Post-mortem forensic neuroimaging: Correlation of MSCT
and MRI findings with autopsy results§
Kathrin Yen a,b,*, Karl-Olof Lovblad c, Eva Scheurer a, Christoph Ozdoba d,Michael J. Thali a, Emin Aghayev a, Christian Jackowski a, Javier Anon a,d,
Nathalie Frickey e, Karin Zwygart f, Joachim Weis g, Richard Dirnhofer a
a Institute of Forensic Medicine, University of Bern, 3012 Bern, Switzerlandb Forensic Radiology Department, Center of Clinical-Theoretical Medicine, Medical University of Graz, Austria
c Department of Neuroradiology, University of Geneva, Switzerlandd Department of Radiology, Insel Hospitel Bern, Switzerland
e Department of Anesthesiology and Intensive Care, University Hospital of Vienna, Austriaf Department of Clinical Research, Magnetic Resonance Spectroscopy and Methodology, University of Bern, Switzerland
g Institute of Neuropathology, RWTH University, Aachen, Germany
Received 28 August 2006; received in revised form 15 December 2006; accepted 21 January 2007
Available online 28 February 2007
www.elsevier.com/locate/forsciint
Forensic Science International 173 (2007) 21–35
Abstract
Multislice-computed tomography (MSCT) and magnetic resonance imaging (MRI) are increasingly used for forensic purposes. Based on broad
experience in clinical neuroimaging, post-mortem MSCT and MRI were performed in 57 forensic cases with the goal to evaluate the radiological
methods concerning their usability for forensic head and brain examination. An experienced clinical radiologist evaluated the imaging data. The
results were compared to the autopsy findings that served as the gold standard with regard to common forensic neurotrauma findings such as skull
fractures, soft tissue lesions of the scalp, various forms of intracranial hemorrhage or signs of increased brain pressure. The sensitivity of the
imaging methods ranged from 100% (e.g., heat-induced alterations, intracranial gas) to zero (e.g., mediobasal impression marks as a sign of
increased brain pressure, plaques jaunes). The agreement between MRI and CT was 69%. The radiological methods prevalently failed in the
detection of lesions smaller than 3 mm of size, whereas they were generally satisfactory concerning the evaluation of intracranial hemorrhage. Due
to its advanced 2D and 3D post-processing possibilities, CT in particular possessed certain advantages in comparison with autopsy with regard to
forensic reconstruction. MRI showed forensically relevant findings not seen during autopsy in several cases. The partly limited sensitivity of
imaging that was observed in this retrospective study was based on several factors: besides general technical limitations it became apparent that
clinical radiologists require a sound basic forensic background in order to detect specific signs. Focused teaching sessions will be essential to
improve the outcome in future examinations. On the other hand, the autopsy protocols should be further standardized to allow an exact comparison
of imaging and autopsy data. In consideration of these facts, MRI and CT have the power to play an important role in future forensic
neuropathological examination.
# 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: CT; MRI; Forensic imaging; Virtopsy; Post-mortem neuroradiology
§ Supported by grants from the Gebert-Ruef-Foundation, Basel, Switzerland,
and from the Government of Vorarlberg, Bregenz, Austria.
* Corresponding author at: Forensic Radiology Department, Center of
Clinical-Theoretical Medicine, Medical University of Graz, Harrachgasse 21,
A-8010 Graz, Austria. Tel.: +43 316 380 7586.
E-mail address: [email protected] (K. Yen).
0379-0738/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.forsciint.2007.01.027
1. Introduction
Neurotraumatology and neuropathology play an important
role in forensic medicine. This is reflected in the statistics that
show traumatic head and brain injury to be the cause of death or
severe disablement in thousands of persons each year.
According to available European statistics, traumatic head
and brain injury has an incidence rate ranging between 150/
100,000 p.a. and 836/100,000 p.a., with serious and fatal cases
K. Yen et al. / Forensic Science International 173 (2007) 21–3522
ranging from 9/100,000 p.a. to 22/100,000 p.a. [1–4]. In one
German study, 68.4% of those with severe head injuries died
before hospital admission [3]. Traumatic head and brain
injuries are especially common in young children and the
elderly, and in Europe and Canada are primarily the result of
motor vehicle accidents, work or sport accidents, and falls in
the elderly. In the United States, most head and brain injuries
occur in young adults and are caused by firearms [5–8]. There is
a need for exact and reliable investigation methods in the
forensic examination of these manifold cases.
The gold standard for the post-mortem forensic assessment
of neurotraumatologic and neuropathological findings is the
forensic autopsy including histological examination. Primary
advantages of this method include direct information by
inspection and palpation and the possibility of taking tissue
specimens. One limitation of autopsy is that it is subjective and
observer-dependent, and cannot be used to provide a second
opinion in court due to the fact that the body tissues are cut and
cannot be stored for a longer time except for selected parts or
small specimens for histological examination. Radiological
imaging methods such as MRI and CT are increasingly entering
the field of forensic medicine, offering a non-invasive
investigation approach, thereby allowing an unlimited storage
of the imaging data and facilitating second opinions in the
course of legal proceedings [9–13]. Considering that CT and
MRI might play an ever-increasing role in post-mortem
forensic neurotraumatology, the principal advantages and
limitations of these imaging methods will have to be evaluated
concerning the possibility of the detection, interpretation and
visualization of forensically relevant findings in comparison
with standard forensic autopsy.
The goal of this study was to evaluate the value of CT and
MR imaging as diagnostic tools for their use in routine forensic
examination of the head, and to investigate the potential
benefits and limitations of the imaging methods in comparison
with autopsy.
2. Methods
2.1. Subjects
The responsible justice department and the local ethics committee approved
the present retrospective study which was part of the ‘‘Virtopsy’’ project [13].
Fifty-seven bodies representing a continuous sample of ‘‘routine’’ forensic
cases were studied using post-mortem pre-autopsy imaging (39 male, 18
female, mean age 42.3 years, range 22 weeks to 87 years).
Table 1
Typical MR imaging parameters
Sequence Coil TRa (ms) TEa (ms) Matrixa,b (mm)
PD/T2 Head 4000 15/85 256 � 192
GRASS Head 300 8–20 256 � 224
T1 Head 400 10–20 256 � 192
T2 Head 4000 85–105 512 � 256
a Slightly deviant parameters in early cases.b Depending on slice direction and volume.c The number of slices exceeded up to 88 when the neck was scanned within thd depending on slice thickness and sequence.
Forty-five of the deceased had suffered head trauma (motor vehicle acci-
dents, n = 22; gunshot injuries, n = 7; falls, n = 6; airplane crashes, n = 4; blunt
force trauma and beating, n = 4; shaken baby syndrome, n = 1, birth trauma,
n = 1), two were natural deaths due to heart failure. The remaining incidents
were hanging, n = 2; throttling, n = 3; drowning, n = 1; mechanical trauma to
regions other than the head (suicidal stabbing), n = 1, medical malpractice,
n = 1, abortion, n = 1, and one was a diving incident. In addition to these, the
MR data of one decomposed body that underwent MR-spectroscopy were
compared to the autopsy findings.
2.2. Post-mortem MSCT and MR imaging
Except for the MR-spectroscopy case, all bodies underwent post-mortem
MSCT and MRI with the scans being performed in clinical units. For imaging,
the bodies were wrapped in two body bags to prevent contamination of the
scanners with blood or other materials and to guarantee the anonymity of the
deceased. A local undertaker transported the corpses to the MSCT and MRI
units. The mean delay between the declaration of death and imaging was
approximately 20 h.
MSCT (GE Lightspeed QX/i unit, General Electric Systems, Milwaukee,
WI) of the head and neck was performed with a collimation of
4 mm � 1.25 mm and a slice thickness of 1.5 mm. All MR examinations were
performed on a 1.5-T system (GE 1.5 T Signa Echospeed Horizon, version 5.8,
General Electric Systems). T1 and T2 weighted sequences, and Gradient
Recalled Acquisition in the Steady State (GRASS) and proton density weighted
sequences were run; the parameters from a typical protocol that was used are
listed in Table 1. All sequences were run in an axial slice orientation. The T2-
sequence was in all cases performed in two different slice orientations (axial and
coronal), and in cases with specific questions (e.g., unclear cause of death,
special reconstruction issues) in a third one. The other sequences were run in
additional coronal or sagittal slice orientations for specifying ambiguous
findings from the axial images. The PD/T2 sequence served as an axial clinical
overview.
The total MR head examination duration was between 40 and 75 min.
MSCT and MR imaging data were transferred to a Siemens (Leonardo, Siemens
medical systems, Erlangen, Germany) or a GE Advantage Windows work-
station respectively (version 9.1, General Electric Medical Systems, Milwau-
kee, WI, USA). Using software provided with the workstations, 2D and 3D
reformations were generated from the MSCT data.
2.3. Forensic autopsy
All bodies were examined externally prior to scanning and the subsequent
autopsy was done by forensic pathologists (K.Y., C.J., E.A., E.S., M.J.T., R.D.).
Standard autopsy was performed with an average delay of 12 h after imaging; in
all corpses, accurate dissection of the cranium was carried out, including
histological analysis in selected cases or bone maceration when a fracture
was present. Forensic reconstruction based on the radiological data was
performed in selected cases (e.g., motor vehicle accidents, gunshot incidents).
According to the autopsy protocols, in 40 of the investigated cases the brain was
considered as the primary ‘‘atrium mortis’’; among these, 24 had suffered
mechanical trauma of the head. Sixteen persons died from central respiratory
arrest due to other reasons (e.g., brain hypoxia following strangulation), and in
FOVb (cm) Slice thicknessa
(mm)
Spacingb
(mm)
Slicesb,c Nexd
24 4 1 56–88 2
24 4 1 18–24 4
24 4 1 22–44 2
24 4 1 56–88 2
e same series.
Fig. 1. MSCT image of the upper head of a man who had fallen from a roof. The
subcutaneous tissue shows swelling and hemorrhage in the left occipito-parietal
region; the location of impact is characterized by contusion bleeding of the
tissue layers under the skin (arrow). Note the hyperdense areas inside the
cranium, which correspond to subarachnoidal hemorrhage.
K. Yen et al. / Forensic Science International 173 (2007) 21–35 23
17 cases the primary atrium mortis was not the brain. As usual in forensic
casework, the main autopsy findings that served as the basis for the definition of
the cause of death were documented in a summary report.
2.4. Radiological evaluation and data analysis
A radiologist from the clinical unit reviewed the MSCTand MRI data during
imaging and suggested preliminary diagnoses. A board-certified radiologist
from a separate radiology unit (K.O.L.) with many years of experience in
diagnostic neuroradiology was responsible for the detailed radiological evalua-
tion on the GE Advantage Windows workstation. The radiologist did the
evaluation blinded to the preliminary evaluation as well as to the autopsy
findings and the photographic documentation. The analysis of the radiological
data was performed with regard to neurotraumatological findings as mentioned
below, which took an average of 30 min per case. As the specific forensic
findings had partially been unknown to the evaluating radiologist, a short
teaching session was held before the evaluation. During this procedure, a
photographic autopsy documentation of the teaching cases (which were not
included in the study) was shown to the radiologist.
A forensic pathologist (K.Y., E.A., C.J., M.J.T.) participated at the MSCT
and MRI scans and the reading sessions (K.Y.). The evaluating radiologist did
not attend the autopsy. In few selected cases where the radiological evaluation
had failed to show a specific autopsy finding, a second look was taken at the
imaging data (K.O.L., C.O.) in knowledge of the autopsy results. The results of
these targeted follow-up examinations have not been included in the statistical
analysis.
Finally, a comparison of radiological and neuropathological findings was
carried out, with the findings documented in the autopsy protocols used as the
gold standard. Sensitivity and specificity of the imaging methods were calcu-
lated for each diagnostic criterion. The following findings were specifically
evaluated in each case: soft tissue injuries of the skin, subcutaneous fatty tissue
and galea; post-mortem alterations (e.g., heat induced injuries, signs of decom-
position); temporal muscles injuries; fractures of the skull and skull base, the
facial bones and cervical vertebrae 1 and 2; intracranial, extra- and intraaxial
hemorrhage, brain contusions and lacerations; plaques jaunes; injuries of the
cerebellum and brain stem; lacerations of the dura mater and tentorium;
pneumencephalon and intracranial foreign bodies; signs of brain edema and
increased brain pressure (e.g., flattened gyri, herniation of the cerebellar tonsils,
midline shifting); vascular embolization, infarction, and pathological disorders
such as atrophy, tumor and congenital malformations. The list of forensically
relevant findings that the radiologist was asked to consider included 122
keywords. Evaluation of the findings was performed in view of a finding being
present in a case or not; exact anatomical or size correlation was not performed
in this study due to the large number of potential findings in each case. This was
also the reason why the radiologist did not search extensively for very discrete
or rare lesions. This procedure was thought to represent a realistic approach of
what could be achieved with a reasonable effort in a routine forensic-radi-
ological examination. In addition, the main findings that were reported in the
autopsy summary report as being the relevant basis for the definition of the
cause of death were compared to the results of the radiological evaluation. The
goal of this procedure was to determine whether the imaging methods are suited
for the detection of the most essential findings concerning the definition of the
cause of death. For forensic reconstruction, the impact axis and the sequence of
events were analyzed as usual in forensic practise in selected cases. These data
were compared to the imaging results regarding the presence, visibility and
presentation of the relevant findings for the reconstruction.
3. Results
3.1. Extracranial findings: skin, galea and temporal
muscles (Table 2a and b; Fig. 1)
Findings that were regularly present were abrasions,
contusions and lacerations of the scalp, which were detected
by MRI rather than CT; however and not surprisingly,
concerning all forms of scalp injury, autopsy was far superior
to the imaging methods. Abrasions were found only in 1 of 18
cases using MRI or CT (sensitivity 6%). MRI and CT showed a
sensitivity of 100% in the evaluation of entrance gunshot
wounds (n = 6) and heat-induced alterations of the skin and
galea (n = 3). Hemorrhage of the temporal muscles was present
in 20 autopsy cases and diagnosed by imaging in 15 (MRI) and
13 (CT), respectively. Overall specificity for the skin, galea and
temporal muscle findings was 97% for CT and 98% for MRI.
3.2. Extracranial findings: skull, skull base and cervical
vertebrae 1 and 2 (Table 2c and d; Figs. 2 and 3)
Twenty-four skull fractures and 20 fractures of the skull base
were found at autopsy, and in 3 cases post-mortem heat-induced
fractures were present that were each detected by both MRI and
CT. Unsurprisingly, CT was better suited to the evaluation of
osseous lesions which were detected at rates of 75% (fractures
of the skull, n = 24) to 100% (mandible fractures, n = 3). CT
revealed seven maxilla and three mandible fractures that were
not mentioned in the autopsy protocols. Imaging failed in the
differentiation of the various fracture forms (e.g., burst fracture,
impression fracture), which was most probably due to the
radiologist being unfamiliar with these forensic classifications.
In our cases, two fractures of the first vertebra remained
undetected by imaging whereas CT revealed two of four
vertebra 2 fractures. In all missed vertebral fractures extensive
osseous injuries of the posterior cranial fossa and upper cervical
spine region were present. Concerning the osseous findings, the
specificity was 96% for CT and 98% for MRI.
Table 2
Correlation of MSCT and MRI with the autopsy findings
K. Yen et al. / Forensic Science International 173 (2007) 21–3524
Table 2 (Continued )
1a, c, e, g, i, k, m (left side) display the sensitivity of CT and MRI, and b, d, f, h, j, l, n show the absolute numbers of true positive findings in comparison with autopsy.2The numbers refer to the cases with each finding.
K. Yen et al. / Forensic Science International 173 (2007) 21–3526
3.3. Intracranial, extra-axial hemorrhage: epidural
hematoma, heat-induced epidural hematoma, subdural and
subarachnoid hemorrhage (Table 2e and f; Figs. 3–6)
CT and MRI were almost equivalent in the evaluation of
extra-axial hemorrhage that overall was found in a satisfactory
correlation with the autopsy. The sensitivity ranged between
100% for CT and MRI for the detection of heat-induced
epidural hematoma (n = 3) and 73% (MRI) or 68%, respec-
tively (CT), for the recognition of subdural hemorrhage
(n = 22). In the cases where CT and MRI missed subdural
Fig. 2. Death on site in a motor vehicle accident (driver). The person was
expelled and subsequently overrun by a car. The 3D bone volume-rendered
MSCT scan excellently shows the flexion (and bursting) fracture system on the
left side of the head where a nut from the undercarriage of the car had primary
contact with the skull.
hemorrhage the finding corresponded to a blood layer less than
3 mm in thickness. In the evaluation of extra-axial hematoma,
both imaging techniques showed false positive findings,
particularly of subarachnoid hemorrhage (CT: 11 false positive,
MRI: 9). A young woman who had been manually strangled
presented with distinct subdural hemorrhage at autopsy that
was not visible in CT or MRI even in retrospective analysis,
providing evidence that the hemorrhage might have emerged
post-mortem after the imaging (Fig. 6).
Fig. 3. 3D bone and soft tissue volume-rendered MSCT data demonstrating
heat-induced fracture in a man who died in an airplane crash. Note the typical
‘‘desquamation’’ of the skull bone (white arrows). In the regions where the bone
is missing the dura mater can be seen with parts of epidural hematoma (yellow
arrows).
Fig. 4. Epidural hematoma in a burnt body. (A) In this axial MSCT image epidural hematoma that occurred due to heat is seen in the frontal region; note the inclusion
of air in the hematoma. The covering bones are partially destroyed. (B) Corresponding autopsy finding showing a good correlation to the imaging result.
K. Yen et al. / Forensic Science International 173 (2007) 21–35 27
3.4. Intracranial, intra-axial findings: contusions,
intracerebral hemorrhage, lacerations, brainstem injuries,
decerebration, pneumencephalon; dura mater and
tentorium lesions (Table 2g–l; Fig. 7)
Fifty-three percent of the gray matter contusions were seen
at CT, and MRI detected 41% of those; the radiological
methods were sufficient in the evaluation of findings that had
been termed as ‘‘coup’’ or ‘‘contre-coup’’ lesions during
autopsy. It became obvious that especially findings smaller than
3 mm regularly escaped the radiologist’s analysis. MR and CT
imaging showed a sensitivity of 63% in the detection of
hemorrhages in the white matter and were superior to the
autopsy concerning the evaluation of ventricular hemorrhage as
well as pneumencephalon. As the autopsy was used as the gold
standard in our examination and both findings were rarely
Fig. 5. Eighty-year-old man who died hours after a fall in a tramway. (A) Subdura
components and massive swelling of the brain with compression of the ventricles and
autopsy findings show a good correlation to the imaging data in this case. Due to tech
CT scanning plane. Therefore, the hemorrhagic lesions in the right temporo-occip
mentioned in the autopsy protocols, this was reflected by a high
number of false positive findings. CT revealed ventricular
hemorrhage that had not been described in the autopsy
protocols in 19 cases (MRI: 16) and the finding of a
pneumencephalon in 22 cases (MRI: 17), respectively. The
finding of ‘‘plaques jaunes’’ (n = 2) escaped the radiological
evaluation. MRI was superior to CT concerning the identifica-
tion of lacerations in the brain tissue and brainstem injuries.
The majority of dura mater ruptures were not seen using
imaging methods (sensitivity 31% for MRI, 25% for CT;
specificity 100% for both imaging methods).
Overall specificity for intra- and extra-axial findings was
94% for both CT and MRI. The lowest specificity of each 70%
was found for subarachnoid hemorrhage, ventricular hemor-
rhage and pneumencephalon, the latter being findings that were
rarely mentioned in the autopsy protocols.
l hematoma (yellow arrows) on the right side showing separation of the blood
midline shifting (orange arrows) are easily detected in this MSCT slice. (B) The
nical reasons the plane of the Flechsig cut is hardly ever exactly the same as the
ital region are not displayed in the CT slice shown in (A).
Fig. 6. Twenty-one-year-old female who had been manually strangled. No signs of head trauma. (A) Axial MSCT showing no signs of intracranial hemorrhage.
Diffuse swelling of the brain with levelling of the sulci is however present, and the gray/white matter distinction is markedly reduced. (B) The same case at the
autopsy. Here, the examination revealed distinct subdural hemorrhage that was interpreted to have occurred post-mortem after the imaging, possibly as a
transportation effect. According to clinical experience, subdural hemorrhage of this extent should be seen without difficulties using imaging methods.
K. Yen et al. / Forensic Science International 173 (2007) 21–3528
3.5. Edema, increased brain pressure (Table 2m and n;
Fig. 5)
CT revealed edema of the brain tissue in 85% of the cases
and was slightly superior to MRI (76%) concerning this
common finding. However, the ‘‘classical’’ forensic signs of
increased brain pressure (e.g., flattened gyri, protrusion of
Fig. 7. Intracerebral hemorrhage in a man who died hours after a fall. (A) This axial g
extensive secondary hemorrhage in the right temporo-occipital region of the brain (
arrows). (B) In the formalin-fixed autopsy specimen the finding is also observed. Not
to smearing of blood when cutting the brain tissue.
the cerebellar tonsils) mostly escaped the radiologist’s
evaluation. The overall specificity for edema and increased
brain pressure was 89% for CT and 93% for MRI; among all
findings in this group, the specificity was especially low
concerning generalized brain edema without signs of
increased brain pressure (n = 25; specificity 33% for CT,
52% for MRI, respectively).
radient echo-weighted MR image (TR 300, TE 8.0) well illustrates the finding of
yellow arrows). Furthermore, subdural hemorrhage is seen on this slice (orange
e that the extent of the hemorrhage would easily be overestimated at autopsy due
Fig. 8. MRI findings in a far decomposed body. (A) A hyperintense region in the frontal brain that is consistent with intracerebral hemorrhage is clearly depicted in
this T2 weighted MR image (TR 6000, TE 105). In the right back, a small part of epidural hematoma can be observed in this slice (arrow). MR shows a good imaging
quality despite the brain being in a far decomposed state. (B) At autopsy, the finding of intracerebral hemorrhage is seen well only before the brain is extracted from
the intracranial cavity. Note that the extent of the hematoma seems to be larger than at MRI due to the blood having been smeared at the autopsy. After the first cut,
further dissection is difficult due to the tissue being relatively liquid.
Fig. 9. Suicidal gunshot to the mouth. In this 3D air structure reconstruction
using the MSCT data, air filling of the transverse sinuses is well represented.
The ruptured transverse sinuses were considered as being the portal of air entry
(arrows) that caused air embolism of the heart. The finding was verified by
means of radiology and autopsy.
K. Yen et al. / Forensic Science International 173 (2007) 21–35 29
3.6. Other forensically relevant findings (Figs. 8 and 9)
In a case of a downstairs fall, a large infarction area was seen
at MRI that had been underestimated at autopsy. Beginning
signs of intravital autolysis were present in four cases; all of
them remained undetected at both CT and MRI. On the other
hand, advanced decomposition was detected correctly in all
three cases. In one of these, imaging showed marked epidural
and intracerebral hemorrhage that was more difficult to detect
at autopsy due to the advanced decomposition of the brain
tissue (Fig. 8). Gaseous embolism was shown in two cases by
CT imaging and in one of them by MRI (Fig. 9).
3.7. Evaluation of the cause of death
The main findings for the definition of the cause of death were
detected correctly by imaging in 19 of the 24 (79.2%) head
trauma cases with the brain as the primary atrium mortis. In three
cases (12.5%), the relevant findings that had been noted in the
autopsy summary reports were found to a large part, with one
exception each (i.e., laceration at the base of the brain,
subcortical contusion at the base of the brain, increased brain
pressure). In two cases (8.3%), the main findings were not
detected correctly using imaging methods. Of the 17 cases that
died from extracranial lesions, 10 (58.8%) did not show any
relevant intracranial findings except for small subarachnoid
hemorrhage or slightly increased brain pressure. In the other
seven bodies (41.2%), findings such as intracerebral hemorrhage
or signs of a significant increase of brain pressure were observed.
However, due to the thorax and abdomen being not evaluated in
this study, the assessment of the relevance of intracranial findings
in view of the cause of death was not performed.
3.8. Forensic reconstruction
Due to the advanced possibilities of 2D and 3D
reconstruction of the digital data, especially when based
Fig. 10. Five-month-old baby which was examined because of suspected shaken baby syndrome. (A) 3D volume-rendered MSCT showing the venous sinuses from
behind (t, sinus transversus; ss, sinus sagittalis superior). An extravasation of blood is seen in the frontal cranial vault region (arrows). However, this tiny blood layer
was detected only in a second look examination and in knowledge of the autopsy findings. (B) Corresponding autopsy specimen depicting a small subdural blood layer
(arrows). The finding is not revealed in both axial CT (C) and axial MRI (T1 weighted MR sequence, TR 400, TE 14.0) (D).
K. Yen et al. / Forensic Science International 173 (2007) 21–3530
on CT (Fig. 2), imaging-based reconstruction of the
impact axis or the sequence of events was generally superior
to autopsy especially in view of its feasibility and
the visibility of the traumatic findings. CT and MRI
revealed case-relevant information without the need of
performing time-consuming bone maceration techniques
and provided an excellent two- or three-dimensional over-
view. It took about 30 s to generate a 3D skull recon-
struction, and up to about 10 min when special cuts were
applied.
3.9. Agreement between CT and MRI
Concerning all findings that were evaluated in this
study, the overall agreement between CT and MRI was
69%.
3.10. ‘‘Second-look’’ examination (in knowledge of the
autopsy findings; Fig. 10)
In an exemplary second-look examination of the skull base
with the focus only on orbital roof fractures, seven of eight
fractures were correctly detected; one was not visible even
retrospectively and with knowledge of the autopsy findings.
The diagnosis of specific skull fracture types such as burst or
impression fractures became possible especially when using 3D
reconstructed CT data and after giving the radiologist more
profound forensic background concerning these findings
(Fig. 2). Another forensically relevant issue that was almost
unknown to clinical radiologists was the differentiation of
hematoma caused by direct traumatic impact versus ‘‘indirect’’
fracture hematoma. In the second look examination, this
differentiation was feasible when based on the MR imaging
Fig. 11. Suicidal gunshot to the right temple demonstrating grossly altered anatomy. (A) This sagittal T2-weighted MR image (TR 5000, TE 105) shows massive
destruction of the brain and skull fractures. The brain is sunken back and the frontal region filled with air. (B) Corresponding T1-weighted axial MR slice (TR 480, TE
14) displaying the grossly altered anatomy and partial decerebration.
K. Yen et al. / Forensic Science International 173 (2007) 21–35 31
data, as fracture hematoma of the galea was not accompanied
by subcutaneous fatty tissue hemorrhage of the covering
tissues.
In a case of a motor vehicle accident as well as in one
gunshot injury case, the injury leading to the entrance of air in
the cranial cavity, thus being the origin of gaseous embolism of
the heart, was detected using CT. Missing parts of the brain
could be defined in cases with partial decerebration; however,
in these cases diagnosis was complicated due to the grossly
altered anatomy (Fig. 11). Some lesions of the dura mater were
not seen even in knowledge of the autopsy findings especially
when they were localized near the skull base. In one case of
shaken baby syndrome, CT was found to be negative but
retrospectively revealed the finding of a slight subdural blood
layer (Fig. 10).
4. Discussion
Post-mortem plain radiography of the head has been
routinely used in forensic medicine mainly for the evaluation
of gunshot injuries and for identification purposes [14, and
references therein]. Cranial CT imaging is increasingly being
performed in forensic examinations [9–11,13,15–24], whereas
most reports that exist on post-mortem MRI of the head and in
situ brain [12,13,19,23–31] are based on small case samples. In
a post-mortem MRI study of six cases Ros et al. [32] concluded
that MRI was well suited for the detection of air and fluids in the
body spaces; however, the autopsy correlation concerning
intracranial findings was poor. Hart et al. [33] found a good
correlation between MRI and autopsy in the post-mortem
examination of 11 cases of suspected child abuse, especially for
subdural hematoma and diffuse edema; on the other hand,
subarachnoid hemorrhage and small subdural hematoma
escaped the radiological evaluation. Forensically relevant CT
or MRI examinations of the formalin-fixed brain have been
performed by several authors [34–38]. Further post-mortem CT
and MRI studies that are of forensic interest to some extent
comprise fetal necropsy [39–45] and imaging of archeological
specimens, as recently performed on the Tutankhamun mummy
(unpublished data).
In clinical forensic medicine, imaging offers the only
possibility to obtain a non-invasive insight into the cranium.
The forensic examiner is thus occasionally confronted with
plain radiographs or CT and MRI data when it comes to
investigate neurotraumatological findings in cases of living
persons. Neuroradiological evaluation in forensic medicine is
based on numerous clinical imaging studies, which have been
performed on living patients over many years; the listing of all
the relevant literature would go far beyond the scope of this
study. In accordance with recent studies, the extensive clinical
experience with CT and MR imaging can be transferred to post-
mortem situations and serve as a basis for post-mortem
diagnostics, as there is no relevant difference between the
radiological appearances of most findings in ante- or post-
mortem brains in the first days after death [12–14,31,32,34].
The sound clinical experience in the field of head and brain
radiology is useful for post-mortem examinations as the clinical
neuroradiologists are familiar with many of the findings
expected. However, our results show that this was not the case
when it came to evaluating several specific forensic aspects
such as particular fracture forms, or cases with massive
destruction of anatomical structures. In the latter group, the
image reader regularly had major difficulties in orientation and
therefore interpretation of the findings (Fig. 11). The problem is
well known from autopsy when destruction of the skull and
brain is so extensive that the structures cannot be anatomically
allocated anymore, but for the forensically inexperienced
radiologist this turned out to be especially problematic.
K. Yen et al. / Forensic Science International 173 (2007) 21–3532
To cover the whole forensic neurotrauma spectrum we
included the evaluation of extracranial findings that are visible
at the external examination of a body (e.g., abrasions or
lacerations of the skin, gunshot wounds) in our study, despite
knowing that the role of imaging for these regions is and
probably will continue to be of little forensic value. The minor
relevance of imaging externally visible findings was reflected
by the poor outcome in this group of findings, which was
probably aggravated by the lack of experience of the radiologist
concerning the evaluation of these findings that are clinically
irrelevant. Furthermore, especially when using MRI data,
radiological analysis was generally difficult in peripheral
regions that were surrounded by air due to artefacts.
Reflecting the results of this study, CT and MR imaging
seem to have a realistic potential to become useful adjuncts to
forensic autopsy in future neurotraumatologic examinations.
The forensic potential of MRI and CT became obvious when it
came to the evaluation of findings such as gunshot-induced
injuries or complex skull fracture systems, where forensic
reconstruction benefited from the excellent image processing
possibilities offered primarily by CT imaging. Compared to
autopsy, imaging was also superior concerning the detection of
pneumencephalon or ventricular hemorrhage. These findings
were rarely mentioned in the autopsy protocols, but appeared
obvious not only to the radiologist, but also to the forensic
examiner in the imaging data. Furthermore, imaging revealed
maxilla and mandible fractures which had not been documen-
ted in the autopsy protocols. Not surprisingly, the finding of
intracranial gas is hardly detected at autopsy even if clearly
present radiologically. As the facial tissues are not cut in the
routine autopsy process due to ethical reasons, facial bone
fractures can easily escape the autopsy evaluation especially if
they are not accompanied by externally visible deformation or
obvious crepitation. For the findings mentioned above,
radiology might represent the new ‘‘golden standard’’, rather
than the autopsy. Follow-up studies will figure out the forensic
value of CT and MRI concerning these findings.
Although there were only three burnt bodies among our
cases, epidural hematoma (Figs. 3 and 4) was seen by means of
radiology in all of them, as were osseous fractures due to heat
(Fig. 3). In a very decomposed body that underwent MR
spectroscopy, the findings of epidural and intracerebral
hemorrhage were accurately diagnosed (Fig. 8); at autopsy,
the location and extent of the findings were harder to evaluate
due to the advanced decomposition and liquefaction of the
brain. This demonstrates that MRI can be of diagnostic value
even in cases with a longer post-mortem interval, and that the
quality of the imaging seems not to be significantly diminished
even by longer post-mortem periods. Another situation in
which MRI was notably advantageous compared to autopsy
was a case of occipital brain infarction due to a massive
increased brain pressure; here, MRI revealed the extent of the
infarction area more distinctly than autopsy.
In the case of a child with suspected shaken baby syndrome,
no craniocerebral abnormalities were found by imaging.
Following autopsy that depicted a thin subdural blood layer,
a second retrospective evaluation including reformatting of the
CT data revealed a tiny subdural hemorrhage (Fig. 10). In
contrast, one manual strangulation case showed distinct
subdural hemorrhage at autopsy to an extent that is normally
detected by both CT and MRI without difficulties. As the
radiological examinations were both negative even when
performed retrospectively, it was concluded that the finding
might have occurred post-mortem after the imaging (Fig. 6).
Concerning the cause of death, CT and MRI showed an
overall good correlation with autopsy. The main findings that
were reported in the summary autopsy reports were detected
correctly in the majority of cases.
Despite the aforementioned, in the present study both MRI
and CT were to a varying extent inferior to autopsy in view of
the detection of several craniocerebral findings. For example,
due to technical limitations (limited resolution), lesions smaller
than 3 mm regularly escaped the radiological analysis. Injuries
that were localized in the base of the brain were also generally
difficult to detect.
4.1. Standardization of the imaging protocols
In some cases no gradient echo sequences had been
performed despite their being especially suited for the detection
of hemorrhagic lesions, and some of the MRI protocols used
were not fully optimized for post-mortem situations, thus
limiting the study’s outcome. Future studies should provide a
standardization of the MRI and CT protocols for post-mortem
craniocerebral imaging as this will be an essential basis for
future forensic neuroimaging, allowing an optimized evaluation
of the traumatological findings and making the results
comparable.
4.2. Technical improvements
As mentioned already, a general problem of using imaging
methods for forensic purposes is the still restricted resolution of
the images that can be obtained. This limited resolution
explains that alterations smaller than about 3 mm in size mostly
escaped imaging, both by CT and MRI. The quality of the
radiological examination was further reduced by diagnostic
difficulties based on imaging artefacts (e.g., susceptibility
artefacts at the scalp/hair and surrounding air barrier
complicating the evaluation of the skin and subcutaneous
tissue). Future technology (e.g., 3 T or more MRI, special post-
mortem sequences) might overcome these problems that are
also relevant in clinical medicine and therefore the topic of
extensive studies in ongoing clinical research. Minimally
invasive imaging techniques (post-mortem angiography [37],
post-mortem biopsy) are currently being developed to increase
the diagnostic range that can be obtained based on imaging
data. Additionally, some specific MRI applications such as
diffusion weighted and diffusion tensor imaging have a
potential value in forensic diagnostics. Diffusion-weighted
MRI is routinely used in clinical medicine for the detection of
acute ischemic lesions [46]. There, it has shown specific
advantages by offering an early and exact demarcation of the
ischemic region, and by allowing a differentiation between
K. Yen et al. / Forensic Science International 173 (2007) 21–35 33
vasogenic and cytotoxic edema through unequal values of the
apparent diffusion coefficient ADC. In other brain lesions such
as hematomas, the utility of diffusion weighted imaging has
been shown to be limited due to the presence of susceptibility-
related artifacts when using echo-planar imaging, but it can,
however, probably help to differentiate between perihemorra-
gic edema and ischemia [47]. Diffusion tensor imaging, on the
other hand, will be very useful in assessing the presence of
small intracerebral lesions that might disrupt normal tissue
integrity, and has a great forensic potential of directly
displaying traumatic disruption of nerve fiber structures [48].
4.3. Forensic training of the radiologists
The present study showed a partially unsatisfactory
correlation between radiological and autopsy findings espe-
cially when it came to evaluate special forensic findings such as
soft tissue injuries of the scalp, various fracture forms, or
specific forensic signs of increased brain pressure. As all these
findings were not familiar to the clinical radiologist and
therefore hardly diagnosed, to our opinion future evaluations
could be improved with a previous training of the involved
radiologists, giving them a sound basis for what findings they
will have to expect and which of these are essential for the
forensic expert. The somewhat unsatisfying concordance of CT
and MR imaging with autopsy concerning a few specific
forensic issues demonstrates the limited outcome when the
forensic-radiological evaluation is done from a radiologist’s
point of view without sufficient forensic training. This is also
reflected by a comment that the reader had ‘‘not especially
searched for orbital roof fractures when the whole skull was
vastly burst’’; in his eyes, this finding was of no relevance
facing the extent of traumatic injury. In a second look, when he
had been asked to look only for orbital fractures, he detected
seven of eight correctly and without problems. Similarly, facing
the extent of accompanying posterior fossa and upper cervical
spine fractures in some neck injury cases, the radiologist did not
focus specifically on vertebral fractures and thus did not
mention them. Concerning the forensically important fracture
forms, the examiner could define various fracture patterns after
having received more profound teaching about the morphology
of these findings. In conclusion, one basic inference that can be
drawn from this study is that the quality of future forensic
expertises that are based upon radiological data will depend
largely on the previous forensic training of the involved
radiological experts.
4.4. Standardization of the autopsy protocols
Besides illustrating the need for forensic training for the
radiologists, the study also demonstrates that the autopsy
protocols need to be further standardized. Since the autopsy
was used as the gold standard, false positive findings occurred
in the radiological examinations; this was due to the fact that
the lesions were indeed present but had not been mentioned in
the autopsy protocols. For example, the finding of a
pneumencephalon had not been noted in the autopsy protocols
even if the head had been partially destroyed, and the autopsy
protocols were generally characterized by a high inter-observer
variance concerning, among others, the description of signs of
increased brain pressure. It appeared that the diagnosis of some
findings such as brain swelling is based on different criteria in
radiological and autopsy evaluation. Midline shifting along
with compression of the liquor spaces is the main sign
indicating increased brain pressure at the radiological evalua-
tion. For the forensic pathologist, swelling of the gyri and
leveling of the sulci, swelling of the cerebellar tonsils, and other
signs such as pressure induced gray matter hemorrhage or the
presence of mediobasal pressure lines are of equal or even
higher diagnostic value concerning the detection of increased
brain pressure at autopsy. These often slight signs are not well
known to the clinical radiologists, which is expressed by low
CT and MRI sensitivity values when comparing the two
methods.
5. Conclusions
The present study has shown some promising results
concerning the diagnostic abilities of CT and MRI in forensic
neuropathology, but it has also demonstrated that further
improvements are needed in order to increase the sensitivity of
forensic-radiological analysis. Allowing the radiological
examiners to gain knowledge about forensically relevant
findings and using standardized autopsy and imaging protocols
as a basis for the comparison of autopsy and radiology will help
to bring the two specialized disciplines closer to each other and
open the door for a prolific interdisciplinary knowledge
transfer. Future forensic-radiological studies are expected to
broaden the basis of the challenging field of forensic
neuroimaging.
Acknowledgments
Special thanks goes to Roland Dorn, Urs Koenigsdorfer and
Therese Perinat (Institute of Forensic Medicine Bern) for
excellent technical assistance and to Verena Beutler, Elke
Spielvogel, Carolina Dobrowolska and Christoph Laeser from
the Insel Hospital Bern for their unremitting help with late-
night data acquisition. Also, many thanks to Christina
Jacobsen, University of Copenhagen, Denmark, for reviewing
the manuscript.
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