Postmortem CT: Applications in Clinical and Forensic Medicine.

Postmortem CT: Applications in Clinical and Forensic Medicine - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Radiographics . 2025 May 15;45(6):e240192. doi: 10.1148/rg.240192 Postmortem CT: Applications in Clinical and Forensic Medicine Nadia Solomon 1, ✉ , Jamie Elifritz 1 , Natalie L Adolphi 1 , Summer J Decker 1 , Laura Filograna 1 , Jeroen J F Kroll 1 , Dominic Gascho 1 , Michael J Thali 1 , Babina Gosangi 1 , Harold Sanchez 1 , Margarita V Revzin 1 , Albert J Sinusas 1 Author information Article notes Copyright and License information 1 From the Departments of Radiology and Biomedical Imaging (N.S., B.G., M.V.R.) and Pathology (H.S.), Yale University School of Medicine, 20 York St, New Haven, CT 06510; Investigative Medicine Program, Yale University Graduate School of Arts and Sciences, New Haven, Conn (N.S.); Yale Translational Research Imaging Center, Yale University School of Medicine, New Haven, Conn (N.S., A.J.S.); The Forensic Radiology Group, Anderson, SC (J.E.); Center for Forensic Imaging, Office of the Medical Investigator, University of New Mexico, Albuquerque, NM (J.E., N.L.A.); Center for Advanced Visualization Technologies in Medicine (VISTA), Keck School of Medicine, University of Southern California, Los Angeles, Calif (S.J.D.); Department of Radiological Sciences, Institute of Radiology, Catholic University of the Sacred Heart, Milan, Italy (L.F.); Eurofins The Maastricht Forensic Institute, Maastricht, the Netherlands (J.J.F.K.); Institute of Forensic Medicine Zurich, University of Zurich, Zurich, Switzerland (D.G., M.J.T.); and Department of Medicine, Section of Cardiology, Yale Translational Research Imaging Center, Yale University School of Medicine, New Haven, Conn (A.J.S.). ✉ Address correspondence to N.S. (email: nsolomon12@gmail.com ). ✉ Corresponding author. Received 2024 May 22; Revision requested 2024 Jun 20; Revised 2024 Jul 11; Accepted 2024 Jul 26; Collection date 2025 Jun. © 2025 by the Radiological Society of North America, Inc. PMC Copyright notice PMCID: PMC12142271  PMID: 40372934 Abstract Just as radiography has been used in forensic medicine since shortly after the discovery of x-rays in 1895, CT was introduced to postmortem investigation not long after its introduction to medicine in the 1970s. In recent decades, forensic radiology has declared itself as a new subspecialty capable of revolutionizing death investigation and research. A variety of postmortem imaging techniques have emerged. Postmortem CT (PMCT) is widely accepted around the world as a supplementary tool and, in specific cases and settings, an alternative to full autopsy. As its popularity grows, however, it is important for radiologists and pathologists to expand their understanding of the applications, benefits, and limitations of these techniques, as well as the unique nuances of postmortem imaging interpretation. This will ensure high-quality interpretations and avoid potential pitfalls that could result in premature or erroneous conclusions. The authors introduce the reader, particularly the radiologist, to the growing subspecialty of forensic imaging (focusing on imaging of the deceased), specifically focusing on PMCT and its applications in death investigation in both clinical and forensic settings. The authors also discuss the benefits and limitations of PMCT as well as important nuances of PMCT interpretation, emphasizing the similarities and differences between clinical and postmortem studies, the necessity of conducting thorough death investigations, and the importance of pursuing specialized education or training in postmortem imaging interpretation. Applications of more specialized imaging techniques to postmortem and forensic investigations are described, including developing research in this area. © RSNA, 2025 Supplemental material is available for this article. Open in a new tab Introduction The vital role of autopsy in medicine has been emphasized since at least the mid-1700s ( 1 ). The word autopsy —from the Greek autopsia , “the act of seeing for oneself”—refers to the postmortem examination of a human body to investigate disease mechanisms and effects and to determine cause of death ( 2 ). There are several components and, therefore, permutations of autopsy procedures. An external examination of the intact body is performed jto provide a detailed description of the remains and to document, typically along with diagrams and digital photographs, the presence of medical devices or superficial marks, scars, or injuries, or any other identifying features (eg, tattoos) ( 3 ). A full or complete autopsy—considered the standard of care at most forensic centers—includes both external examination and internal examination, which is performed by opening and dissection of the body cavities, organs, neck, and brain ( 3 ). When any part of a full autopsy is forgone, the process is referred to as a partial autopsy ( 3 ). While autopsy with histopathologic analysis remains the standard method for determining cause of death, hospital autopsy rates have fallen substantially since the 1950s. Once performed in 50% of cases in the United States, autopsy rates decreased to 7.4% by 2020 ( 4 , 5 ). In the United Kingdom and Wales, rates are now less than 1% ( 6 , 7 ). In fact, autopsy was temporarily stopped altogether at many institutions worldwide during the COVID-19 pandemic, leading some researchers to posit that the resultant absence of data on exact cause of death delayed understanding of disease pathophysiology and development of effective treatment strategies ( 8 ). Irrespective of COVID-19, the decline in the hospital autopsy rate has occurred for a wide variety of reasons, including financial, legal, and religious or otherwise related to personal preference by decedents’ families. Simultaneously, in the forensic setting, the world faces a critical international forensic pathology workforce shortage that has been exacerbated by the high death tolls associated with the opioid epidemic and the COVID-19 pandemic ( 9 ). Taken independently or together, the declining autopsy rate and shortage in the forensic pathology workforce have significant downstream effects. Death certificates are the primary source for mortality data, and mortality data are used to inform on trends in human health and health care. The lack of autopsies therefore leads to unreliable epidemiologic statistics, which ultimately undermines the efficacy of public health efforts and service planning ( 10 ). Despite maintaining its status as the standard method for diagnostic investigation, autopsy is not without its limitations, mainly related to its invasive nature and consequent alteration of the body. As in any activity that relies to a degree on human observation, some findings are subjective. Undocumented gross findings are irrevocably lost with inevitable decomposition or at cremation. Just as radiography has been used in forensic medicine since shortly after the discovery of x-rays in 1895, CT was rapidly incorporated in postmortem investigation after its introduction to medicine in the 1970s ( 11 ). The first reported use of postmortem CT (PMCT) was quickly followed by individual publications and even textbooks. By the new millennium, the Institute of Legal Medicine at the University of Berne in Switzerland founded the Virtopsy Project, the primary aim of which is to establish protocols for incorporating postmortem imaging—including PMCT, postmortem MRI (PMMRI), and optical three-dimensional (3D) documentation of the body surface—into forensic investigations ( 11 , 12 ). Over the decades to follow, forensic radiology would declare itself as a new subspecialty that would revolutionize death investigation all over the world ( 11 ). Technique and Protocols Flach et al ( 11 ) in 2014 and Gascho et al ( 13 ) in 2018 published extensive recommendations on imaging protocols for postmortem imaging, starting with full-body imaging and followed by dedicated sections for higher-resolution imaging as well as reconstructions ( Table 1 ). Because radiation risk is no longer a concern, multiple acquisitions can be performed at higher doses than would be applied in clinical settings, allowing investigators to optimize image quality. Table 1: Imaging Protocol for Multidetector CT (>16 Row) as Part of the Virtopsy Project Open in a new tab Clinical Indications and Applications Postmortem imaging can serve a wide variety of purposes in both hospital and forensic settings. One of the most obvious is to help determine cause of death. The determination of cause of death depends on the correlation of clinical history and the scene narrative with a variety of pathologic findings including gross pathology, histopathology, toxicology, and other laboratory investigations. Manner of death—classified as natural, accident, suicide, homicide, or undetermined—is based on “the circumstances surrounding a particular cause of death and how that cause came into play” ( 14 ). To effectively determine cause of death, the method of investigation must be able to help identify pathologic findings, including findings related to death. In cause of death investigation, PMCT is increasingly used in a wide range of settings and circumstances, and research on its utility and accuracy in each of these settings and the nuances of imaging interpretation is ongoing. In addition to being used to investigate natural deaths, in-hospital deaths, and deaths related to medical treatment, PMCT has demonstrated utility as a supplemental tool in the assessment of blunt and sharp force injury, including penetrating trauma, and in the evaluation of gunshot wounds ( Figs 1 , S1 ) ( 15 – 17 ). In drug overdose deaths, imaging findings combined with toxicology results (for example, opioid toxicity combined with the finding of cerebral edema, pulmonary edema, and a distended urinary bladder at PMCT) support the diagnosis ( Fig 2 ) ( 18 ). PMCT may also allow identification of osseous and cartilaginous injuries related to asphyxiation and strangulation, including choking and hanging. The “gas bubble” sign, the presence of gas within or near the laryngeal structures in a decedent with minimal decomposition, is considered diagnostic of neck trauma ( 19 ). However, it is important to note that autopsy is more sensitive for detecting soft-tissue findings related to such injuries (such as hemorrhage) ( 15 ). The potential for PMCT to assist in investigations of drownings and self-contained underwater breathing apparatus (SCUBA)–related deaths, despite—or perhaps because of—the complex nature of such cases, is an area of particular interest to researchers and forensic investigators ( Fig 3 ) ( 20 – 22 ). In trauma cases, especially those involving a blunt force and polytrauma with extensive bodily injury, PMCT has demonstrated superiority over autopsy for detecting and documenting the type, mechanism, and extent of traumatic injuries, as autopsy often fails to identify many skeletal injuries unless there are obvious signs of their presence ( Figs 4 , S2, S3 ) ( 15 , 23 , 24 ). Figure 1. Open in a new tab PMCT for assessment of trauma. A 63-year-old man was found unresponsive in his hotel room with abundant blood throughout the room. PMCT and autopsy revealed numerous sharp force injuries, particularly concentrated on the left half of the head. Injuries ranged from superficial cuts to full-thickness chop wounds characterized by underlying bruising, bony fractures, and amputations. Defensive-type injuries were identified on the hands and right forearm (not shown). (A, B) Axial PMCT images of the head (bone window) show small fragments of metal in the scalp (arrowhead). (C–E) Axial PMCT images with application of metal windowing using an extended Hounsfield unit range (C, D) and 3D rendering (E) allow improved visualization and characterization of the metallic foreign bodies (arrowheads). Figure 2. Open in a new tab Pulmonary edema and lividity in a 36-year-old man with a history of HIV infection, alcohol use disorder, and illicit drug abuse who was found unresponsive. Axial PMCT image of the chest (lung window) shows diffuse ground-glass opacities with a more dependent distribution in the left lung, accompanied by a small right pleural effusion (arrow) and frothy fluid in the airway (arrowhead), reflecting a combination of pulmonary edema and lividity. Figure 3. Open in a new tab PMCT was performed to investigate the death of a 16-year-old adolescent boy with a history of seizures of unknown cause who did not resurface while swimming in a lake. (A) Coronal PMCT image (lung window) shows diffuse ground-glass opacities, septal thickening (black arrowheads), and layering of high-attenuation sediment in the airways (white arrowheads). (B) Axial PMCT image (bone window) better shows the aspirated high-attenuation sediment in proximal and more distal small airways (arrowheads), a finding highly suggestive of drowning as the cause of death. Figure 4. Open in a new tab PMCT in the assessment of blunt force trauma in a 14-year-old adolescent boy who was riding in a vehicle as a passenger. The driver came to an intersection and slowed but was rear-ended by another car, pushing the vehicle into the intersection and causing a collision. (A) Axial PMCT image of the jaw (bone window) shows a displaced mandibular fracture (arrow), likely obvious at the time of the first responders’ assessment. (B) Further evaluation, however, also shows an acute mildly displaced fracture of the dens (arrow), as demonstrated on the coronal PMCT image. While its utilization for cause of death determination may be its most intuitive application, postmortem imaging has utility even before commencing this inquiry. PMCT, for example, can help establish the “zero status” of the body, the untouched condition before intervention ( 25 ). This can include the ability to verify the presence and placement of medical devices in forensic and clinical settings, including identification of misplaced or suboptimally positioned resuscitative devices (with the caveat that some degree of dislodgment or misplacement may occur during resuscitation attempts or postmortem handling, or when a body is relocated, for example, from a hospital to a medical examiner’s office) ( 15 , 25 ). If postmortem imaging is used in this manner, reevaluation of the imaging study is always possible, even if evidence is lost. Imaging at this time point is also useful for unpacking the body, allowing rapid detection of weapons or explosives or signs of dangerous infectious diseases ( 23 ). One application of whole-body PMCT at some forensic centers is to triage decedents for either external examination or traditional autopsy ( 23 , 26 ). If there are no suspicious findings or circumstances surrounding death and PMCT reveals clear evidence of natural disease or an accidental cause, a full autopsy might be forgone ( 23 ). Determination of cause of death by PMCT combined with noninvasive investigations, but in absence of full autopsy, has been described in a select few case studies ( 27 – 29 ). For some religious and cultural groups opposing traditional autopsy, use of PMCT is highly preferable as it allows the body to remain relatively undisturbed ( 23 ). Certain circumstances are particularly challenging for forensic pathologists, and postmortem imaging can be especially helpful as a supplemental tool in these cases. Although insensitive for detecting signs of vitality during a fire, PMCT of burn victims can help detect foreign bodies or hidden evidence of trauma (signs of potential third-party interference), as well as heat-related fractures and epidural hematomas and postmortem gas collections ( Fig 5 ) ( 30 , 31 ). In investigations of events with mass fatalities, PMCT can be used to determine whether all body parts are collected or if body parts from more than one victim are present ( Fig 6 ) ( 11 ). As with burned bodies, PMCT can also reveal signs of third-party interference ( 11 ). Figure 5. Open in a new tab Examination of a charred body represents a particular forensic challenge, for which imaging can be helpful in documenting injuries caused by burns, as well as those related to cause of death. (A) Photograph shows a charred body. (B) 3D volume-rendered image shows the decedent with original positioning otherwise undisturbed. (C, D) Coronal (C) and sagittal (D) PMCT images show a heat epidural (arrowheads). Figure 6. Open in a new tab Three-dimensional volume-rendered CT images of train crash fatalities display bony and soft-tissue structures. Extensive trauma poses three important questions: (1) are all the body parts present; (2) is there any sign of third-party influence or interference (eg, projectiles or findings suggesting death transpired before the traumatic event); and (3) is identification possible? Postmortem imaging can play a role in decedent identification in a variety of ways. Using biomedical data and known standards, imaging can be used to help establish age, sex, stature, and ethnicity. It can also be used to demonstrate known injuries or congenital or developmental variants or anomalies that may assist in identification. When more traditional methods fail, postmortem imaging can be used in facial reconstruction. These applications can be particularly helpful in the setting of advanced decomposition and in situations necessitating disaster victim identification, including mass fatality events ( 32 , 33 ). Postmortem imaging can also play a role in crime scene reconstruction, helping to demonstrate features like body positioning. Additionally, it can aid in hypothesis testing, evaluating the plausibility of the speculated mechanisms of injury or confirming or questioning the likelihood of events as described by witnesses or perpetrators. Three-dimensional (3D) reconstructions can be used to aid in image interpretation or to create exhibits for courtroom presentation. Diagnostic Accuracy Studies on the diagnostic accuracy of various postmortem imaging methods in determining cause of death have shown promising results. A 2018 systematic review and meta-analysis by Ampanozi et al ( 34 ) of 66 eligible studies compared the diagnostic accuracy of postmortem imaging findings to that of autopsy and revealed high sensitivities of PMCT, postmortem CT angiography (PMCTA), and PMMRI for detecting cause of death. More recently, in 2023, a prospective validation study by Lathrop et al ( 35 ) demonstrated that PMCT and autopsy (while both imperfect) were comparably sensitive for injury detection and that PMCT findings can sufficiently establish cause of death in blunt force injuries, firearm injuries, drug poisoning deaths, and pediatric trauma. These results are reassuring, as they support the idea that applying postmortem imaging to death investigation can help preserve the accuracy of mortality data in the setting of declining autopsy rates. While inferior to autopsy for identifying superficial injuries and soft-tissue and cardiovascular pathologic conditions, PMCT more readily depicts the nature, extent, and distribution of skeletal injuries (including fracture patterns), abnormal accumulations of gas, and foreign bodies ( Figs 3 , 7 , S4 ) ( 36 , 37 ). With diagnostic capabilities similar to those of clinical imaging, postmortem imaging can also reveal evidence of infectious processes and other acute and chronic medical conditions ( Figs S5 , S6 ), and it also plays an important role in investigating certain mechanisms of injury ( Fig S7 ), particularly in the pediatric population ( 38 , 39 ). Even in the presence of the growing body of research demonstrating the accuracy of postmortem imaging and supporting its use in postmortem investigations, it is important to recognize that a degree of “user dependence” applies, as diagnostic accuracy in postmortem imaging interpretation relies on both the completeness of the examination and the experience of the interpreter (these issues will be expanded on later in this article). Figure 7. Open in a new tab PMCT in the assessment of abnormal gas accumulations. A 59-year-old man with a history of alcohol abuse was found on the floor 1 day after experiencing severe abdominal pain, nausea, and vomiting. Axial PMCT images of the abdomen show a shrunken appearance of the liver and ascites (black *). A moderate amount of pneumoperitoneum is present (white *). The presence of pneumoperitoneum in the absence of other postmortem changes in the abdomen suggests this is a true pathologic finding. The cause of death was determined to be intraperitoneal infection, likely spontaneous bacterial peritonitis in the setting of cirrhosis, with gas-forming microbes. Benefits and Advantages Numerous studies have demonstrated undeniable advantages of applying various postmortem imaging techniques to forensic investigation, including cost reduction, the potential to review data at any given time, and expedient acquisition times ( 40 ). Other unique benefits of postmortem imaging include lack of motion artifact and the potential to apply higher radiation doses, both of which improve image quality. PMCT has demonstrated sensitivities comparable to those of autopsy and sufficiency in establishing cause of death in a variety of scenarios, including blunt force injuries, pediatric trauma, firearm injuries, and drug poisonings ( 35 ). In the United Kingdom and Wales, PMCT has gained such widespread acceptance as an alternative to autopsy that the public can request it ( 6 , 7 ). Thus far, however, experts agree that, while PMCT might effectively replace autopsy in some cases, optimal evaluation includes both autopsy and postmortem imaging, with pathologists having access to both a CT scanner and a consulting radiologist who is experienced in postmortem imaging interpretation ( 35 ). Accordingly, the combination of postmortem imaging, autopsy, and histopathologic analysis should be regarded as the new reference standard. Pitfalls, Limitations, and Other Considerations Accurate interpretation of postmortem imaging requires knowledge of forensic pathology, knowledge of radiology, and experience in postmortem imaging interpretation. A thorough understanding of the postmortem appearance of tissues and imaging artifacts, including changes associated with the process of decomposition, is vital. As forensic postmortem investigation is performed primarily by forensic pathologists, it is common for forensic pathologists to also interpret PMCT examinations, and those who routinely do so are able to use PMCT to reliably certify cause and manner of death ( 41 ). As previously mentioned, however, access to a consulting radiologist with the relevant experience is recommended ( 41 ). Accuracy of interpretation also heavily relies on the completeness of the investigation. In some offices, PMCT is increasingly used independently—without autopsy or toxicology—and images are predominantly interpreted by clinical personnel who are not always specifically trained in the nuances of PMCT interpretation ( 42 ). This is problematic as incomplete forensic investigations and the employment of physicians or other personnel without designated training in postmortem imaging interpretation predispose investigators to multiple pitfalls. Ideally, radiologists and forensic pathologists collaborate to ensure a robust investigation, leading to the determination of an accurate cause of death. While PMCT is increasingly used around the world, it is important to recognize that most settings limit investigation to nonenhanced studies. This is important to highlight since one of the most obvious pitfalls in postmortem imaging interpretation results from the technical limitations surrounding interpretation of nonenhanced images. Although its capacity to reveal a wide variety of acute medical pathologic findings is similar to that of nonenhanced clinical CT, nonenhanced PMCT is similarly limited, for example, in its ability to depict signs of vascular pathologic conditions. This is particularly problematic as vascular pathologic conditions represent some of the most common causes of sudden death ( Fig S8 ) ( 40 , 43 ). Individuals with varied forensic imaging training and experience may not understand the limitations of unenhanced studies. Another important pitfall results from incomplete or “targeted” PMCT. In such scenarios, imaging only part of the body can result in missing any pathologic findings located outside of the field of view ( 42 ). Put simply, a failure to look is a failure to find. Whole-body PMCT is therefore recommended before targeted investigations including MRI. Furthermore, PMMRI should never be performed before whole-body PMCT unless the body has been dutifully screened for ferromagnetic foreign bodies that could serve as safety hazards. Ideally, forensic cases should always undergo whole-body PMCT. Beyond the intrinsic limitations of nonenhanced PMCT and incomplete imaging, investigations by personnel lacking training in postmortem imaging interpretation and death investigation carry increased risks of coming to incorrect conclusions regarding cause of death. Potential scenarios include missing fatal findings (especially superficial soft-tissue and many vascular injuries), incorrectly identifying nonfatal findings as fatal, and confusing postmortem changes with pathologic findings. While imaging combined with contextual information and external examination by a pathologist may be sufficient to determine cause of death in some scenarios, the risk of interpretive error increases in the setting of limited pathologic and histopathologic examinations or if PMCT is interpreted in the absence of important contextual information. All PMCT examinations should be evaluated in the context of the external examination, decedent history, circumstances surrounding death, scene narrative, and laboratory test results. History and context are equally vital in postmortem imaging investigations as in clinical imaging. In forensic settings, it is important to be aware that mistakes can carry legal, including criminal, consequences that are life changing for those involved. In terms of dedicated training, its necessity in postmortem imaging interpretation and death investigation may be best emphasized via discussion of postmortem changes. Postmortem and clinical imaging have distinct differences, and it is vital for the interpreting radiologist to be aware of and able to recognize them. When inexperienced or untrained interpreters are presented with postmortem changes, they are at increased risk of erroneously interpreting the causes of these findings. Recognition and accurate interpretation of postmortem changes rely on a thorough understanding of these changes, the mechanisms behind them, and how they affect the appearance of the body on postmortem images ( 44 ). Since these findings are expected, they should not be misinterpreted as pathologic findings related to cause of death. Given its growing popularity as a method to triage for (and, in select cases, replace) full autopsy, PMCT is the primary imaging modality discussed in this article in terms of the appearance of postmortem changes. Expected Findings: Postmortem Changes and Imaging Artifacts Death incites a series of complex chemical and physical changes, some of which begin almost immediately, while the onset of others is more delayed ( Table 2 ) ( 44 – 48 ). The rate at which these changes occur is highly variable and can be hastened or slowed by several variables, both internal (eg, body habitus) and external (eg, ambient temperature, humidity, or the presence of clothing or a heat source) ( 46 ). Because of this, very few generalizations can be made regarding the rate and timeline of decomposition. Determination of the postmortem interval (ie, the time elapsed since death) is a complicated process ( 49 ). Table 2: Physical and Chemical Processes Underlying Decomposition and Postmortem Changes Open in a new tab Postmortem Changes of the Brain The earliest changes associated with decomposition can be appreciated at PMCT within 4–6 hours after death, becoming more obvious within 24–48 hours ( 50 ). One of the first organs affected by postmortem changes is the brain. Some of the earliest findings are similar to those observed in clinical imaging in brain death: loss of gray-white matter differentiation, sulcal effacement, and diffuse parenchymal hypoattenuation (secondary to autolysis, vasogenic edema, and liquefaction) ( 48 , 50 , 51 ). Depending on the degree of swelling, mild effacement of the ventricles and cisterns may also be seen ( 51 ). Other early findings are those associated with lividity—otherwise known as livor mortis and postmortem hypostasis—which occurs throughout the body. In the brain, sedimentation of blood in the setting of diffuse parenchymal hypoattenuation manifests as hyperattenuating cerebral vessels. Therefore, the “hyperdense (hyperattenuating) vessel” sign, a finding on clinical nonenhanced CT images associated with the presence of thrombus, loses relevance in the postmortem setting ( Fig 8 ) ( 51 ). The hyperattenuating appearance of vessels, particularly congested veins, contrasted against hypoattenuating parenchyma can also contribute to an important diagnostic pitfall called pseudosubarachnoid hemorrhage ( Fig 9 ) ( 48 , 52 ). This occurs in both clinical and postmortem settings when nonenhanced CT images demonstrate high-attenuation areas along the cortical sulci, cisterns, or tentorium that resemble subarachnoid hemorrhage but are related to the relative hyperattenuation of the vessels compared with the severely edematous brain ( 48 , 53 ). A symmetric appearance, thickness not exceeding the size of the vessel, and the absence of additional findings such as intra-axial or intraventricular hemorrhage or skull fracture help to differentiate pseudo from true subarachnoid hemorrhage ( Fig S9 ) ( 53 ). Figure 8. Open in a new tab Axial PMCT image of the brain at the circle of Willis in a 63-year-old woman shows hyperattenuating middle cerebral arteries (white arrowheads) as well as hyperattenuating dural venous sinuses (black arrowheads). This postmortem change occurs secondary to sedimentation of cellular elements within small vessels. As such, hyperattenuating cerebral artery is not a reliable sign in the postmortem setting. Figure 9. Open in a new tab Pseudosubarachnoid hemorrhage in a 20-year-old man who was an unrestrained driver in a motor vehicle collision. He was ejected when the vehicle left the roadway and overturned multiple times. Axial PMCT of the brain shows pneumocephalus (*), calvarial fractures (white arrowheads), and linear high-attenuation areas (black arrowheads) along the anterior falx, tentorium cerebelli, and sylvian fissures. While these high-attenuation areas were initially interpreted to represent subarachnoid hemorrhage, no hemorrhage was identified at autopsy (a surprising finding given the nature and extent of trauma). Such pseudosubarachnoid hemorrhage can occur due to the hyperattenuating appearance of vessels contrasted against hypoattenuating edematous parenchyma. Postmortem Vascular Changes While hypostasis and subsequent sedimentation lead to a hyperattenuating appearance of smaller vessels, in larger vessels and the cardiac chambers, sedimentation is associated with dependent layering of hyperattenuating cellular elements and iron-containing components relative to serum, resulting in a hematocrit level ( Fig 10 ) ( 48 ). This finding is useful for identifying hemopericardium, revealing the presence of layering fluid of different densities within the pericardial space ( 48 ). A few studies have investigated whether the configuration of the blood products can indicate whether the pericardial hemorrhage is antemortem (eg, due to aortic dissection) or peri- or postmortem (eg, due to chest compressions) in nature. In “hammer heart” or “hyperdense armored heart,” a high-attenuation clot forms a shell around the heart with a separate encasing layer of serum, giving a more circumferential appearance, and is generally considered an antemortem phenomenon occurring due to molding of the clot within the hemopericardium by persistent cardiac pulsation ( Fig 11 ) ( 48 , 54 , 55 ). Alternatively, a more linear fluid-fluid level is considered more likely to result from chest compressions ( 54 , 55 ). Of note, blood outside the vascular system tends to maintain a high-attenuating appearance even in the setting of decomposition. Figure 10. Open in a new tab Fluid-fluid levels in the large vessels (aorta, main pulmonary artery) and cardiac chambers (arrowheads) in an 80-year-old woman, best depicted on axial (A–C) and sagittal (D) PMCT images. This occurs with cessation of circulation and sedimentation of cellular elements. Figure 11. Open in a new tab Hammer heart in a 61-year-old woman who experienced cardiac arrest and was transported to the emergency department. Family members reportedly heard a thud and found her unresponsive. First responders found her pulseless and apneic. Axial PMCT image of the chest shows a large pericardial effusion with a hyperattenuating component surrounding the heart (black arrowhead) and a peripheral lower-attenuating component (white arrowhead). This appearance is known as “hammer heart” or “hyperdense armored heart.” There is also apparent flattening of the right ventricle. The cause of death at autopsy was determined to be ascending aortic rupture secondary to hypertension, with resultant hemopericardium and cardiac tamponade. The morphology of vessels, particularly large vessels, also changes following death, with loss of blood pressure leading to vascular collapse and facilitating the passage of fluid and gas into potential spaces and recesses ( Fig 12 ) ( 48 ). For example, hemopericardium may result in the appearance of a “pseudodissection” of the ascending aorta secondary to the accumulation of blood in the pericardial space tracking along the aortic root ( Fig 13 ) ( 48 ). Figure 12. Open in a new tab Axial (A, B) and sagittal (C) PMCT images in a 36-year-old man show a grossly retained shape of the thoracic aorta (black arrowhead in A and C ), with decompression or flattening of the abdominal aorta (white arrowhead in B and C ). Figure 13. Open in a new tab Hemopericardium in a 50-year-old man who worked as a chef and reported stomach pain. Although he assumed it was food poisoning, he had no vomiting or diarrhea, and he could not identify what he might have eaten to make him ill. He was witnessed to collapse outside of his apartment. Reformatted coronal oblique PMCT image shows a high-attenuation pericardial effusion representing hemopericardium (black arrow) and a dissection flap extending from the ascending aorta (black arrowhead) into the brachiocephalic artery (white arrowhead). The presence of a trace amount of epicardial fat (white arrows) along the outer wall of the false lumen confirms that the fluid tracking outside of the true lumen is indeed within a false lumen created by a dissection flap and does not represent fluid tracking upward from the pericardial space into a pericardial recess. Postmortem Changes in the Lungs and Airways Postmortem evaluation of the airways and lungs presents multiple diagnostic challenges, especially for those unexperienced in postmortem imaging interpretation. Unlike in clinical imaging, liquid in the trachea and bronchi is a common postmortem finding that occurs due to cellular breakdown. Loss of tone in the esophageal sphincter often results in agonal aspiration with similar findings ( 48 ). Although some studies have identified the presence of “frothy” fluid in the airways as suggestive of drowning death, frothy or foamy sputum has also been described as a clinical symptom of severe pulmonary edema, identified in cases of heart failure or opioid overdose ( 56 ). As such, correlation with decedent history and toxicology results are vital for making an accurate determination of the nature of airway findings ( Figs 1 , 14 ). Although less common, other findings relating to cellular breakdown include small pleural or pericardial effusions, small ascites, or mild periportal edema ( 44 ). Figure 14. Open in a new tab Postmortem evaluation of the airways and lungs. A 69-year-old man with known dysphagia began choking during breakfast. His nurse attempted to perform the Heimlich maneuver, but no bolus emerged. Reformatted oblique PMCT image shows the aspirated material (arrowheads) filling the trachea, main bronchi, and several lobar bronchi. A small amount of ingested material was also seen in the distal esophagus (not shown). As in the rest of the body, hypostasis in the lungs leads to dependent settling of the blood, which, combined with dependent atelectasis and postmortem pulmonary edema (resulting from vascular congestion, altered capillary-alveolar pressure gradients, and increased capillary permeability) leads to the formation of an attenuation gradient within the lung parenchyma. More lucent antegravitationally dependent areas transition in the gravitationally dependent regions to increasingly radiopaque ground-glass or even consolidative-appearing patterns, which can mask underlying pathologic conditions ( Fig 15 ) ( 57 ). Dependent versus antidependent classifications relate to the native body position (not necessarily the body position in the CT scanner). Pulmonary lividity can initially change with decedent repositioning and eventually becomes positionally fixed ( 57 ). Although not always possible, effort should be made to distinguish these gradients of lividity and atelectasis from pathologic pulmonary opacities such as pneumonia, contusions, or sequelae of other circumstances, such as drowning. In such cases, combinations of findings (eg, consolidations accompanied by pneumothorax and rib fractures; septal thickening combined with sediment in the airways) or decedent history (eg, infectious symptoms) can help clarify the cause of the findings ( Figs 16 , 17 ) ( 57 ). Figure 15. Open in a new tab Characteristic postmortem pulmonary lividity in a 31-year-old man with a history of seizures of unknown cause (most recent episode 1 week prior) who was found unresponsive. Axial PMCT image of the chest (lung window) shows dependently layering ground-glass opacities with a relatively well-defined linear border (arrowheads) between the affected and nonaffected parenchyma in an appearance that somewhat resembles a fluid level. This appearance is characteristic of postmortem pulmonary lividity. Note that these opacities can potentially obscure underlying pathologic findings. Figure 16. Open in a new tab Emergency service responders attempted to resuscitate a 70-year-old man who was found unresponsive, but efforts were unsuccessful. Axial PMCT image (lung window) shows a right-sided costochondral cartilage fracture (black arrow), pneumothorax (white arrow), and hemothorax (white arrowhead). Bilateral patchy consolidations (black arrowheads) on a background of ground-glass opacities likely represent a combination of pulmonary contusions and postmortem pulmonary lividity. Figure 17. Open in a new tab Staphylococcus bronchopneumonia in a 27-year-old woman who experienced nausea, vomiting, and dizziness. She told her boyfriend she was thinking about going to urgent care and was later found unresponsive on the couch. Axial (A) and coronal (B) PMCT images show diffuse patchy ground-glass opacities with smaller areas of focal consolidation bilaterally. Culture revealed Staphylococcus bronchopneumonia. It is also important to note that a gradient may be absent in decedents with substantial blood loss ( 57 ). Incorporation of postmortem ventilation and alternation from supine to prone positioning have been suggested as methods for mitigating postmortem changes related to pulmonary lividity and enhancing detection of concomitant findings ( 58 ). Although hypostasis has also been shown at PMMRI to lead to formation of density gradients in other organs, such as the liver and spleen, these do not tend to be appreciable at PMCT ( 44 ). Postmortem Gas Formation and Other Changes of Putrefaction In the postmortem setting, gas formation occurs secondary to putrefaction, a process of bacterial growth and fermentation that begins in the intestines and results in diffuse gaseous distention of the bowel. As decomposition progresses, loss of mucosal integrity facilitates the entrance of gas into the venous system: intravascular gas is typically first noticed in the portal venous system and right heart and continues to spread throughout the venous system as decomposition progresses ( 48 , 50 ). Eventually, gas may be seen throughout organ parenchyma and within muscle ( Fig S10 ) ( 44 ). It is important to note that while portal venous gas is a common early postmortem finding, gas in the hepatic arteries, hepatic veins, or biliary tree—especially before the more obvious diffuse dissemination of gas that occurs with significant decomposition—tends to be associated with trauma or other pathologic causes, as does the presence of intra-arterial gas (eg, due to gunshot wounds, sharp force injuries, or other trauma) ( 50 ). Over time, necrosis of the viscera and brain leads to dependent collapse ( Figs 18 , S11 ). Combined with the accumulation of gas, this can give an appearance misleading for antemortem pathologic gas ( 48 ). In the early stages of decomposition, a focal accumulation of gas in the absence or sparsity of intravascular gas or other obvious signs of decomposition is more suggestive of true pathologic findings, especially under certain circumstances (eg, the setting of known trauma) or if other suggestive findings are present (eg, pneumocephalus accompanied by skull fracture) ( Fig 19 ) ( 50 ). Figure 18. Open in a new tab Axial PMCT images show the progression of decomposition-related changes. Figure 19. Open in a new tab Accumulation of gas in a 63-year-old man with alcohol-related seizure disorder who was found unresponsive by his neighbor. There was no obvious evidence of external trauma, but signs of decomposition were already present. Axial PMCT image of the brain shows pneumocephalus (*), intravascular gas (black arrowheads), and intraventricular gas (white arrowhead), findings representing decomposition-related changes. A notable exception is the postmortem rupture of the esophagus or stomach due to autolytic processes. This can occur earlier in the decomposition process and result in pneumomediastinum or pneumoperitoneum without significant intravascular gas or other signs of decomposition. This scenario presents a particular diagnostic dilemma and requires additional investigation ( 48 ). Additionally, while more widespread gas throughout the vasculature and body cavities could suggest decomposition as the origin, its presence could also interfere with the identification of gas related to true pathologic findings ( 48 ). Changes during and Immediately following Death Other important changes to consider are extrinsic ones taking place either during the agonal period—the period of being moribund or “actively” dying—or shortly after death ( 48 ). Such changes can be related to medical intervention, cardiopulmonary resuscitation (CPR) attempts, organ harvesting, or any other activities or events taking place before imaging. For example, resuscitation attempts are commonly associated with anterior or lateral rib or costochondral cartilage fractures ( Figs 16 , 20 , 21 ) and may also cause medical device misplacement and associated injury, cardiac rupture, pneumothorax, widespread intravascular gas, or laceration or contusion of the lungs or upper abdominal organs, especially when CPR was prolonged or a compression device was applied. When such findings are detected, either in combination or in the setting of reported CPR attempts, extra care should be taken before attributing the findings to another cause ( 48 ). Figure 20. Open in a new tab 3D volume-rendered image of the ribs shows multiple bilateral anterolateral rib fractures (arrowheads) in a 68-year-old man who experienced cardiac arrest and for whom resuscitation was attempted. Such rib fractures are commonly seen as consequences of resuscitative efforts. Figure 21. Open in a new tab PMCT performed before autopsy in a 61-year-old woman shows evidence of harvesting. Coronal (A) and 3D volume-rendered (B) images show replacement of the bilateral humeri, femora, tibiae, fibulae, calcanei, and tali with structural prostheses (arrowheads). These were likely placed for the purpose of maintaining structural integrity of the body for funeral services. Skeletonization In the end stages of decomposition, complete decay of soft tissues results in skeletonization ( Fig 18 ). While the utility of postmortem imaging in cause of death determination is limited in this setting, it can still be useful for anthropologic investigations related to decedent identification, to identify patterns of skeletal trauma or foreign bodies (eg, a bullet or tip of a knife), or to locate residual areas of soft tissue, which can be collected for analysis. Advanced Techniques and Areas of Ongoing Research Postmortem CT Angiography Early studies revealed weaknesses of PMCT in identifying common natural causes of sudden death, such as myocardial infarction or pulmonary embolism ( Fig S8 ) ( 59 ). Although PMCT is limited due to poor visualization of vascular structures, the addition of intravascular contrast material in PMCTA improves characterization of vascular findings and is currently an area of intense ongoing research ( 40 , 43 ). PMCTA may be particularly valuable in cases where pathologic evaluation is difficult due to aberrant coronary anatomy or the presence of stents or other postsurgical changes ( Figs 22 , 23 ). Figure 22. Open in a new tab 3D volume-rendered PMCTA images of an ex vivo heart, retrieved during autopsy in a 68-year-old man, show proximal coronary artery calcifications (arrowheads) and progressive opacification of the coronary arteries following contrast material injections. Figure 23. Open in a new tab Whole-body PMCTA 3D renderings (A–D) with contrast material delivery via a balloon catheter (white arrow in A and B ) inserted into the left subclavian artery and a pressure-controlled heart-lung machine show a large leak at the distal end of a proximal right iliac stent (white arrowhead in A, D , and E ) and a smaller leak at the left common iliac artery (black arrowhead in D and E ). Note the presence of an aortic valve replacement (black arrow in B and C ). Image-guided Biopsy Investigation can also be enhanced by incorporating PMCT-guided biopsy, which can provide tissue samples for histologic analysis ( 60 ). In a 2010 study by Bolliger et al ( 60 ), a combination of PMCT, PMCTA, and PMCT-guided biopsy allowed investigators to accurately determine cause of death in 18 of 20 cases (90%). Although biopsy specimens cannot provide the same breath of data as would be provided by autopsy with extensive microscopic examination of specimens from all organs, the limited histologic examinations or microbial cultures provided by incorporating this minimally invasive approach may serve as a suitable compromise in certain cases, for example, when autopsy is advised but opposed by next of kin ( 60 ). Micro-CT High-resolution micro-CT, commonly used in preclinical research to provide detailed information on the volume, texture, anatomy, and abnormal changes of internal structures, is becoming increasingly used in medical research to study the microstructure of human tissues at a near-histologic spatial resolution ( 61 , 62 ). Studies have identified a role for postmortem micro-CT or CT angiography in the evaluation of atherosclerotic disease, the cardiac conduction system, congenital variants in small fetuses and fetal organs, microvasculature of organs, and small airway pathologic conditions, as well as in the detection of evidence of trauma otherwise too subtle to be detected during traditional autopsy ( 62 – 64 ). In forensic investigations, micro-CT has shown utility in estimating firing range from gunshot wounds, identifying tool marks on or age-related changes of bone, estimating age, and even estimating postmortem interval (via the investigation of pupae development of blowflies) ( 65 ). It has also demonstrated utility as a method of identifying classic metaphyseal lesions, injuries that are highly specific for child abuse ( 66 ). Dual-Energy and Photon-counting CT In dual-energy CT, a second attenuation measurement is obtained by capturing images at a different beam energy (kilovoltage peak), allowing differentiation of materials based on their composition (eg, differentiating foreign bodies and bone, classifying lodged projectiles, and potentially allowing discrimination of antemortem thrombi from postmortem clotting) ( 67 , 68 ). Furthermore, while the diagnostic capacity of PMCT, like that of conventional CT, is limited by beam-hardening artifacts from metal objects such as bullets, application of dual-energy CT can mitigate the effects of such artifacts ( 69 ). The application of photon-counting detector CT to postmortem investigations is a new and exciting prospect for researchers, as photon-counting detector CT is anticipated to further improve the diagnostic capacity of PMCT through improved spatial resolution, decreased noise, and (like dual-energy CT) spectral imaging capabilities that support material differentiation ( Fig 24 ) ( 70 ). Figure 24. Open in a new tab Axial PMCT images of the head (bone window) provide a side-by-side comparison between images acquired with (left) the SOMATOM Definition Flash (Siemens Healthineers) (section thickness, 0.6 mm; matrix, 512 × 512) and (right) the NAEOTOM Alpha (Siemens Healthineers) (section thickness, 0.2 mm; matrix, 1024 × 1024) photon-counting detector CT. Note the marked improvement in spatial resolution in the image acquired using the photon-counting scanner (right). Postmortem MRI As in clinical imaging, PMMRI is superior to PMCT when it comes to soft-tissue discrimination and detail ( Fig 25 , S12 ). This quality has led some researchers to investigate its potential applications to death investigation. Especially in pediatric examinations, PMMRI is increasingly being used. For adults, PMMRI has shown high sensitivity for depicting sequelae of traumatic injury, and it effectively depicts changes in the myocardium, such as focal necrosis with surrounding edema signifying the presence of acute myocardial infarction ( 71 – 73 ). One of the main reasons that PMMRI has not yet been widely adopted in forensic centers is likely that this examination technology is more difficult to adapt to postmortem examinations. Factors such as body temperature and biochemical decomposition processes have a strong influence on the relaxation times and thus on image contrast. Some of these influences are not yet fully understood ( 44 ). Figure 25. Open in a new tab PMCT and PMMRI in a 34-year-old woman with renal failure who was feeling unwell after dialysis. She reported a headache and lower extremity pain and had elevated blood pressure. The next morning, she was found on the floor. The decedent had a history of two kidney transplants, with the most recent transplant having failed over the months preceding her death. (A, B) Axial PMCT images show a right-sided scalp hematoma (arrow in A ), multiple subtle areas of hypoattenuation in the bilateral cerebral hemispheres (arrowheads in A ), and ill-defined low- and mixed-attenuating areas within the cerebellum (arrowheads in B ). An edematous renal transplant with hydronephrosis was seen in the left lower quadrant (not shown). (C, D) Axial postmortem MR images of the brain were obtained and again show the right scalp hematoma (arrow in C ) and multiple T2-hyperintense lesions in the bilateral cerebral (arrowheads in C ) and cerebellar (arrowheads in D ) hemispheres corresponding with the PMCT findings. In the setting of organ transplantation (necessitating immunosuppressive medications, especially in the setting of multiple failed transplants), the findings are concerning for progressive multifocal leukoencephalopathy from John Cunningham (JC) virus infection. Another likely reason is the complexity of the technology, which requires special training of the personnel—including safety training—to both carry out examinations and interpret images ( 44 , 72 ). In this context, PMMRI better fits to target organ analysis, such as the brain or heart. Increased examination time may also be prohibitive to its adoption, particularly in centers with high case volumes or where physician time is limited. Cost to perform the imaging examination is also a factor. However, while PMMRI is more expensive than PMCT, under certain circumstances even imaging protocols that include PMMRI still may be more cost effective compared with autopsy ( 74 ). Nevertheless, special analytic examinations using postmortem MR spectroscopy could provide important knowledge for death investigations. As such, their use could be of particular importance, at least in postmortem research ( 75 ). Conclusion Postmortem imaging is revolutionizing death investigation, and its application will only continue to grow as the subspecialty of forensic radiology continues to prove its utility. It is already an established practice internationally and is becoming established in the United States. PMCT, specifically, is already widely accepted as a supplementary tool and, in select cases, even an alternative to full autopsy. While this transition to incorporation of imaging in death investigation is exciting, it is vital to acknowledge the strengths and limitations of postmortem imaging so that it is responsibly applied and appropriately interpreted. Given the innumerable nuances and caveats of postmortem imaging interpretation, just as with traditional methods of forensic examination, it is important to consider all available information, including postmortem interval, conditions and circumstances under which the body was discovered, any information on the time period leading up to death, and other laboratory findings such as toxicology. As Voltaire eloquently expressed, “To the living we owe respect, but to the dead we owe only the truth.” Acknowledgments Acknowledgments We would like to acknowledge Gary Israel, MD, and David Well, MD, MSE, for reviewing the postmortem imaging studies performed at Yale Translational Imaging Research Center. Funding.— Supported by the National Institutes of Health (T32HL098069, S10RR025555; A.J.S. is principal investigator) and National Institute of Justice (2016-DN-BX-0173; N.L.A. is principal investigator). N.S. supported by RSNA Research Resident Grant (RR2208). Presented as an education exhibit at the 2023 RSNA Annual Meeting. Disclosures of conflicts of interest.—: J.E. Partner and chief medical officer of the The Forensic Radiology Group; board member, editorial board member, and Guidelines Committee chair of the International Society of Forensic Imaging. H.S. Chair of the Autopsy Committee of the College of American Pathologists. S.D. Board member of the International Society of Forensic Radiology and Imaging and RSNA 3D SIG board member and Scientific Advisory Board member. M.V.R. Editorial board member of RadioGraphics . A.J.S. Member of the Cardiovascular Council (CVC) of the Society of Nuclear Medicine and Molecular Imaging (SNMMI). Abbreviations: PMCT postmortem CT PMCTA PMCT angiography PMMRI postmortem MRI 3D three dimensional References 1. Sblano S , Arpaio A , Zotti F , Marzullo A , Bonsignore A , Dell’Erba A

. Discrepancies between clinical and autoptic diagnoses in Italy: evaluation of 879 consecutive cases at the “Policlinico of Bari” teaching hospital in the period 1990-2009 . Ann Ist Super Sanita 2014. ; 50 ( 1 ): 44 – 48 . [ DOI ] [ PubMed ] [ Google Scholar ] 2. Autopsy . Encyclopedia Britannica . https://www.britannica.com/topic/autopsy . Updated July 12, 2024. Accessed January 10, 2024 . 3. Postmortem Examination Types . DC Office of the Chief Medical Examiner Standard Operating Procedures . https://ocme.dc.gov/sites/default/files/dc/sites/ocme/publication/attachments/Postmortem%20Examination%20Types.pdf . Published January 5, 2015. Accessed January 10, 2024 . 4. Dehner LP

. The medical autopsy: past, present, and dubious future . Mo Med 2010. ; 107 ( 2 ): 94 – 100 . [ PMC free article ] [ PubMed ] [ Google Scholar ] 5. Hoyert DL

. Autopsies in the United States in 2020 . https://stacks.cdc.gov/view/cdc/126588 . Published May 24, 2023. Accessed January 10, 2024 . [ PubMed ] 6. Rutty GN , Morgan B , Robinson C , et al . Diagnostic accuracy of post-mortem CT with targeted coronary angiography versus autopsy for coroner-requested post-mortem investigations: a prospective, masked, comparison study . Lancet 2017. ; 390 ( 10090 ): 145 – 154 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Turnbull A , Osborn M , Nicholas N

. Hospital autopsy: Endangered or extinct? J Clin Pathol 2015. ; 68 ( 8 ): 601 – 604 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 8. Salerno M , Sessa F , Piscopo A , et al . No Autopsies on COVID-19 Deaths: A Missed Opportunity and the Lockdown of Science . J Clin Med 2020. ; 9 ( 5 ): 1472 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 9. Weedn VW , Menendez MJ

. Reclaiming the Autopsy as the Practice of Medicine: A Pathway to Remediation of the Forensic Pathology Workforce Shortage? Am J Forensic Med Pathol 2020. ; 41 ( 4 ): 242 – 248 . [ DOI ] [ PubMed ] [ Google Scholar ] 10. Royal College of Pathologists of Australasia Autopsy Working Party . The decline of the hospital autopsy: a safety and quality issue for healthcare in Australia . Med J Aust 2004. ; 180 ( 6 ): 281 – 285 . [ DOI ] [ PubMed ] [ Google Scholar ] 11. Flach PM , Gascho D , Schweitzer W , et al . Imaging in forensic radiology: an illustrated guide for postmortem computed tomography technique and protocols . Forensic Sci Med Pathol 2014. ; 10 ( 4 ): 583 – 606 . [ DOI ] [ PubMed ] [ Google Scholar ] 12. Dirnhofer R , Jackowski C , Vock P , Potter K , Thali MJ

. VIRTOPSY: minimally invasive, imaging-guided virtual autopsy . RadioGraphics 2006. ; 26 ( 5 ): 1305 – 1333 . [ DOI ] [ PubMed ] [ Google Scholar ] 13. Gascho D , Thali MJ , Niemann T

. Post-mortem computed tomography: Technical principles and recommended parameter settings for high-resolution imaging . Med Sci Law 2018. ; 58 ( 1 ): 70 – 82 . [ DOI ] [ PubMed ] [ Google Scholar ] 14. Hanzlick R , Hunsaker JC , Davis GJ

. A Guide For Manner of Death Classification . https://name.memberclicks.net/assets/docs/MANNEROFDEATH.pdf . Published February 2002. Accessed January 10, 2024 . [ Google Scholar ] 15. Chandy PE , Murray N , Khasanova E , Nasir MU , Nicolaou S , Macri F

. Postmortem CT in Trauma: An Overview . Can Assoc Radiol J 2020. ; 71 ( 3 ): 403 – 414 . [ DOI ] [ PubMed ] [ Google Scholar ] 16. Kranioti EF , Spanakis K , Flouri DE , Klontzas ME , Karantanas AH

. Post-mortem CT in the investigation of homicides . Clin Radiol 2023. ; 78 ( 11 ): 832 – 838 . [ DOI ] [ PubMed ] [ Google Scholar ] 17. van Kan RAT , Haest IIH , Lahaye MJ , Hofman PAM

. The diagnostic value of forensic imaging in fatal gunshot incidents: A review of literature . Journal of Forensic Radiology and Imaging 2017. ; 10 : 9 – 14 . [ Google Scholar ] 18. Winklhofer S , Surer E , Ampanozi G , et al . Post-mortem whole body computed tomography of opioid (heroin and methadone) fatalities: frequent findings and comparison to autopsy . Eur Radiol 2014. ; 24 ( 6 ): 1276 – 1282 . [ DOI ] [ PubMed ] [ Google Scholar ] 19. Schulze K , Ebert LC , Ruder TD , et al . The gas bubble sign-a reliable indicator of laryngeal fractures in hanging on post-mortem CT . Br J Radiol 2018. ; 91 ( 1084 ): 20170479 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 20. Lo Re G , Vernuccio F , Galfano MC , et al . Role of virtopsy in the post-mortem diagnosis of drowning . Radiol Med (Torino) 2015. ; 120 ( 3 ): 304 – 308 . [ DOI ] [ PubMed ] [ Google Scholar ] 21. Stephenson L , Van den Heuvel C , Byard RW

. The persistent problem of drowning - A difficult diagnosis with inconclusive tests . J Forensic Leg Med 2019. ; 66 : 79 – 85 . [ DOI ] [ PubMed ] [ Google Scholar ] 22. Edmonds C , Caruso J

. Recent modifications to the investigation of diving related deaths . Forensic Sci Med Pathol 2014. ; 10 ( 1 ): 83 – 90 . [ DOI ] [ PubMed ] [ Google Scholar ] 23. Decker SJ , Braileanu M , Dey C , et al . Forensic Radiology: A Primer . Acad Radiol 2019. ; 26 ( 6 ): 820 – 830 . [ DOI ] [ PubMed ] [ Google Scholar ] 24. Pham L , Portelli Tremont JN , Bruderick A , et al . Post-Mortem CT Delivers Fast and Accurate Injury Identification in Trauma Patients . Am Surg 2022. ; 88 ( 5 ): 973 – 980 . [ DOI ] [ PubMed ] [ Google Scholar ] 25. Norii T , Makino Y , Unuma K , et al . Extraglottic Airway Device Misplacement: A Novel Classification System and Findings in Postmortem Computed Tomography . Ann Emerg Med 2021. ; 77 ( 3 ): 285 – 295 . [ DOI ] [ PubMed ] [ Google Scholar ] 26. Chatzaraki V , Heimer J , Thali M , Dally A , Schweitzer W

. Role of PMCT as a triage tool between external inspection and full autopsy – Case series and review . Journal of Forensic Radiology and Imaging 2018. ; 15 : 26 – 38 . [ Google Scholar ] 27. Ruder TD , Hatch GM , Thali MJ , Fischer N

. One small scan for radiology, one giant leap for forensic medicine - Post-mortem imaging replaces forensic autopsy in a case of traumatic aortic laceration . Leg Med (Tokyo) 2011. ; 13 ( 1 ): 41 – 43 . [ DOI ] [ PubMed ] [ Google Scholar ] 28. Filograna L , Bolliger SA , Spendlove D , Schön C , Flach PM , Thali MJ

. Diagnosis of fatal pulmonary fat embolism with minimally invasive virtual autopsy and post-mortem biopsy . Leg Med (Tokyo) 2010. ; 12 ( 5 ): 233 – 237 . [ DOI ] [ PubMed ] [ Google Scholar ] 29. Filograna L , Tartaglione T , Vetrugno G , Guerra C , Fileni A , Bonomo L

. Freshwater drowning in a child: A case study demonstrating the role of post-mortem computed tomography . Med Sci Law 2015. ; 55 ( 4 ): 304 – 311 . [ DOI ] [ PubMed ] [ Google Scholar ] 30. de Bakker HM , Roelandt GHJ , Soerdjbalie-Maikoe V , van Rijn RR , de Bakker BS

. The value of post-mortem computed tomography of burned victims in a forensic setting . Eur Radiol 2019. ; 29 ( 4 ): 1912 – 1921 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 31. Thali MJ , Yen K , Plattner T , et al . Charred body: virtual autopsy with multi-slice computed tomography and magnetic resonance imaging . J Forensic Sci 2002. ; 47 ( 6 ): 1326 – 1331 . [ PubMed ] [ Google Scholar ] 32. Brough AL , Morgan B , Rutty GN

. Postmortem computed tomography (PMCT) and disaster victim identification . Radiol Med (Torino) 2015. ; 120 ( 9 ): 866 – 873 . [ DOI ] [ PubMed ] [ Google Scholar ] 33. Rutty GN , Biggs MJP , Brough A , et al . Remote post-mortem radiology reporting in disaster victim identification: experience gained in the 2017 Grenfell Tower disaster . Int J Legal Med 2020. ; 134 ( 2 ): 637 – 643 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 34. Ampanozi G , Halbheer D , Ebert LC , Thali MJ , Held U

. Postmortem imaging findings and cause of death determination compared with autopsy: a systematic review of diagnostic test accuracy and meta-analysis . Int J Legal Med 2020. ; 134 ( 1 ): 321 – 337 . [ DOI ] [ PubMed ] [ Google Scholar ] 35. Lathrop SL , Wiest PW , Andrews SW , et al . Can computed tomography replace or supplement autopsy? J Forensic Sci 2023. ; 68 ( 2 ): 524 – 535 . [ DOI ] [ PubMed ] [ Google Scholar ] 36. Jalalzadeh H , Giannakopoulos GF , Berger FH , et al . Post-mortem imaging compared with autopsy in trauma victims--A systematic review . Forensic Sci Int 2015. ; 257 : 29 – 48 . [ DOI ] [ PubMed ] [ Google Scholar ] 37. Melvinsdottir I , Solomon N , Wadia R , Muniraj T , Huber S , Sinusas AJ

. Massive Air Embolism Following Necrotizing Pancreatitis and COVID-19 Infection-The Role of Postmortem Computed Tomography . Acad Forensic Pathol 2022. ; 12 ( 1 ): 31 – 38 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 38. Lawson M , Tully J , Ditchfield M , Kuganesan A , Badawy MK

. Using Computed Tomography skeletal surveys to evaluate for occult bony injury in suspected non-accidental injury cases - A preliminary experience . J Med Imaging Radiat Oncol 2022. ; 66 ( 1 ): 41 – 48 . [ DOI ] [ PubMed ] [ Google Scholar ] 39. Hong TS , Reyes JA , Moineddin R , Chiasson DA , Berdon WE , Babyn PS

. Value of postmortem thoracic CT over radiography in imaging of pediatric rib fractures . Pediatr Radiol 2011. ; 41 ( 6 ): 736 – 748 . [ DOI ] [ PubMed ] [ Google Scholar ] 40. La Russa R , Catalano C , Di Sanzo M , et al . Postmortem computed tomography angiography (PMCTA) and traditional autopsy in cases of sudden cardiac death due to coronary artery disease: a systematic review and meta-analysis . Radiol Med (Torino) 2019. ; 124 ( 2 ): 109 – 117 . [ DOI ] [ PubMed ] [ Google Scholar ] 41. Makino Y , Unuma K , Nolte KB , Adolphi NL

. Accuracy of forensic pathologists in incorporating post-mortem CT (PMCT) in forensic death investigation . J Forensic Sci 2022. ; 67 ( 6 ): 2351 – 2359 . [ DOI ] [ PubMed ] [ Google Scholar ] 42. Yoshida M , Makino Y , Hoshioka Y , et al . Technical and interpretive pitfalls of postmortem CT: Five examples of errors revealed by autopsy . J Forensic Sci 2022. ; 67 ( 1 ): 395 – 403 . [ DOI ] [ PubMed ] [ Google Scholar ] 43. Chevallier C , Doenz F , Vaucher P , et al . Postmortem computed tomography angiography vs. conventional autopsy: advantages and inconveniences of each method . Int J Legal Med 2013. ; 127 ( 5 ): 981 – 989 [Published correction appears in Int J Legal Med 2014;128(3):577.]https://doi.org/10.1007/s00414-012-0814-3. [ DOI ] [ PubMed ] [ Google Scholar ] 44. Wagensveld IM , Blokker BM , Wielopolski PA , et al . Total-body CT and MR features of postmortem change in in-hospital deaths . PLoS One 2017. ; 12 ( 9 ): e0185115 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 45. Levy AD , Harcke HT , Mallak CT

. Postmortem imaging: MDCT features of postmortem change and decomposition . Am J Forensic Med Pathol 2010. ; 31 ( 1 ): 12 – 17 . [ DOI ] [ PubMed ] [ Google Scholar ] 46. Shedge R , Krishan K , Warrier V , Kanchan T

. Postmortem Changes . In: StatPearls [Internet] . Treasure Island (FL) : StatPearls Publishing; ; 2023. . [ Google Scholar ] 47. Jackowski C , Thali M , Sonnenschein M , Aghayev E , Yen K , Dirnhofer R

. Adipocere in postmortem imaging using multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) . Am J Forensic Med Pathol 2005. ; 26 ( 4 ): 360 – 364 . [ DOI ] [ PubMed ] [ Google Scholar ] 48. Sutherland T , O’Donnell C

. The artefacts of death: CT post-mortem findings . J Med Imaging Radiat Oncol 2018. ; 62 ( 2 ): 203 – 210 . [ DOI ] [ PubMed ] [ Google Scholar ] 49. Cockle DL , Bell LS

. Human decomposition and the reliability of a ‘Universal’ model for post mortem interval estimations . Forensic Sci Int 2015. ; 253 : 136.e1 – 136.e9 . [ DOI ] [ PubMed ] [ Google Scholar ] 50. Panda A , Kumar A , Gamanagatti S , Mishra B

. Virtopsy Computed Tomography in Trauma: Normal Postmortem Changes and Pathologic Spectrum of Findings . Curr Probl Diagn Radiol 2015. ; 44 ( 5 ): 391 – 406 . [ DOI ] [ PubMed ] [ Google Scholar ] 51. Ishida M , Gonoi W , Okuma H , et al . Common Postmortem Computed Tomography Findings Following Atraumatic Death: Differentiation between Normal Postmortem Changes and Pathologic Lesions . Korean J Radiol 2015. ; 16 ( 4 ): 798 – 809 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 52. Baumeister R , Thali MJ , Ampanozi G

. Postmortem radiological imaging of natural causes of death in adults – a review . Forensic Imaging 2021. ; 26 : 200473 . [ Google Scholar ] 53. Shirota G , Gonoi W , Ikemura M , et al . The pseudo-SAH sign: an imaging pitfall in postmortem computed tomography . Int J Legal Med 2017. ; 131 ( 6 ): 1647 – 1653 . [ DOI ] [ PubMed ] [ Google Scholar ] 54. Filograna L , Thali MJ , Marchetti D

. Forensic relevance of post-mortem CT imaging of the haemopericardium in determining the cause of death . Leg Med (Tokyo) 2014. ; 16 ( 5 ): 247 – 251 . [ DOI ] [ PubMed ] [ Google Scholar ] 55. Yamaguchi R , Makino Y , Chiba F , et al . Fluid-Fluid Level and Pericardial Hyperdense Ring Appearance Findings on Unenhanced Postmortem CT Can Differentiate Between Postmortem and Antemortem Pericardial Hemorrhage . AJR Am J Roentgenol 2015. ; 205 ( 6 ): W568 – W577 . [ DOI ] [ PubMed ] [ Google Scholar ] 56. Pelletier DE , Andrew TA

. Common Findings and Predictive Measures of Opioid Overdoses . Acad Forensic Pathol 2017. ; 7 ( 1 ): 91 – 98 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 57. Filograna L , Thali MJ

. Post-mortem CT imaging of the lungs: pathological versus non-pathological findings . Radiol Med (Torino) 2017. ; 122 ( 12 ): 902 - 908 . [ DOI ] [ PubMed ] [ Google Scholar ] 58. Germerott T , Preiss US , Ebert LC , et al . A new approach in virtopsy: Postmortem ventilation in multislice computed tomography . Leg Med (Tokyo) 2010. ; 12 ( 6 ): 276 – 279 . [ DOI ] [ PubMed ] [ Google Scholar ] 59. Roberts IS , Benamore RE , Benbow EW , et al . Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study . Lancet 2012. ; 379 ( 9811 ): 136 – 142 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 60. Bolliger SA , Filograna L , Spendlove D , Thali MJ , Dirnhofer S , Ross S

. Postmortem imaging-guided biopsy as an adjuvant to minimally invasive autopsy with CT and postmortem angiography: a feasibility study . AJR Am J Roentgenol 2010. ; 195 ( 5 ): 1051 – 1056 . [ DOI ] [ PubMed ] [ Google Scholar ] 61. Rosenhain S , Magnuska ZA , Yamoah GG , Rawashdeh WA , Kiessling F , Gremse F

. A preclinical micro-computed tomography database including 3D whole body organ segmentations . Sci Data 2018. ; 5 ( 1 ): 180294 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 62. Papazoglou AS , Karagiannidis E , Moysidis DV , et al . Current clinical applications and potential perspective of micro-computed tomography in cardiovascular imaging: A systematic scoping review . Hellenic J Cardiol 2021. ; 62 ( 6 ): 399 – 407 . [ DOI ] [ PubMed ] [ Google Scholar ] 63. Sandrini C , Rossetti L , Zambelli V , et al . Accuracy of Micro-Computed Tomography in Post-mortem Evaluation of Fetal Congenital Heart Disease. Comparison Between Post-mortem Micro-CT and Conventional Autopsy . Front Pediatr 2019. ; 7 : 92 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 64. Baier W , Burnett BA , Payne M , Warnett JM , Williams MA

. Using micro-computed tomography to examine the larynx in cases of suspected strangulation-a comparison of case findings and control images . Int J Legal Med 2020. ; 134 ( 4 ): 1441 – 1450 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 65. Rutty GN , Brough A , Biggs MJ , Robinson C , Lawes SD , Hainsworth SV

. The role of micro-computed tomography in forensic investigations . Forensic Sci Int 2013. ; 225 ( 1-3 ): 60 – 66 . [ DOI ] [ PubMed ] [ Google Scholar ] 66. Tsai A , McDonald AG , Rosenberg AE , Gupta R , Kleinman PK

. High-resolution CT with histopathological correlates of the classic metaphyseal lesion of infant abuse . Pediatr Radiol 2014. ; 44 ( 2 ): 124 – 140 [Published correction appears in Pediatr Radiol 2014;44(9):1190.]https://doi.org/10.1007/s00247-013-2813-z. [ DOI ] [ PubMed ] [ Google Scholar ] 67. Persson A , Jackowski C , Engström E , Zachrisson H

. Advances of dual source, dual-energy imaging in postmortem CT . Eur J Radiol 2008. ; 68 ( 3 ): 446 – 455 . [ DOI ] [ PubMed ] [ Google Scholar ] 68. Gascho D , Zoelch N , Richter H , Buehlmann A , Wyss P , Schaerli S

. Identification of Bullets Based on Their Metallic Components and X-Ray Attenuation Characteristics at Different Energy Levels on CT . AJR Am J Roentgenol 2019. ; 213 ( 3 ): W105 – W113 . [ DOI ] [ PubMed ] [ Google Scholar ] 69. Filograna L , Magarelli N , Leone A , et al . Value of monoenergetic dual-energy CT (DECT) for artefact reduction from metallic orthopedic implants in post-mortem studies . Skeletal Radiol 2015. ; 44 ( 9 ): 1287 – 1294 . [ DOI ] [ PubMed ] [ Google Scholar ] 70. Flohr T , Schmidt B

. Technical Basics and Clinical Benefits of Photon-Counting CT . Invest Radiol 2023. ; 58 ( 7 ): 441 – 450 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 71. Ross S , Ebner L , Flach P , et al . Postmortem whole-body MRI in traumatic causes of death . AJR Am J Roentgenol 2012. ; 199 ( 6 ): 1186 – 1192 . [ DOI ] [ PubMed ] [ Google Scholar ] 72. Michaud K , Genet P , Sabatasso S , Grabherr S

. Postmortem imaging as a complementary tool for the investigation of cardiac death . Forensic Sci Res 2019. ; 4 ( 3 ): 211 – 222 . [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 73. Ruder TD , Ebert LC , Khattab AA , Rieben R , Thali MJ , Kamat P

. Edema is a sign of early acute myocardial infarction on post-mortem magnetic resonance imaging . Forensic Sci Med Pathol 2013. ; 9 ( 4 ): 501 – 505 . [ DOI ] [ PubMed ] [ Google Scholar ] 74. Pluchinotta FR , Porayette P , Zaidi AH , et al . Postmortem imaging in congenital heart disease: preliminary experience . Acta Radiol 2015. ; 56 ( 10 ): 1264 – 1272 . [ DOI ] [ PubMed ] [ Google Scholar ] 75. Heimer J , Gascho D , Thali MJ , Zoelch N

. Fundamentals of in situ postmortem magnetic resonance spectroscopy of the brain in the forensic framework:a review and outlook . Forensic Imaging 2022. ; 29 : 200499 . [ Google Scholar ] Articles from Radiographics are provided here courtesy of Radiological Society of North America ACTIONS View on publisher site PDF (6.3 MB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

Related documents

• Complications After CT-guided Lung Biopsies at St. Olavs Hospital#895641
• Feasibility of micro-CT-based digital reassociation of dental fragments in forensic odontology#8001
• Ancillary and Advanced Techniques for the Postmortem Examination.#342468
• Trial Using Octreotide to Enhance Liver Recovery After Hepatectomy#981677
• Implementation and Clinical Utility of Ultra-Low-Field Portable Magnetic Resonance Imaging for Postprocedural Neurological Evaluation in Ambulatory Neurosurgery: Illustrative Cases#1067432