesis still needs to be verified by more studies with the comparison between PMCTA and autopsy.
Figure 4. The axial PMCT images of pneumopericardium. Lung laceration, bilateral pneumothoraces, hemothoraces were also presented in the images. Top: Tension pneumopericardium of a 23-year-old male fall from the height of 20m; Bottom: Pneumopericardium of a 30-year-old male fall from the height of 30m. 30
Limitations of PMCT also exists when analyzing high energetic accidental fall cases. Although they are only discussed in limited number of literatures, it is still worthy to take into account of these limitations and improve the performance of PMCT. The most critical report of limitation comes from the PMCTA case: According to Mokrane et al., several injuries were only diagnosed by autopsy but not PMCTA, such as: Humeral fractures, testicular contusions/fractures as well as disc dislocation. Humeral fractures were totally invisible on PMCTA image, while dislocation of the disc is somehow visualized in image, but was diagnosed as degenerative. Although an epidemiological summarized that testicular trauma is one of the most frequently observed genitourinary trauma in traffic accident, 37 Mokrane’s study is the only one that mentioned
testicular contusions/fractures diagnosed by PMCT in all retrieved studies .It is possible that testicular injuries are mostly unrelated to the cause of death, thus somehow ignored by forensic radiologists when assessing PMCT images. What’s more, soft tissues showed limited visibility in PMCTA image, caused difficulties in diagnosing lesion. But the rare lesions are reported to be successfully identified by both PMCTA and autopsy. The article didn’t give an explanation on such discrepancy. A possible explanation could be that, the signs of rare lesions are so unique that even under low visibility, they can still be identified by experienced forensic radiologists.31 Another limitation was revealed by Heimer et al. when diagnosing PPC. It is
outlined in the discussion that, typically, it is recommended to calculate cardiothoracic ratio for a ‘small-heart sign’ when there is an attempt to detect PPC. However, PMCT cannot give an accurate estimation of the cardiothoracic ratio for in post-mortem process, heart will be larger than living patients due to the fact that lung volume will be significantly reduced during post-mortem process.
To avoid the limitations and improve the performance of PMCT when analyzing HET caused by accidental fall, similar goals should be set: improve current techniques to make PMCT more feasible for analyzing HET induced by accidental fall, or combine PMCT with other conventional forensic techniques. Different from traffic accident, there was more studies concentrate on analyzing bone fractures by PMCT in accidental fall cases. It would be valuable to development specific procedure for fracture assessment in accidental cases. Besides, as several studies revealed the relationship between the characteristics of injuries (e.g. type and pattern of fractures) and the mechanism of high energetic accidental fall (e.g. the height of fall). It is worthy to directly correlate particular sign on images with the specific mechanism of trauma, to make the diagnosing process more efficient. However, the exception of some rare situation still needs to be considered if such improvement method is taken into account. Regarding the combination of PMCT and other examination methods, the importance of autopsy is still being highlighting by studies. When diagnosing HET induced by accidental fall, the golden standard should still be conventional autopsy combined with PMCT. Despite of technical advantages, the cooperation between forensic pathologists and radiologists will allow them to complement their diagnosing report with the discussion between each other. PMCTA combining with autopsy is another promising direction. The correlation of these two techniques will be a powerful tool for diagnosing organ injuries and internal bleeding. However, as reported that some fractures may be ignored by PMCTA31, the combination between PMCTA and autopsy may take criticism on
its’ ability on diagnosing fractures. 3-D model reconstruction based on PMCT image will be a promising technology combination set on revealing all the injuries caused by HET in accidental fall cases, while it is still better to perform an autopsy to ensure the reliability of final report.
Aside from technical improvements, it is essential to improve the reliability of studies on this topic. Similar as the problem when assessing HET induced by traffic accident, it is difficult to access to a larger amount of data due to the rarity of these HET cases.25,30 There is also a
necessity to conduct a research concentrate on intra-observer/inter-observer variation between forensic radiologist and pathologist on injuries diagnosing based on PMCT image. Similar as its’ role in traffic accident cases, the reliability of PMCT on accidental fall cases can be ensured by clarifying the influence of human factor.
Aviation accident
Aviation accident is a relatively new type of scenario that involves in HET. Differ from other scenarios, aviation accident is always more severe, considered as a ‘disaster’, of which present the forensic examiners with a different set of challenges. Radiography techniques were widely applied in case of disaster identification. The importance of PMCT in aviation disasters were emphasized by not only separated studies but also international investigation communities. For example on 2014, the investigation of MH-17 crashing, one of the most severe aviation accidents in history,
In this review, with distinctive case reports and case series overviews, the potential of PMCT in analyzing HET was certified.35 There is an increasing trend of using PMCT in cases of aviation
accident. As comparing to ‘regular’ traffic accidents and fall from height, aviation accident involves in greater energy and a corpse with more severe trauma, the value of PMCT diagnosing these traumas is praised in all the cases selected for this review. Comparing to the accidental fall and traffic accident cases, Bone fractures is still the most reported diagnosing result in aviation accident cases. Generally, it is proved by Levy et al. that PMCT has the ability of diagnosing musculoskeletal injuries, especially bone fractures, in most body areas including head, chest (most ribs), pelvis and vertebrae.36 PMCT were also applied to analyze a specific
type of fracture in aviation accident: Acetabular fracture, a rare fracture that mainly occur after HET, was reported in two thirds of the victims of aviation accident. In De Bakker et al.’s research, PMCT was applied as the sole diagnosing base for fractures at different site of acetabulum (all categorized as acetabular fractures). 35 What’s more, PMCT did diagnosed organ injuries in
aviation accident cases, including laceration on lung, heart and kidney.34 Levy et al. also
reported the detection of central nervous system injuries by PMCT, but there is no further explanation on such finding so it is hard to evaluate the value of PMCT on diagnosing nervous system injuries under HET.36 The combination of PMCT technique and 3-D model
reconstruction was also applied by several researchers, and was proved as a powerful tool for analyzing HET in aviation accident. The first description of 3-D CT investigating case by Folio et al. on 2009. Two cases were analyzed while one of which were diagnosed with a special injury: “control injury”, which refers to the hand and lower extremity injuries. The 3-D reconstruction model of hands clearly showed a displaced open fracture of ulna and comminuted radius. Regarding the lower extremities, the sign of comminuted fracture at tibia and fibula were also clearly illustrated by 3-D model. The details of the fractures accord with the sign of control injury, thus based on the detailed 3-D reconstruction model by PMCT image, the “control injury” was confirmed and reported by the researchers.32 Høyer et al. reported
this research also rebuilt the model of lower extremities, while the model of upper extremities was also built. These models helped researchers identifying all the fractures and lesions around extremities. Control injuries were diagnosed on the ankles of a victim. Combining with the whole body PMCT images, researchers correlated the control injuries with the scene and the assumption of the controller of the plane when the aviation accident happened had been formulated.34
Figure 5. “Control injury” induced by aviation accident. Left: The 3D reformatted model of collective control injury on the left wrist and hand based on PMCT image. An open fracture-dislocation of radius and ulna was shown by black arrow. Right: An artistic illustration of formation mechanism of collective control injury. The gray arrow indicates the direction of forces upon aviation accident. 34
It is clearly that PMCT has its’ unique advantages on analyzing HET in aviation accident. The most distinguish advantage is, as indicated by the research of Blau et al., PMCT can help identifying body parts in severe aviation accident cases. In the case, the victims were torn apart and remains were estimated scattering over a large area. PMCT were applied in the case and successfully identified all the ‘real’ remains. The use of PMCT technique in such cases means that the remains doesn’t need to be mechanically cleaned to be identified, of which can speed up the reconciliation process. 33 Such application of PMCT can also prevent
Furthermore, comparing to autopsy, PMCT showed a higher sensitivity in detecting abnormally located air collections, which ranking as second most frequent traumatic diagnosing in aviation accidents according to Levy et al.36 The 3-D model reconstructed by
PMCT images showed an advantage on giving details of fractures, and this advantage will benefit forensic experts for its’ value on determining mechanism of injuries, such as ‘control injuries’ that cause in HET in aviation accident. On the contrary, the limitations of PMCT technique were hardly reported in related studies. It is mentioned by Levy et al. that PMCT performed worse than conventional autopsy on diagnosing superficial lesions or
subcutaneous tissue.36 However, such phenomenon is due to the fact that external inspection
was conducted only before invasive autopsy, but not considered as an essential step in PMCT analysis.
Figure 6. Identification of body parts in severe aviation accident cases. Left: Heavily
damaged body parts from the victim of aviation accident. Surgical screws from the victim were emphasized by the arrow. Right: 3D reconstruction model based on PMCT image of the body parts present in left figure. Surgical screws were indicated by arrows. 33
To improve the usability of PMCT technique in aviation accident cases, concentrating on the advantages of PMCT will be an appropriate choice. The most prominent advantage of PMCT on identification of human remains relies on the quality of image. With higher quality, the difference between human remains and irrelevant materials can be more easily distinguished. The quality of image depends on several parameters of PMCT technique, for example, the contrast and the spatial resolution. 38 By adjusting parameters to a proper status, the best
quality of image will be achieved. Despite of technical objective parameters, subjective parameter regarding applying PMCT for aviation accident can also be improved. Subjective parameter refers to the experience of forensic radiologists. Comparing to traffic accident and accidental fall, aviation accidents can hardly happen and be examined by forensic expert. Such fact also reflects on the articles retrieved for the review: only 5 articles of which discuss a total of 30 cases were selected (without exclude duplicated cases). A better performance of forensic radiologists on using PMCT technique analyzing HET induced by aviation accident can be expected with more cases report as well as studies on this topic.
Conclusion and Perspectives
The applicability of PMCT technique in cases involves in HET was certified by studies in past 20 years. HET is mainly caused by specific types of traffic accidents and accidental fall from great height. In recent years, with the increasing opportunity of performing forensic
examination for more cases, it is outlined that HET also frequently occur in cases of aviation accidents. Nowadays, the improvement of technology allows forensic radiologists applying developed PMCT techniques instead traditional radiography. MSCT/MDCT is the conventional applied PMCT techniques when analyzing HET. Aside from them, the potential of PMCTA was investigated by studies and has become a new topic of intense research. As the plain images obtained by PMCT and PMCTA sometimes lacks certain details of an area, 3-D reconstruction model based on images were developed and currently being used as an adjunct to PMCT and autopsy.
Conventional PMCT techniques were proved to be a great tool for diagnosing HET in related cases. HET can cause severe injuries, some of the frequently reported types including: skeletal injuries, organ injuries and internal bleeding. Skeletal injuries, mostly bone fractures, is the ideal diagnosing objective for PMCT due to the radiopaque bones. The general
conditions of fractures around whole-body can be clearly collated by PMCT images, while detailed images on specific areas are also used to determine the severity as well as the mechanism of injuries. Rare fractures, including atlas fractures, bilateral fractures, occipital condylar fractures and ‘control injuries’ can be clearly observed with details on PMCT images. These fractures are typically correlated to certain mechanism of trauma or cause of death. Organ injuries around the body can sometimes be revealed by PMCT, typical traumatic injuries that correlate with HET such as heart dislocation and axonal injury can be diagnosed by PMCT. Moreover, PMCT showed a higher sensitivity in detecting abnormally located air collections, which may contribute to its strength on diagnosing air-related injuries. Internal bleeding can be observed as hemorrhage and hematoma in multiple locations of the body. PMCT can be used to diagnose hemorrhage and hematoma caused by HET and use the diagnosing result to determine the cause of death. Despite of conventional PMCT techniques, PMCTA is proved to be an ideal diagnosing tool for certain type of vascular and organ injuries in specific high energetic traumatic scenarios. 3-D reconstruction model based on PMCT image is an emerging technique that collaborate with conventional PMCT. Such technique is proved to be a great tool for reconstructing scene, assessing severity of injuries and
determine cause of death.
Comparing to traditional autopsy, PMCT has plenty of advantages, which makes such technique efficient and reliable. PMCT performs better when assessing severe HET comparing to autopsy. It is able to give more precise details and added value to the trauma interpretation due to its advantage of producing high resolution, multi-angle images of specific body parts. What’s more, the efficacy of PMCT on diagnosing skeletal injuries and certain type of organ injuries is higher than of autopsy. A special advantage of PMCT was revealed when assessing high energetic aviation accident. To distinguish between human remains and unrelated materials, PMCT is a perfect tool with high efficacy and lower risk of damaging remains. However, even if PMCT is proved to be a powerful tool for investigating HET death,
limitations still exist and must be considered during the process of PMCT as well as analyzing the image obtained by PMCT. When assessing injuries with lower severity, autopsy performs better than PMCT. Soft tissue injuries and superficial lesions are also easier to be diagnosed with autopsy. Such limitation may due to the lack of thorough body inspection in PMCT protocols, and transradiancy of soft tissues.
In order to improve the applicability of PMCT in assessing HET, such recommendations are drawn:
(1). Enhancing the quality of PMCT images by adjusting related parameters.
(2). Ameliorating the ability of PMCT on diagnosing cause and manner of death in exceptional cases.
(3). Developing advanced techniques based on PMCT, involving other forensic techniques that can collaborate with PMCT when diagnosing high energetic trauma
(4). Providing more specific training of assessing high energetic trauma PMCT images for forensic radiologists.
(5). Improving the quality of research articles. Conducting studies with more available data and reliable methodology.
In conclusion, the hypotheses of the literature review are proved right. The role of PMCT techniques in analyzing high energetic trauma death is irreplaceable. It has been proved that PMCT is a useful tool for assessing high energetic trauma that are caused by traffic accident, fall from height or aviation accident. PMCT is able to reveal some findings that can hardly be given by autopsy. The golden standard for analyzing high energetic trauma nowadays is using PMCT in combination with conventional autopsy, either as an adjunct or plays the main role.
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Appendix A. Searching strategy
("post mortem"[All Fields] OR "postmortem"[All Fields]) AND ("Tomography, X-Ray Computed"[Mesh] OR "x-ray computed tomography"[All Fields] OR ("Multidetector Computed Tomography"[Mesh] OR "Computed Tomography Angiography"[Mesh] OR "Tomography, Spiral Computed"[Mesh])) AND "accidents"[All Fields] NOT "animals"[All Fields]
A total of 68 articles were retrieved
("post mortem"[All Fields] OR "postmortem"[All Fields]) AND ("Tomography, X-Ray Computed"[Mesh] OR "x-ray computed tomography"[All Fields] OR ("Multidetector Computed Tomography"[Mesh] OR "Computed Tomography Angiography"[Mesh] OR "Tomography, Spiral Computed"[Mesh])) AND "accidents"[MeSH Terms] NOT "animals"[All Fields]
A total of 109 articles were retrieved
("post mortem"[All Fields] OR "postmortem"[All Fields]) AND ("Tomography, X-Ray Computed"[Mesh] OR "x-ray computed tomography"[All Fields] OR ("Multidetector Computed Tomography"[Mesh] OR "Computed Tomography Angiography"[Mesh] OR "Tomography, Spiral
Computed"[Mesh])) AND "accidental falls"[MeSH Terms] NOT "animals"[All Fields]
A total of 16 articles were retrieved
("post mortem"[All Fields] OR "postmortem"[All Fields]) AND ("Tomography, X-Ray Computed"[Mesh] OR "x-ray computed tomography"[All Fields] OR ("Multidetector Computed Tomography"[Mesh] OR "Computed Tomography Angiography"[Mesh] OR "Tomography, Spiral Computed"[Mesh])) AND "accidents, traffic"[MeSH Terms] NOT "animals"[All Fields]
A total of 47 articles were retrieved
("post mortem"[All Fields] OR "postmortem"[All Fields]) AND ("Tomography, X-Ray Computed"[Mesh] OR "x-ray computed tomography"[All Fields] OR ("Multidetector Computed Tomography"[Mesh] OR "Computed Tomography Angiography"[Mesh] OR "Tomography, Spiral Computed"[Mesh])) AND "Accidents, Aviation"[MeSH Terms] NOT "animals"[All Fields]
