Figure - available from: Pediatric Radiology
This content is subject to copyright. Terms and conditions apply.
Bowel distention in a 13-month-old girl with osteogenesis imperfecta who died after cardiac arrest. a Axial CT image shows gas both distending the bowel lumen (large arrows) and in the bowel wall (small arrows). In this case, there was at least a 3-h interval between the time of death and the CT scan. The intraluminal and intramural gas likely represents expected changes related to putrefaction. b Coronal maximum-intensity projection CT image shows the healed fractures creating bowing deformities of the extremities (single arrows). The double arrows indicate two foci of subtle periosteal reaction indicating incompletely healed fractures. Multiple vertebral compression deformities are identified (levels between the arrowheads). In this child, the manner of death could not be determined and the cause of death was attributed to “cardiorespiratory failure with contributing factors including chronic respiratory failure, ventilator dependent, and osteogenesis imperfecta”
Source publication
Postmortem CT might provide valuable information in determining the cause of death and understanding disease processes, particularly when combined with traditional autopsy. Pediatric applications of postmortem imaging represent a new and rapidly growing field. We describe our experience in establishing a pediatric postmortem CT program and present...
Similar publications
In many circumstances, the increase in life expectancy when certain causes of death are eliminated is sought. These calculations are typically based on the assumption that the causes in question are simply omitted, which is equivalent to the causes being taken out of consideration, from the outset, with certainty. In
this paper, we propose models w...
Citations
... How to perform/acquire CT Whole-body PMCT should be performed according to international guidelines. These have been published by EPSR (jointly with the International Society of Forensic Radiology and Imaging (ISFRI) [8]) and the Society of Pediatric Radiology (SPR) [9]. Whilst there are reports that have demonstrated some utility in ventilated PMCT [10] or the addition of intravascular contrast (e.g., PMCTA) [11,12], neither is routinely practiced in children. ...
... This may be one of the reasons why PMCT services are not as widespread and easily accessible as we would ideally like. Whilst there are some barriers to adoption (e.g., funding, training, and administrative processes [31][32][33][34][35]), several solutions are also possible and discussed in previous key publications issued by international societies, such as the ESPR and SPR taskforces [9,31,[36][37][38][39]. ...
Postmortem CT (PMCT) has become increasingly accepted alongside skeletal surveys as a critical part of investigation in childhood deaths, either as part of a suite of non-invasive investigations through parental choice, or comprehensive evaluation in a forensic setting. Whilst CT image acquisition and protocols have been published and are relatively standardised, CT imaging reporting remains highly variable, largely dependent upon reporter experience and expertise. The main “risk” in PMCT is the over-interpretation of normal physiological changes on imaging as pathological, potentially leading to misdiagnosis or overdiagnosis of the disease. In this article, we present a pragmatic standardised reporting framework, developed over a decade of PMCT reporting in children in our institution, with examples of positive and negative findings, so that it may aid in the interpretation of PMCT images with those less experienced in paediatric findings and postmortem imaging.
Critical relevance statement
Standardised reporting using a common framework with a sound understanding of normal postmortem changes that occur in children are crucial in avoiding common reporting errors at postmortem CT.
Key Points
Familiarity with postmortem imaging is required for useful image reporting, and reporting standards vary.
Understanding normal postmortem change from significant abnormalities requires training and experience.
Following a template may remind reporters what to include and help improve performance.
Graphical Abstract
... PMCT is particularly useful for those suffering from internal injuries [13,14]. PMCT is very quick and available; it can also elucidate bone detail, provide a rapid overview of the body interior, and reveal skeletal abnormalities and radiopaque bodies [15]. ...
The essential role of the autopsy is seen in its contributions to medical care, scientific research, and family counseling. Major contributions are also noted in forensic pathology as a means to determine cause-of-death for legal and medical experts. However, autopsy acceptance rates are quite low due to an array of reasons including delayed burials, faith, and moral burdening. Thus, non-invasive post-mortem imaging strategies are becoming increasingly popular. The objective of this literature review is to evaluate the strengths and weaknesses of numerous post-mortem imaging modalities and consider their benefits over the traditional autopsy. The need for expertise in image interpretation for pediatric and perinatal cases is also discussed. A variety of publications, totaling 32 pieces, were selected from available literature on the basis of relevance. These articles studied various perinatal and pediatric post-mortem imaging strategies and their applications in clinical practice. Key strategies include post-mortem MRI, post-mortem CT, fetal post-mortem sonography, post-mortem computed tomographic angiography, and three-dimensional surface scanning. There is a general consensus that no standard model for post-mortem imaging currently exists in the United States and European countries. Amongst the imaging modems studied, post-mortem MRI has been acknowledged to show the greatest promise in diagnostic accuracy for fetal age groups. Most studies demonstrated that post-mortem CT had limited use for autopsy. Post-mortem imaging strategies for autopsy have high potential given their minimal invasiveness and increasing popularity. Furthermore, it is vital to crafting a global standard procedure for post-mortem imaging for prenatal, perinatal, and pediatric cases to better understand the cause of death, decomposition factors, and effects in-utero, and to provide an alternative to traditional autopsy.
... Child abuse or non-accidental injury (NAI) in its severest form is fatal. 1 The World Health Organization (WHO) defines child abuse and child maltreatment as: [A]ll forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power. 2 resource constrained environment in terms of the availability of imaging equipment, radiographers and radiologists with experience in post-mortem imaging. Post-mortem CT as the primary post-mortem imaging modality has shown promise in some international centres; 14,15 however, this is not currently the standard in SA. ...
Background: In its severest form, non-accidental injury (NAI) in children is fatal. South Africa has been reported to have double the global average of child homicides. Autopsy is the main investigation in fatal NAI with post-mortem skeletal surveys (PMSS) playing an adjunctive role. Whilst fracture patterns associated with NAI in living patients have been established, this has not been investigated in PMSS in South Africa.
Objectives: To determine the incidence and characteristics of fractures in suspected fatal NAI cases. To calculate the incidence of fractures according to high-, moderate- and low-specificity fracture locations for NAI.
Methods: A retrospective review of all PMSS performed between 01 January 2012 and 03 December 2018 was conducted at the Charlotte Maxeke Johannesburg Academic Hospital.
Results: Of the 73 PMSS, 33 (45.2%) demonstrated fractures. No statistical significance in sex was found: 38 (52.1%) were male and 35 (47.9%) were female (p 0.05). The mean age of those who sustained fractures was 28 months (standard deviation [s.d.]: 21 months). A total of 115 fractures were sustained, of that the top five bones fractured were the ribs 37 (32.2%), parietal bone 13 (11.3%), ulna 13 (11.3%), femur 13 (11.3%), and radius 11 (9.6%). High-specificity fracture locations accounted for 40/133 (30.1%).
Conclusion: The fracture types in PMSS were similar to those in live skeletal surveys. Our study’s fracture rate was higher in comparison to international studies. The PMSS is a valuable adjunct to autopsy in detecting occult fractures of the limbs. We recommend that PMSS be performed in suspected fatal NAI cases at least in children up to 24 months of age.
... This has resulted in a spectrum of coroner and medical examiner (ME) offices operating under different statutes with variable funding. For those in the United States, this presents unexpected challenges and the need for different solutions [30]. ...
... It is helpful to identify a point person, perhaps the physician who performs the majority of pediatric autopsies. Conversations should emphasize the goal of imaging to provide data to assist in the medicolegal death investigation, not to replace conventional autopsy [30]. Patient confidentiality requirements of the Health Insurance Portability and Accountability Act (HIPAA) also need to be addressed early. ...
... Postmortem cross-sectional imaging is best performed as close to death as possible to minimize changes associated with decomposition, although we have performed scans after autopsy and organ harvest and on exhumed remains [30]. We aim to scan as soon as possible after notification, and, because we have CT technologists in-house 24/7, our CT technologist is the contact person for the ME. ...
Postmortem CT is widely used in the general adult and military populations. It is used extensively in pediatric death investigations in Europe and Asia, but distinctive challenges are encountered when launching a postmortem imaging program in the United States. We describe the issues we have encountered specific to establishing a pediatric postmortem imaging service in this country and propose potential solutions.
... The forensic anthropologist can use radiography to identify skeletal fractures, provide an estimate of TSI, or identify skeletal abnormalities that are suggestive of underlying natural illness or increased fracture risk. In the United States, obtaining full-body radiographs for the purposes of detecting skeletal injuries is considered an essential component of a complete pediatric autopsy (Gould et al., 2019) and is considered standard practice (Bilo, Robben, & van Rijn, 2010c;Pinneri & Matshes, 2017). According to a survey distributed to the United States-based National Association of Medical Examiners (NAME) listserv inquiring about current pediatric autopsy techniques, 93% (n = 79) of respondents reported that full body radiographs are routine and 91% (n = 77) reported they are required (Pinneri & Matshes, 2017). ...
... The resolution of the CT scanner plays a major role in the ability to obtain optimal image quality to enable the identification of skeletal injuries, however, a detailed discussion of the appropriate protocols for obtaining quality PMCT images is beyond the scope of this review (see Gould et al., 2019 andShelmerdine et al., 2019 for pediatric protocols). In short, CT image quality depends on the parameters used to acquire the CT scans. ...
... These parameters include voltage, amperage, field of view, slice thickness, slice interval, detector collimation, pitch, rotation time, and filter (Dedouit et al., 2014;Shelmerdine et al., 2019). Some protocols suggest conducting multiple scans (whole body, head and neck only, and extremities only) at specific settings tailored to the anatomical region being scanned and the age/size of the pediatric decedent (Gould et al., 2019). Obtaining multiple scans increases the overall time for image acquisition, however, the development of spiral and multidetector CT scanners has decreased scan times while improving the spatial resolution of images in the longitudinal axis (Brough et al., 2012). ...
Child maltreatment is a growing medicolegal and social concern and forensic anthropologists in the United States are more frequently being asked to participate in pediatric autopsies to evaluate skeletal injuries. These injuries may be occult to medical imaging and the autopsy itself, but the forensic anthropologist directly evaluates the skeletal tissue which can dramatically improve the sensitivity and specificity of the analysis. The training and methods of forensic anthropologists provide them with the unique perspective of comprehending the anatomical, biomechanical, and physiological properties of human pediatric bone which informs their interpretations of time since injury and mechanism of trauma. This perspective also permits the ability to differentiate between growth and development, skeletal anomalies/variants, and traumatized bone which can be of distinct consequence to the forensic pathologist's cause and manner of death determination. This review is intended for forensic anthropologists and others in the medicolegal community who are tasked with identifying and interpreting pediatric skeletal trauma. The research and scholarly work cited herein is the most current bibliography for comprehending the role and contribution(s) of the forensic anthropologist in the pediatric autopsy, the techniques and methods available to them, and the challenges and cautions associated with this delicate work.
This article is categorized under:
• Forensic Anthropology > Trauma Analysis
• Forensic Medicine > Imaging Modalities
• Forensic Medicine > Medicolegal Death Investigation Systems
... While a large percentage of children who die receive complete autopsies for determination of cause of death, this is much less common for older adults. 41 Full body post-mortem CT imaging is much less expensive and resource-intensive than such extensive imaging antemortem. 42,43 It's utility in child abuse is under study, and preliminary work has been done on the utility in elder abuse, which has the potential to identify reliable imaging correlates for abuse in this population. ...
Elder abuse is an under detected, under reported issue with severe consequences. Its detection presents unique challenges based on characteristics of this vulnerable population, including cognitive impairment, age-related deconditioning, and an increased number of co-morbidities, all of which predispose to increase vulnerability to injury. While radiologists play a critical role in detection of child abuse, this role is currently not paralleled in detection of elder abuse. We conducted a thorough review of the literature using MEDLINE to describe the current knowledge on injury patterns and injury findings seen in elder abuse, as well as barriers to and recommendations for an increased role of diagnostic imaging in elder abuse detection. Barriers limiting the role of radiologists include lack of training and paucity of rigorous systematic research delineating distinctive imaging findings for physical elder abuse. We outline the current ways in which imaging can help raise clinical suspicion for elder abuse, including inconsistencies between purported mechanism of injury and imaging findings, injury location, multiple injuries at differing stages of healing, and particular patterns of injury likely to be intentionally inflicted. We additionally outline the mechanism by which medical education and clinical workflow may be modified to increase the role for imaging and radiologist participation in detecting abuse in older adult patients, and identify potential future directions for further systematic research.
Purpose
The purpose of this study was to review the findings of computed tomography (CT) performed early postmortem on infants and to clarify the postmortem CT lung findings that occur in the absence of abnormal histopathological findings.
Materials and methods
From July 2016 to March 2022, 72 infants were autopsied with postmortem CT (41 boys 31 girls, aged 0–36 (mean 8.2) months). Autopsy and postmortem CT lung findings were compared with the causes of death identified by the autopsies, namely sudden infant death syndrome (n=37), acute circulatory system disease (18), drowning (7), asphyxia (5), and dehydration/undernutrition (5).
Results
The %aerated lung volume (−700 HU or less) ranged from 0%–33% (mean 1.5%, median 0%), being less than 1% in 61 cases (84.7%) and more than 3% in 3/5 (60%) of the dehydration/undernutrition group. The dehydration/undernutrition group showed significant preservation of lung field air content compared with the other causes of death groups (p<0.05). Receiver characteristic curve analysis showed a cut off value of 0.8% and area under the curve of 0.88806. The drowning group had significantly greater pleural cavity fluid retention than the other causes of death groups (p<0.05). No correlation was found between postmortem interval and pleural cavity fluid retention. However, resuscitation time and pleural cavity fluid retention were correlated.
Conclusion
Evaluation of CT values on postmortem lung fields of infants usually reveals a marked decrease in air content. When air content exceeds 0.8% on infant postmortem CT, dehydration/undernutrition should be considered in the differential diagnosis.
Objective: The proximal tibia is a recommended and commonly used site for pediatric emergency intraosseous vascular access (IO). During forensic whole body postmortem computed tomography (PMCT), we evaluated accuracy of emergency placement of tibial IO access.
Methods: We conducted a retrospective review of 92 state medical examiner cases to assess presence and placement of tibial IO needles. Insertions were classified as successful (needle tip in the medullary portion of the bone) or unsuccessful (all other non-medullary placements) based upon position of the needle tip. Medical records were reviewed for patient age, equipment, and where an insertion was attempted, as well as if IO placement occurred in a prehospital or hospital environment.
Results: Thirty-one cases with 42 tibial devices (aged 3 weeks to 16 years, median 4 months) were identified. In 25 insertions (60%), the needle tip was in satisfactory position. In 17 placements (40%), needle tip was unsatisfactory and included tibia perforation (6), tip embedded in the cortex (6), and needle missed the bone (5). In patients older than 6 months, all six placements of a 15-mm needle were successful. In infants age 6 months or younger, 14 placements (56%) were successful and 11 (44%) unsuccessful. The 25-mm IO needle was successfully placed in five of six children older than 6 months. In infants age 6 months or younger, the 25-mm needle was unsuccessfully placed in five of five attempts.
Conclusion: In infants 6 months of age or younger, tibial IO needle insertion had a 53% failure rate (non-medullary placement). Failures occur during both prehospital and emergency department care. In infants age 6 months or younger, use of a 25-mm needle should be avoided. Procedures for IO insertion in infants age 6 months or younger should be reviewed and modification considered.
