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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 4  |  Page : 149-156

Application and Prospect of Postmortem Imaging Technology in Forensic Cardiac Pathology: A Systemic Review

1 Department of Forensic Pathology, Shanghai Key Laboratory of Forensic Medicine, Key Laboratory of Forensic Science, Ministry of Justice, Shanghai Forensic Service Platform, Academy of Forensic Science, Shanghai, China
2 Special Standard Laboratories Dept, China National Accreditation Service for Conformity Assessment, Beijing, China

Date of Submission03-Nov-2022
Date of Decision11-Dec-2022
Date of Acceptance12-Dec-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. Yanbin Wang
Special Standard Laboratories Dept., China National Accreditation Service for Conformity Assessment, Beijing 100062
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfsm.jfsm_129_22

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Postmortem imaging (PMI) technology known as virtual autopsy or virtopsy is regarded as a useful method of noninvasive or minimally invasive autopsy in forensic practice. Postmortem computed tomography is applicable to traumatic investigation, acute hemorrhage, pulmonary parenchyma disease, calcification (calculus, atherosclerosis), and gas accumulation. Postmortem magnetic resonance (PMMR) has been proven to have advantages in soft tissue identification. Cardiac death is one of the keys and difficult points in forensic practice. With the introduction and development of PMCT angiography and PMMR, it was proved to be a very promising tool in the investigation of cardiac death, including vascular cavities and ischemic myocardium. This article reviewed the applications of the latest PMI and its related technologies in forensic cardiac pathology, including advantages, limitations, and development prospects.

Keywords: Forensic cardiac pathology, postmortem computed tomography angiography, postmortem computed tomography, postmortem imaging, postmortem magnetic resonance, review, sudden cardiac death, virtopsy

How to cite this article:
Liu N, Yang M, Tian Z, Dong H, Lu Y, Zou D, Wang Y. Application and Prospect of Postmortem Imaging Technology in Forensic Cardiac Pathology: A Systemic Review. J Forensic Sci Med 2022;8:149-56

How to cite this URL:
Liu N, Yang M, Tian Z, Dong H, Lu Y, Zou D, Wang Y. Application and Prospect of Postmortem Imaging Technology in Forensic Cardiac Pathology: A Systemic Review. J Forensic Sci Med [serial online] 2022 [cited 2023 Feb 3];8:149-56. Available from: https://www.jfsmonline.com/text.asp?2022/8/4/149/366419

  Introduction Top

Postmortem imaging (PMI) technology has been proven to be a useful diagnostic tool in forensic practice.[1],[2] Having many advantages over traditional autopsy,[3],[4] PMI technology is also known as virtual autopsy or virtopsy. A traditional autopsy report depends on the descriptive records by a forensic examiner. Due to destructiveness, autopsy not only may lead to evidence lost, which might make it difficult to carry out an independent secondary examination again but also may cause potential pain to the family members of the deceased. Especially in some religious and cultural groups, such as the Jewish and Muslim communities, a traditional autopsy always incurred strong opposition.[5],[6] After used PMI, a large amount of reliable evidence can be obtained through noninvasive or minimally invasive autopsy. Digital image data can be easily transmitted and permanently stored for future viewing. Moreover, the imaging scanning before autopsy can also guide the focus of autopsy, so that pathologists can prepare in advance for possible accidental discoveries such as hemorrhage or foreign bodies during autopsy.[7],[8],[9],[10] Among PMI technologies, postmortem computed tomography (PMCT) is applicable to traumatic investigation, acute hemorrhage, pulmonary parenchyma disease, calcification (calculus and atherosclerosis), gas accumulation, and other conditions.[11],[12],[13] Postmortem magnetic resonance (PMMR) has been proven to have advantages in soft-tissue identification although it is rarely used.[14]

Cardiac death is a common cause of death in forensic medicine. It is also one of the keys and difficult points in forensic practice. Sudden cardiac death (SCD) is a catastrophic complication of many heart diseases, which usually occurs without warning.[15],[16] 10%–15% of SCDs are caused by cardiomyopathy with morphological matrix, such as hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy/dysplasia, and myocardial invasive diseases (i.e., sarcoidosis).[17],[18] To clarify the cause of SCD death, autopsy is generally regarded as the “gold standard.” Initially, PMI was considered to have limited effect and low accuracy in the investigation of cardiovascular (CV) diseases.[19] With the introduction and development of PMCT angiography (PMCTA) and PMMR, it was proved to be a very promising tool in the investigation of cardiac death, including vascular cavities and ischemic myocardium.[20]

This article reviewed the applications of the latest PMI and its related technologies in forensic cardiac pathology, including advantages, limitations, and development prospects. It intends to deepen readers' understanding of these new technologies in forensic cardiology.

  Postmortem Imaging Technologies in Cardiac Death Investigation Top

In the late 1990s, PMI was gradually introduced as an alternative to traditional autopsy. More and more studies have evaluated the diagnostic value of PMCT and magnetic resonance imaging (MRI), with or without image-guided biopsy.[21],[22] Postmortem systemic angiography using computed tomography (CT) or MRI has become technically feasible. Angiography of organ or tissue has also been used in autopsy procedures.[23] In recent years, a series of PMI techniques related to forensic cardiac pathology have gradually been performed.

Postmortem computed tomography

PMCT can help to better locate the cause of traumatic death, especially in the detection of injuries which cannot be proved by traditional autopsy. As for the cardiac death, PMCT can be used to identify diseases such as pericardium or aortic rupture. In addition, other technologies such as the positioning of CV medical implants and the definition of heart size seemed to become more and more helpful.[24]

PMCT can detect blood in the body cavity, such as pericardium or hemothorax, which showed high-density fluid. It can be a clue to confirm bleeding.[25] However, if there is doubt about the exact location of the bleeding source, the recognition ability of PMCT will be limited. Gas or air can be accurately displayed on PMCT due to its low density,[26] even if there is a small amount of gas in blood vessels, soft tissues, or body cavities. The discovery of gas in the body could be helpful for the diagnosis of iatrogenic stab injuries or medical accidents since they are difficult to find in ordinary forensic autopsy.[27] However, PMCT is unable to monitor the source of gas accumulation and distinguish between prenatal gas (such as air embolism) and early putrid gas, so it is also limited in the application of gas source search.[28] To detect emboli or blood clots in the CV system, some scientists tried to evaluate them on the unenhanced PMCT, for example, by distinguishing between different pulmonary artery contents and the presence of perivascular edema in the lower limbs,[29] or evaluate the forensic application value of identifying thrombus in the cardiac cavity by studying the images of massive and casting high-density areas in the right cardiac cavity.[30]

As for SCD, PMCT is more sensitive in identifying coronary atherosclerosis, valve calcification,[31] and hypertrophic or dilated cardiomyopathy,[32] but less sensitive in identifying coronary stenosis, coronary thrombosis, acute myocardial infarction, and fibrotic cardiac scar.[13],[33] For ischemic heart disease (IHD), PMCT can improve suspicion by showing the degree of coronary artery calcification. However, due to the low contrast of soft tissue, PMCT cannot evaluate the degree of coronary artery stenosis, so it has limited application value for vascular system visualization.[28]

Postmortem computed tomography angiography

In order to provide adequate visualization of vascular structure, forensic scholars established PMCTA. It is a method of selective angiography of CV system for PMI investigation, which was similar to the method of contrast agent injection in clinical CT practice.[1],[23],[34],[35] PMCTA can be performed in a single organ,[36] or in the whole-body vascular system.[37],[38] The former is allowed by injecting a contrast agent into a target organ in situ or extracted from the body,[38] the latter is to display the entire vascular system by injecting contrast agent into the vessel.[39] PMCTA shows great potential for comprehensive and objective assessment of important vascular structures.[24]

PMCTA techniques mainly include three methods: angiography during terminal cardiopulmonary resuscitation, selective angiography, which is also called targeted coronary angiography, and systemic angiography. The whole-body angiography method using a modified heart-lung machine and large amount of contrast agents could display the whole-body vascular circulation including the coronary artery.[40] Postmortem selective CT angiography of single organs has been developed as an effective method in forensic pathology to study the vascular diseases of specific organs, such as the heart or brain.[41],[42] Targeted coronary angiography can be performed by two injection routes: selective coronary angiography by injecting contrast agent into the aorta before autopsy,[36],[43] or directly injecting contrast agent into the coronary artery after removing the heart during autopsy. Full frontal angiography of a single organ can be used as a supplement to macroscopic and microscopic examinations.[42],[44]

Grabherr et al.[20] introduced multistage postmortem computed tomography angiography (MPMCTA) method. It has become one of the best technologies for studying the CV system. This technology has greatly improved the clarity and resolution of postmortem angiography through three stages of angiography. Comparing MPMCTA with autopsy results, it was found that,[20],[34],[39],[45] MPMCTA can effectively develop vascular dissection, aneurysm, or vascular occlusion, proving that this method is the first choice for displaying vascular abnormalities. It was found that the combination of left ventricular (LV) puncture angiography and PMCT findings was helpful to diagnose the forensic cases of aortic rupture.[46],[47] A method of PMCTA targeting the lung through the right ventricle, which can be used as an effective auxiliary tool to identify Pulmonary thromboembolism (PTE), was also introduced in forensic practice.[48]

PMCTA has considerable potential in the diagnosis of fatal acute bleeding and the detection of the source of bleeding. It was found that PMCTA seemed to be more sensitive than pre-mortal angiography in detecting the involved blood vessels.[49] The whole-body PMCTA can display the aortic arch and the whole thoracoabdominal aorta, so it has advantages in the diagnosis of aortic dissection and rupture. In addition, it can also assess the location and extent of aortic dissection, as well as the extent to which the lesion involves other branches.[50] In the case of myocardial rupture, PMCTA showed that the contrast agent directly infiltrates the pericardium cavity. It located the ruptured infarction or traumatic myocardial injury accurately. Hence, it was helpful for the determination of the cause of pericardial hematocele.[51] The combination of PMCT and PMCTA has a better effect on the diagnosis of CV or cerebrovascular system injuries and diseases.[37],[40],[52] For patients who died of CV disease, PMCTA can detect the severity of coronary artery stenosis, evaluate its impact on hemodynamics, judge the location of infarcted myocardium by contrast agent defect[9] or accumulation,[53] and serve as a guide for autopsy and histological sampling.[27],[54] It was found by cases study that PMCTA can prove the functional correlation of vascular stenosis by showing the degree of organ perfusion.[55],[56]

Postmortem magnetic resonance imaging

Unlike its clinical examination methods, forensic PMI allows isolated hearts to be examined separately, which was named postmortem cardiac magnetic resonance (PMCMR). Some preliminary results have been obtained by PMCMR on animal hearts that dipped into a box filled with saline,[57] as well as human hearts fixed with formaldehyde were also examined.[58] There are the following benefits of PMCMR examination on isolated hearts: (i) enabling high-resolution images at the submillimeter level, (ii) the heart can be kept at room temperature, and PMCMR examination can be scheduled to overcome the limitation of examination time, and (iii) the heart was examined separately, which would reduce the cost of cadaver transport. Although PMCMR has high sensitivity and specificity in identifying structural heart disease, no systematic study has been conducted to evaluate the effect of fixation on the magnetic properties of myocardial tissue.[59]

The advantage of MRI technology is soft-tissue imaging. Compared with CT, PMMR has benefits in the diagnosis of myocardial infarction. Some studies have shown that the imaging effect is not only better than PMCTA,[11],[60] but also has a good performance in distinguishing the old or new degree of infarction. Jackowski et al.[61] compared the results of 8 patients with nonenhanced PMMR and histological examination after autopsy. In acute myocardial ischemia cases, it was found that there were signal reduction areas on the T2-weighted, STIR, and FLAIR sequences of myocardial PMMR. The positions corresponded to the core necrotic areas detected by autopsy and histology. In subacute myocardial infarction cases, the myocardium could be found to have increased signal on T2-weighted, STIR, and FLAIR sequences. The necrotic tissue was replaced by fibroblasts and accompanied by new blood vessels in this area by histological comparison. In the case of chronic myocardial infarction, the signal of the myocardial PMMR images on T2, STIR, FLAIR, and T1 sequences showed a continuous decrease in area, which was identified as a large amount of collagen deposition by histological examination. Another study of 16 cases showed that[62] even in aging cases of acute, subacute, and chronic infarction, there is a good correlation of abnormal areas between PMMR and histological findings. The main findings were as follows: acute infarction showed hypointensity in the central infarct area on T2-weighted sequence as well as that in the peripheral edema area. Subacute infarction area showed hyperintensity, and chronic infarction showed an extensive signal loss in all sequences. Zech et al.[63] and Schwendener et al.[64] got similar conclusions by compared the PMMR results of myocardial infarction with the histological findings of the autopsy.

Ruder et al.[65] evaluated the ability of PMCMR to detect chemical shift artifacts (CSA) in the identification of coronary artery disease (CAD). Differences in resonant frequencies of fat and water on T2-weighted images can produce CSA which can represent markers of vascular patency because they are visible if the coronary arteries are unaffected. The authors also found that another marker of CAD was associated with the presence of arterial stiffness, the so-called pairwise dark bands. Using high-resolution 3D-SSFP, the pulse train technique exploits the ability of PMMR to assess coronary artery anatomy.

Although PMMR has value in forensic cardiological pathology, its application is still limited in forensic practice study because of the high cost, long testing time, complex technology, lack of technical standard, and lack of forensic experts with both radiological and CV pathological experience and ability.[11]

  New Application and Prospect of Postmortem Imaging Technologies Top

With the development of PMI research, more and more new other technologies were gradually introduced. Multi-technologies fusion has produced many meaningful results, showing a promising prospect in the forensic medical area.

Image-guided cardiac biopsy

In order to obtain tissues for histopathological examination, some researchers tried to use postmortem biopsy as an alternative method of autopsy tissue sampling. The success rate of biopsy sampling has been evaluated.[66] Ross et al.[10] performed whole-body CT angiography in 20 patients with acute chest pain before death. Image-guided myocardial biopsy was then conducted after PMCTA. Through preliminary analysis of the cross-sectional images, additional pulmonary clot biopsies were performed to distinguish pulmonary embolism from postmortem clots. Subsequently, traditional autopsy and histopathology samples were taken from all cases. The results showed that in 19 of the 20 corpses, the causes of death found in the traditional autopsy could be confirmed by postmortem CT and angiography combined with CT-guided biopsy. The authors believed that the combination of PMCTA and image-guided biopsy may serve as a minimally invasive triage tool to assist in forensic diagnosis of suspected CV causes of death.

Bolliger et al.[67] also examined 20 corpses in a minimally invasive manner, and compared the results with those obtained in the subsequent autopsy and histological analysis. The results showed that in terms of main findings and diagnosis of causes of death, 18 out of 20 cases of minimally invasive examination obtained almost the same results as autopsy and histopathology. Wagensveld et al.[68] performed routine autopsy, unenhanced whole-body MRI and CT, and then CT-guided biopsy for 100 adult patients who died consecutively in the hospital. The results showed that MRI combined with biopsy had the highest accuracy in detecting acute and chronic myocardial infarction. The sensitivity and specificity were 0.97 and 0.95 for acute myocardial infarction and 0.95 for chronic MI, respectively. In comparison, MRI without biopsy showed high specificity, but low sensitivity. CT (Total Agaston Calcium Score) has a good diagnostic value for chronic myocardial infarction, but it is not applicable to acute myocardial infarction. Therefore, the authors believe that MRI combined with biopsy can achieve good results in detecting acute and chronic myocardial ischemia.

Postmortem heart measurement

The measurement of CV is an important link in forensic medicine. Some measured data of heart are directly related to the results of cardiac disease. The increase of heart weight may indicate HCM, some valve diseases, advanced chemical heart disease, pulmonary hypertension, and other chronic diseases. The measurement of the circumference of the heart valve can be used to evaluate the cardiac function. The increase in aortic diameter indicates that the most common aortic disease is dominated by various types of aneurysms or noninflammatory mediators associated with inflammation.[69],[70] Conventionally, CV measurement at autopsy is the only objective parameter of pathological cardiac function. All changes in these data should be carefully considered during autopsy and histological examination.[71] Hence, it is necessary to find new radio CV measurements related to autopsy findings with the help of MPMCTA, which becomes an indispensable research field of PMI.

LV hypertrophy may be associated with a high risk of severe heart disease and sudden death.[72],[73],[74] The cardiothoracic ratio (CTR) was initially a common index in clinical imaging evaluation of cardiac hypertrophy. In the early stage, it was measured by chest plain film, and then CTR was measured by CT to diagnose cardiac hypertrophy. Winklhofer et al.[75] proposed 0.5 CTR threshold can be used to identify cardiac hypertrophy with high specificity by investigating the CTR of 170 PMCT cases. Jotterand et al.[76],[77] concluded that CTR can be used to diagnose cardiac hypertrophy on PMCT based on the study of 109 autopsy case samples. However, due to the influence of some variables, such as body mass index (BMI), or perinatal changes, such as cardiothoracic resuscitation, blood clots, and gastric contents or blood inhalation, a careful evaluation of CTR measurements was required.

Cardiac hypertrophy is mainly manifested in the increase of heart weight and/or changes in myocardial thickness or cardiac dilatation. Hatch et al.[78] explored the method of estimating the heart weight by measuring the LV peripheral area (LVCA). They retrospectively measured LVCA through CT scanning of 50 cases, and compared it with the measured heart weight in the time report, and established a linear regression equation between the heart weight and the actual heart weight. Ruder et al.[74] used a similar method to derive a formula for predicting heart weight from magnetic resonance (MR) measurements of the LV area, wall thickness on short axis and four chamber sectional images (LVA-4C) based on 29 patients. Deepened on a linear correlation analysis, it showed that the measurement of the LV area on the four-chamber MR section of the postmortem heart can reflect the actual heart weight of the deceased. Ogawa et al.[79] calculated cardiac and LV weights through PMCT morphometry. They assumed that the left ventricle was an ellipsoid, multiplied its volume by the myocardial specific gravity on PMCT. It was shown that the calculation of LV weight through PMCT could predict the heart weight at autopsy.

Although the accuracy of cardiac measurements in PMCT and PMMR was rather satisfied, there were still significant differences between the measured values of autopsy and virtopsy parameters such as ventricular wall thickness and cardiac valve circumference. The measured values of cardiac in situ measurement may be thicker.[80] Okuma et al.[81] also found that the thickness of the LV wall of 57 cardiac autopsy CT victims was significantly greater than that measured in autopsy specimens. These findings suggested that the conclusion should be carefully in assessing cardiac hypertrophy through PMI. Moreover, a normal range table of cardiac measurements for radiological autopsy needs to be established to more accurately diagnose ventricular hypertrophy and dilation.[82]

Artificial intelligence aided postmortem diagnosis

Recently many AI technologies have been used in the recognition and automatic segmentation of CV tissues in clinical CT images, and have achieved good results. AI is a broadly defined term. The methods of deep learning (DL) and machine learning (ML) used in many current researches belong to AI technology. ML methods can be divided into unsupervised learning and supervised learning according to whether there are manually labeled labels (such as biopsy results of diseases) input into the model.[83] Unsupervised learning does not require manual annotation, but the results obtained from the model may be less intuitive. Compared with unsupervised learning, supervised learning needs professionals to label data based on known results, and to train optimization models based on existing data sets, so the latter may consume a lot of time and energy.

In clinical radiology, there are a lot of development methods based on ML.[84] Baskaran et al.[85] designed an end-to-end DL model, which can automatically segment the cardiac cavity volume and the myocardial mass of the left ventricle, and can greatly reduce the workload. AI has also achieved good results in segmenting epicardial fat.[86],[87] Commandeur et al.[88] used the data set of 850 patients with coronary artery calcification scores from multiple centers to segment epicardial adipose tissue using the DL method, and the results were close to those of experienced radiologists. Martin et al.[89] evaluated a Convolutional neural network (CNN)-based model for automatic coronary artery calcification scoring on plain scan cardiac CT images. The results showed that the model was highly consistent with the reference standard. Xiong et al.[90] developed a new framework using the AdaBoost classifier to obtain three myocardial characteristics (standardized myocardial perfusion density, transmural perfusion ratio, and wall thickness) from resting-state CT myocardial perfusion images. The model has satisfactory results in sensitivity, specificity, and accuracy for predicting obstructive CAD.

PMCT scanning can contain more than 10,000 single images, which may bring a huge workload to forensic pathologists in practice. Therefore, this technology has practical significance for automatic segmentation, recognition, and diagnosis of PMI. Ampanozi et al.[91] proposed the potential application of depth learning technology in forensic radiology in their review article on the potential use of depth learning technology in autopsy imaging. The automatic analysis of PMCT images has also become one of the research priorities determined by the First International Forensic Radiology Research Summit.[92] At present, there have been attempts at the automatic diagnosis of brain injury images, and it is planned to use artificial intelligence DL technology to observe and analyze the CT values and patterns of pulmonary artery contents to distinguish or identify pulmonary artery thrombosis and postmortem clots.[48] With the further integration of clinical imaging technology and AI technology, the use of DL technology in the field of forensic medicine to solve the postmortem diagnosis of cardiac death also has certain technical potential prospects.[77]

  Advantages and Disadvantages Top

Autopsy imaging has played an important role in forensic routine. PMCT has been used as a routine scanning tool. PMCTA allows morphological evaluation of coronary arteries and detection of suspected stenosis and occlusion. PMMR provides better soft-tissue visualization and higher resolution to determine cardiac lesions. However, despite the increasing contribution of autopsy imaging technology to CV pathology, there is no consensus on the role of autopsy imaging in autopsy diagnosis, especially for CV diseases leading to SCD. CV pathology poses special diagnostic challenges in both clinical and postmortem settings. More research is needed to determine the effectiveness and limitations of postmortem radiological evaluation of CV pathology.

  Conclusion and Prospect Top

In the field of forensic cardiac pathology, postmortem imaging technology has made rapid progress in recent years. However, presently PMI can only be used as an auxiliary implement to the identification of the cause of death. The autopsy is still the gold standard. PMCT has advantages in detecting injuries and bleeding, but it is almost impossible to identify CV disease and soft-tissue lesions. PMCTA has advantages in detecting vascular diseases, and PMMR has great application prospects in IHD and myocardial infarction. Image-guided biopsy can make up for the deficiency of histological examination. The introduction of artificial intelligence technology is helpful to the development and application of automatic diagnosis of forensic PMI. With the development of image visualization technology and computer technology, PMI technology is expected to become an important and indispensable new method of forensic cardiac pathology.


This article is supported by grants from the National Key Research and Development Program of China (no. 2022YFC3302002); the Council of National Science Foundation of China (grant number 82171872), the Council of National Science Foundation of Shanghai (grant number 21ZR1464600), Key Laboratory of judicial expertise of Ministry of Justice and Shanghai Key Laboratory of Forensic Medicine (grant number 21DZ2270800), Shanghai Forensic Service Platform (grant number 19DZ2292700), Central Research Institute Public Project (grant numbers 2020Z-4, 2021G-4), and Shanghai Key Laboratory of Forensic Medicine, Key Lab of Forensic Science, Ministry of Justice (grant number KF202120).

Financial support and sponsorship

By grants from the National Key Research and Development Program of China (no. 2022YFC3302002); the Council of National Science Foundation of China (grant number 82171872), the Council of National Science Foundation of Shanghai (grant number 21ZR1464600), Key Laboratory of judicial expertise of Ministry of Justice and Shanghai Key Laboratory of Forensic Medicine (grant number 21DZ2270800), Shanghai Forensic Service Platform (grant number 19DZ2292700), Central Research Institute Public Project (grant numbers2020Z-4, 2021G-4), and Shanghai Key Laboratory of Forensic Medicine, Key Lab of Forensic Science, Ministry of Justice (grant number KF202120).

Conflicts of interest

There are no conflicts of interest.

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