Case ReportPostmortem angiography in computed tomography and magnetic resonance imaging in a case of fatal hemorrhage due to an arterio-venous malformation in the brain☆
Introduction
Postmortem computed tomography (PMCT) and magnetic resonance imaging (PMMR) have become important elements of forensic radiology. These techniques are widely used in routine postmortem forensic investigations, supporting or in some cases even replacing conventional autopsy [1], [2], [3], [4], [5], [6]. Based on radiological data of the deceased, forensic pathologists and radiologists are provided with valuable and rapidly acquired information on the cause and manner of death [6], [7].
Postmortem computed tomography angiography (PMCTA) was recently introduced to forensic investigations [8], [9]. It provides a detailed presentation of the vessel system of the entire body for diagnoses of hemorrhages, vessel ruptures, stenosis, aneurysms and dissections [9], [10], [11], [12].
Whereas the feasibility and potential of PMCTA have been largely explored, postmortem magnetic resonance angiography (PMMRA) has been mostly neglected to date, though the literature indicates that the technical quality of PMMRA images is approximately equivalent to PMCTA [13].
Vascular malformations are the most common cause of intracerebral hemorrhage in young people. The average annual bleeding risk due to malformation is estimated to be approximately 2% in previously unruptured arterio-venous malformation (AVM) cases, and a high rate of morbidity and mortality [14], [15], [16], [17] is noted. The risk of death in the case of brain hemorrhage is 10–15% [18].
So far, direct comparison of CT/CT angiography and MRI/MRI angiography is only described in few clinical cases [19], [20], [21], [22]. To our knowledge, in postmortem imaging this case represents the first of its kind where both PMCT(A) and PMMR(A) were applied.
Section snippets
Case history
A 42-year-old man did not arrive at work and was found dead at home 1 day later. The flat was normally locked. The lock was drilled to allow access by the police. The deceased was found lying on his bed in a supine position. Stomach content was located on the pillow beneath the head. External examination of the body by a local physician revealed no external injuries. The time of death was roughly estimated to the night before. The cause of death and manner of death could not be defined. The body
Results
Both PMCT and PMMR revealed extensive intra-axial brain hemorrhage and perifocal temporo-parietal edema. Imaging revealed a distinct midline shift of 10 mm to the right; liquor ventricles appeared narrow and revealed an intraventricular hemorrhage (Fig. 1). Despite typical postmortem tissue swelling, brain edema was present. Compared with PMCT, better assessment of the soft tissue and parenchymal lesions was noted with PMMR (Fig. 1, Fig. 2).
Both PMCTA and PMMRA depicted an arterial malformation,
Discussion
In this case, extensive forensic imaging was performed to eliminate third-party involvement, as the decedent was relatively young, and to determine cause of death. PMCT previously revealed the large intra-axial hemorrhage, and PMCTA permitted the classification of a natural cause of death. However, PMMR allowed for a better assessment of the brain tissue and the hemorrhage with perifocal edema than PMCT(A). In addition, the small meandered vessels of the nidus were assessable on PMMR due to
Conclusion
PMCT(A) and PMMR(A) are primarily used as an adjunct to standard forensic autopsy. However, in this case, these techniques were able to answer the question of both cause and manner of death. The prosecutor accepted the results and conclusions obtained exclusively from forensic imaging and cancelled the mandate for autopsy. This is yet another case affirming the increasing significance of postmortem imaging in general and virtual autopsy (virtopsy) or minimally invasive autopsy procedures [1],
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Nothing to disclose.