FEBRUARY 2006

VIRTUAL AUTOPSY

HEALTH TECHNOLOGY ASSESSMENT UNIT

MEDICAL DEVELOPMENT DIVISION
MINISTRY OF HEALTH
Project Coordinators
Datin Dr Rugayah Bakri
Deputy Director
Health Technology Assessment Unit
Medical Development Division
Ministry of Health Malaysia

Dr Rusilawati Jaudin
Principal Assistant Director
Health Technology Assessment Unit
Medical Development Division
Ministry of Health Malaysia

December, 2005
1. INTRODUCTION

Autopsy or post-mortem is classically carried out by performing several incisions

and a few specific techniques onto the dead body. It is carried out for either
medico-legal or pathological reasons, with the intention to determine cause of
death, time of death, manner of death and identification e.g. in mass disaster, as
well as documentation and expert testimony. Forensic pathologists face
difficulties in advanced decomposed, completely charred bodies, matching
dismembered and mutilated remains. The classical technique in some situation
gives rise to problem in physical storage. For most people, the idea of an autopsy
is uncomfortable, especially in situations such as the death of an infant. Some
religious group forbid autopsy outside legal necessity.

Until today most of the documentation of forensic relevant medical findings is

limited to traditional 2D photography, 2D conventional radiographs, sketches and
verbal description (Thali et al, 2005). In expert testimonial, classical autopsy has
some disadvantages with regards to its use of 2D X-ray views and non-
reproducible, observer-dependent as well as subjective reconstruction of injuries
which generates difference of expert opinion.

For the benefit of forensic science, virtual autopsy or digital autopsy is a new
technique in radiology that uses a combination of post-mortem multi-slice
computed tomography (MSCT) and magnetic resonance imaging (MRI). The
great improvement in MSCT and MRI technology are increase in both contrast
and resolution as well offer the possibilities of 2D and 3D reconstruction with the
aim to establish observer-independent, objective and reproducible forensic
assessment method using modern imaging technology. This eventually leads to
minimally invasive forensic autopsy (Jackowski1 et al, 2005). Virtual autopsy
technology is a useful tool for documentation, visualisation and analysis of the
findings of blunt force trauma and drowning with a large potential in forensic
medicine (Aghayev E et al, 2005). Using modern imaging methods such as
photogrammetry in combination with optical surface and radiological CT/MRI
scanning, has demonstrated that a real full 3D data based documentation of the
body surface and internal structures of an individual, is possible in a non-invasive
and non-destructive manner (Thali et al, 2005).

2. TECHNICAL FEATURES

Virtual autopsy or digital autopsy combines multi-slice computed tomography

(MSCT) and magnetic resonance imaging (MRI). The MSCT images provide
information about the general pathology of the body and can generate detailed
information about trauma injuries. MRI is used to focus on specific areas of the
body, providing details about soft tissues, muscles and organs. Digital autopsy
provides a 3D geometric documentation of injuries on the body surface and
internal injuries in the living as well as in deceased cases. It allows examiners to
access the same body area from multiple planes without destroying forensic
evidence (M Paula, 2003).

The medical virtual reality technique makes it possible to perform a simulated

autopsy of the body. In the digital morgue, retrospective observation and
quantitative analysis of the structural damage of the body are possible using high
dimension medical imaging and medical virtual reality (Takatsu et al, 1999). The
digital morgue stores the body structure of each case as a 3D data set consisting
of sectioning planes of the whole body obtained from MSCT or MRI figures.
However, to determine the time of death, virtual autopsy uses magnetic
resonance spectroscopy - a technique that measures emerging metabolites in
the brain during post-mortem decomposition.

In addition, virtual autopsy is also able to describe the imaging appearance of

post-mortem alterations e.g. internal livores, putrefaction, post-mortem clotting;
and distinguish them from the forensic findings of the heart, such as calcification,
endocarditis, myocardial infarction, myocardial scarring, injury and other
morphological alterations (Jackowski2 et al, 2005). Using the data merging/fusing
and animation possibilities, it is possible to answer reconstructive questions of
the dynamic development of patterned injuries (morphologic imprints) and to
evaluate the possibility, that they are matchable or linkable to suspected injury-
causing instruments.

3. OBJECTIVE

To determine the effectiveness, cost/economics, organisational, social and legal

implications of virtual autopsy.

4. METHODOLOGY

An online computer search was undertaken using the following databases:

PUBMED, HTA databases, horizon scanning centres and general databases.
There were no limits on year of publication applied. The key words used were
virtual autopsy, virtopsy, digital autopsy, forensic imaging and digital
forensic.

5. RESULTS & DISCUSSION

Effectiveness

Post-mortem MSCT scanning provided an excellent anatomic visualisation of the

human arterial system including intracranial and coronary arteries. Vascular
pathologies such as calcification, stenosis and injury were detected (Jackowski3
et al, 2005). Yen (2004) reported that MSCT has proven to be a valuable
screening method to detect the lesions, but MRI is necessary in order to properly
differentiate and classify the grade of damage. These non-invasive radiological
diagnostic tools can be further developed to play an important role in forensic
examinations, in particular, when it comes to evaluating living trauma victims.
Aghavey, (2004), supported that post-mortem imaging is a good forensic
visualisation tool with great potential for documentation and examination of body
injuries and pathology.

Findings of 40 forensic cases examined using MSCT and MRI, which were
verified by subsequent autopsy were classified as follows: (I) cause of death, (II)
relevant traumatological and pathological findings, (III) vital reactions, (IV)
reconstruction of injuries, (V) visualisation. In these 40 forensic cases, 47 partly
combined causes of death were diagnosed at autopsy, 26 (55%) causes of death
were found by only using independent radiological image data (Thali et al, 2003).

Jackowski stated the advantages of post-mortem imaging, that there is no

concern for biologic effects of ionising radiation and lack of cardiac motion
artefacts during scanning, despite the higher exposure and resolution available in
CT (Jackowski et al3, 2005). Radiology was superior to autopsy in revealing
certain cases of cranial, skeletal, or tissue trauma. Some forensic vital reactions
were diagnosed equally well or better using MSCT and MRI. These preliminary
results, based on the concept of "virtopsy," are promising enough to introduce
and evaluate this radiological technology in forensic medicine (Thali et al, 2003).

Timing of death
One study described the timing of death using changes seen in both MCST and
MRI in head injury cases. However, there was no established method to develop
a time scale for the dating of head injuries in infants based on the modifications
of signal and location of blood on CT and MR images (Vinchon et al, 2004).

Identification
Smith (Smith, 2002) described a case report on positive identification of a
deceased individual which was accomplished by performing a CT scan on an
unidentified cranium and comparing multiple landmarks and images with
corresponding features in an antemortem CT scan of a missing man. A cranium
from an unknown individual is identified by comparison of antemortem and post-
mortem computerized tomographic (CT) images of the bony structure of the skull
(bony details of the frontal and sphenoid sinuses, ethmoid and mastoid air cells,
sagittal cranial suture, and the torcula (the internal occipital protuberance). The
result showed that they were exactly the same on both CT scans, confirming the
identity of the missing person.

Cause of death: trauma (e.g. road traffic accident)

Aghayev2 (Aghayev2, 2004) documented a case report of three cases of fatal
blunt head injury using post-mortem MSCT and MRI which showed massive
bone and soft-tissue injuries of the head and signs of high intracranial pressure
with herniation of the cerebellar tonsils. Similar findings were found in clinical
autopsy which was performed after the digital autopsy.
A case report with the objective to demonstrate new 3D real data based on
geometric technology approaches, stated that approaches to a 3D geometric
documentation of injuries on the body surface and internal injuries in the living
and deceased cases, using modern imaging methods such as photogrammetry,
optical surface and radiological CT/MRI scanning in combination, is possible in a
non-invasive and non-destructive manner. The method of optical and radiological
3D scanning was used to document the forensic relevant injuries of human body
in relation to vehicle damages. By this complementary documentation approach,
individual forensic real data based analysis and animation were possible in
linking body injuries to vehicle deformations or damages. These data allow
conclusions to be drawn for automobile accident research, optimisation of vehicle
safety (pedestrian and passenger) and for further development of crash
dummies. Real 3D data based documentation opens a new horizon for scientific
reconstruction and animation by bringing added value and a real quality
improvement in forensic science (Thali et al, 2005). Aghayev ( Aghayev1, 2004,
supported that post-mortem imaging is a good forensic visualisation tool with
great potential for documentation and examination of body injuries and pathology
in his case report of fatal motor vehicle accident with head injury.

Cause of death: non-trauma

In a study, post-mortem computed tomographic (PMCT) of the lung was
conducted in 150 non-traumatic death cases with cardiopulmonary arrest (acute
heart failure/AHF). The examination by CT was carried out within 2 hours after
certification of death, and the results were in the form of documented imaging
findings on dependent density, ground glass attenuation (GGA), consolidation,
pleural effusion and endotracheal (or endobronchial) air defect. Classical
autopsies conducted in 16 of those cases confirmed that GGA on PMCT in AHF
cases corresponded to pulmonary oedema. Findings of this paper showed when
PMCT of the lung shows no other shadows than dependent density, further
analysis is necessary to detect the cause of death (Shiotani, 2004).

Cause of death hanging or manual strangulation

Yen (Yen2, 2005), reported a case series of post-mortem MSCT and MRI of nine
persons who died from hanging or manual strangulation. The neck findings were
compared with those discovered during forensic autopsy. In addition, two living
patients underwent imaging and clinical examination following severe manual
strangulation and near-hanging, respectively. For evaluation, the findings were
divided into "primary" (strangulation mark and subcutaneous desiccation i.e. soft-
tissue thinning as a result of tissue fluids being driven out by mechanical
compression in hanging, as well as subcutaneous/intramuscular haemorrhage in
manual strangulation) and "collateral" signs. The Wilcoxon two-tailed test was
used for statistical analysis of the lymph node and salivary gland findings. The
results showed that in hanging, the primary and most frequent collateral signs
were revealed by imaging. On the other hand, in manual strangulation, the
primary findings were accurately depicted, with the exception of one slight
haemorrhage. Apart from a vocal cord haemorrhage, all frequent collateral signs
could be diagnosed radiologically. Traumatic lymph node haemorrhage (P =
0.031) was found in all of the manual strangulation cases. The report concluded
that MSCT and MRI revealed strangulation signs concordantly with forensic
pathology findings.

Further more, emphysema could be seen in post-mortem cross-sectional

imaging. Findings from a case series of 5 cases of hanging, demonstrated
pneumomediastinum and cervical emphysema in 3 cases (Aghayev3, 2004).
Evidence of vitality of a hanged person is when putrefaction gas can be excluded
in the findings of pneumomediastinum and cervical soft tissue emphysema.

Cause of death: burn

Thali (Thali2 et al, 2002), reported a charred body case of a single motor
vehicle/fixed object collision with a post-crash fire. The radiological methods of
MSCT and MRI made it possible to document the injuries caused by burn as well
as the forensic relevant vital reactions (air embolism and blood aspiration). He
concluded that post-mortem imaging is a good forensic visualisation tool with a
great potential for the forensic documentation and examination of charred bodies
(Thali et al, 2002).

Another case reported by Thali (Thali5 et al, 2004) to validate magnetic resonance
microscopy (MRM) studies of forensic tissue specimens (skin samples with
electric injury patterns) against the results from routine histology, found that
three-dimensional high-resolution MRM images of fixed skin specimens provided
a complete 3D view of the damaged tissues at the site of an electric injury as well
as in neighbouring tissues, consistent with histologic findings. This is another
area where digital autopsy offers a non-invasive alternative to conventional
histology in forensic wound analysis and can be used to perform 3D virtual
histology.

Cause of death: gunshot

A case series of eight gunshot victims were scanned by MSCT and MRI; the data
from these imaging techniques were post-processed on a workstation,
interpreted and subsequently correlated with the findings of classical autopsy.
The spiral CT and MRI examinations with the subsequent 2D multi-planar
reformation and 3D shaded surface display reconstruction, the entire gunshot
created complex skull fractures and brain injuries (such as wound channels and
deeply-driven bone splinters) could be documented in complete and graphic
detail. CT and MRI also documented vital reaction to the gunshot by
demonstrating air emboli in the heart and blood vessels and the classic pattern of
blood aspiration to the lung. Gunshot residues deposited within and under the
skin were visible (Thali et al, 2003).

Experimental gunshots to a skull-brain model with high-speed photography and

subsequent radiographic examination for comparison of the morphologic findings
in the model found very similar findings to those from classic head autopsy, but
which was derived in a hands-off and non-destructive manner (Thali et al, 2002).

Cause of death: infection

A case report by Jackowski (2005) revealed that relevant autopsy findings could
be obtained and visualised by post-mortem imaging and confirmed by
histological and microbiological investigations supporting the idea of a minimal
invasive autopsy technique (Jackowski2 et al, 2005).

Cause of death: drowning

Plattner (2003) reported a case report of virtual autopsy due to drowning,
whereby the findings of a massive vital decompression with pulmonary
barotrauma and lethal gas embolism were identified in the radiological images. In
this situation, MSCT and MRI were superior to autopsy in their ability to
demonstrate the extent and distribution of gas accumulation in intraparenchymal
blood vessels of internal organs as well as in areas of the body which were
inaccessible by standard classical autopsy (Plattner, 2003).

Forensic reconstruction
Traumatic lesions of the subcutaneous fatty tissue provide important clues for
forensic reconstruction. The interpretation of these patterns requires a precise
description and recording of the position and extent of each lesion. During
conventional autopsy, this evaluation is performed by dissecting the skin and
subcutaneous tissues in successive layers. In this way, depending on the force
and type of impact (right angle or tangent), several morphologically distinct
stages of fatty tissue damage can be differentiated: (I) perilobular haemorrhage,
(II) contusion, or (III) disintegration of the fat lobuli, and (IV) disintegration with
development of a subcutaneous cavity. These lesions can also be recorded and
classified using MSCT and MRI in cases with blunt trauma to the skin and fatty
tissue (Yen et al, 2004).

Yen (Yen2 et al, 2005), in a case report of 5 deceased persons (1 female and 4
male, mean age of 49.8 years and age range of 20-80 years) who had suffered
odontoid fractures or atlantoaxial distractions with or without medullary injuries,
showed that the imaging methods for forensic reconstruction were superior to
autopsy neck exploration in all cases. This is due to the post-processing
possibilities of viewing the imaging data to determine the value of post-mortem
neck imaging in comparison to forensic autopsy regarding the evaluation of the
cause of death and the analysis of biomechanical aspects of neck trauma.
Evaluation of the findings was performed by radiologists, forensic pathologists
and neuropathologists and the cause of death could be established radiologically
in three of the five cases. The MRI data, however, were insufficient in detecting
ascending medullary oedema as the cause of delayed death which was detected
by histological analysis (Yen2 et al, 2005).
Until now, only a few institutes of forensic medicine have acquired experience in
post-mortem cross-sectional imaging. Protocols, image interpretation and
visualisation have to be adapted to the post-mortem conditions. Especially, post-
mortem alterations, such as putrefaction and livores, different temperature of the
corpse and the loss of the circulation are a challenge for the imaging process and
interpretation (Jackowski1 et al, 2005). Bolliger ( Bolliger, 2005) supported and is
agreeable to further post-mortem research and validation is needed.

Radiological imaging techniques are particularly beneficial for reconstruction and

visualisation of forensic cases, including the opportunity to use the data for
expert witness reports, teaching, quality control, and telemedical consultation
(Thali et al, 2003). Limitations of the approach are cases of major vessel injury
and cases that show an advanced stage of decay (Jackowski2 et al, 2005).
Digital autopsy technique would impact and prompt the teaching, experiment,
research and application of forensic pathology with the development of operation
guiding system and micro-imaging technique. However, because of the limitation
of software, hardware and the expense, this technique needs to be improved
(Xiao et al, 2005).

Social Implication

MSCT and MRI are useful instruments with an increased value compared with
2D radiographs to augment the external findings of bodies when an autopsy is
refused (Bolliger S et al, 2005). This technology may be a way to overcome
religious and cultural sensitivities (www.medicine.com.my, 2005).

Legal Implication

Church (Church, 2004) affirmed that as long ago as 400 BC, Hippocrates and his
followers recognised that someone must oversee the practice of medicine and
impose effective consequences when practice proves substandard. Key roles
imaging plays in criminal cases must be understood. One must also be aware of
legal concerns raised by new technologies.

Harris (Harris, 1991) reported that MRI of the whole formalin-fixed brain
produced details of pathologic changes deep within brain substance which are
not apparent on external examination. Photographs of these radiographic images
present pathologic features in a black-and-white 2-dimensional format which has
proven particularly effective in court before judge and jury. He also noted
acceptance of such photographs in explaining to jurors the details of his
testimony in selected cases where brain trauma resulted in a wrongful death.
Penetrating missile wounds and blunt impact injuries are particularly well
documented by this method.

Organisational Implication
Training - Human resource
The rapid further development of computed tomography (CT) and magnetic
resonance imaging (MRI) induced the idea to use these techniques for post-
mortem documentation of forensic findings. Until now, only a few institutes of
forensic medicine have acquired experience in post-mortem cross-sectional
imaging. Protocols, image interpretation and visualisation have to be adapted to
the post-mortem conditions (Jackowski3 et al, 2005).

Medical examiners and forensic anthropologists are less versed in the finer
points of radiology than radiologists; nevertheless they are required to interpret
findings from imaging studies to further conduct medico-legal investigations. The
forensic investigator often should call upon the radiologist whose expertise might
prove invaluable in forensic consultations (Kahana & Hiss, 2002). An article in
www.medicine.com.my (2005) noted that interpretation of medical images
requires either a radiologist trained in forensic or a forensic scientist trained in
radiology. This method will not help overcome the issue of shortage of forensic
pathologists.

Cost/Economics Implication

No relevant literature on cost implications was retrieved.

6. CONCLUSION

There is some evidence on effectiveness of digital autopsy in determining the

cause of death that is due trauma. There is insufficient evidence on timing of
death, identification and other causes of death i.e. death due to non-trauma,
hanging or manual strangulation, burnt, gun shot, infection and drowning. Most
evidence gathered on the above mentioned causes of death are case reports,
case studies, case series and review papers.

Socially, this technology may be useful but the legal implications are yet to be
studied for admissibility in court.

Radiology training is required for the forensic pathologists to develop skills in

using virtual autopsy.

7. RECOMMENDATION

Digital autopsy is of use to determine the cause of death that is suspected/due to

trauma, especially involving the skeletal structures. Its use in other forensic
pathologic situations is complementary to clinical autopsy.
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Technology reviews are brief reports, prepared on an urgent basis, which draw on restricted
reviews and analysis of pertinent literature and on expert opinion and regulatory status where
appropriate. They are not subject to an external review process.