Current utilization of pediatric postmortem imaging in North America: a questionnaire-based survey.

BACKGROUND: Postmortem imaging is used more widely as the number of conventional autopsies has decreased over the last several decades. It is widely accepted in Europe, Asia and Oceania, but there has been a delay in acceptance in North America. Education, scanning protocols, resourcing and clinical incentives are needed to support this emerging field. OBJECTIVE: To determine the use of postmortem imaging and define perceived barriers to its implementation with the goal of expanding postmortem imaging in the United States and Canada. MATERIALS AND METHODS: We sent an online survey to active members of the Society for Pediatric Radiology (SPR) addressing the use of postmortem imaging, indications, readers, practical aspects, anticipated barriers and potential solutions to more widespread use. RESULTS: More than 50% of the 50 institutions that returned surveys used postmortem computed tomography; 24% used postmortem magnetic resonance imaging. Most postmortem imaging cases were read by radiologists. Fewer than 50% had formal correlation with autopsy results or an established relationship with the local medical examiner. Seven institutions reported reimbursement for postmortem imaging. Major barriers to postmortem imaging included lack of funding and lack of interest among clinicians. Funding and education were seen as important issues requiring attention. CONCLUSION: While most responding institutions provide pediatric postmortem imaging, the modalities, protocols, reporting procedures and clinical correlation vary widely. A lack of funding and few opportunities for education are limiting factors. Attention to these issues along with active support from the SPR are seen as potential solutions to recognize the value and promote widespread acceptance of postmortem imaging.

Navigating the perils and pitfalls of pediatric forensic postmortem imaging in the United States.

Postmortem CT is widely used in the general adult and military populations. It is used extensively in pediatric death investigations in Europe and Asia, but distinctive challenges are encountered when launching a postmortem imaging program in the United States. We describe the issues we have encountered specific to establishing a pediatric postmortem imaging service in this country and propose potential solutions.

Computerized Tomography Analysis of Young Children for Prevention of Aspiration Injuries.

OBJECTIVE: The Small Parts Test Fixture (SPTF) (16 CFR 1501) was developed from cadavers of young children and foreign body (FB) data. Recent FB studies reveal that the SPTF misses outliers. Computerized tomography (CT) provides detailed dimensional data for young children. Our null hypothesis is that the SPTF (31.75 mm) is smaller than relevant portions of the aerodigestive tract. METHODS: A 3-year retrospective review (2011-2014) of head/neck CT data for infants and children (N = 106) aged 6 months to 6 years was completed. Six measurements (mm) were recorded: 1) maxillary incisors to posterior edge of hard palate (MI/HP); 2) posterior edge of hard palate to first cervical (C1) vertebra (HP/C1); 3) soft palate to posterior pharyngeal wall; and 4) interpalatine tonsillar distance; 5, 6) larynx diameter, and width. Two ratios were calculated: 1) ratio of lengths (hard palate to soft palate), and 2) laryngeal dimensional ratio. RESULTS: A linear trend of increasing dimensions with increased age was noted. The length measured MI/HP best correlates with known data of potential FBs causing injury or death. This MI/HP length can range from 33.8 to 45.8 mm for all children younger than 3 years of age and exceeds the SPTF diameter (31.75 mm). There were no statistical anatomical differences by gender in any of the age groups. CONCLUSION: Computed tomography measurements appear larger than SPTF values developed from cadavers. These CT data support enlargement of the SPTF to enhance safety for choking hazards in children. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1468-1476, 2019.

Maturation of pelvic ossification centers on computed tomography in normal children.

BACKGROUND: The pelvis is composed of three paired primary ossification centers: the pubis, the ischium and the ilium. During maturation, multiple secondary ossification centers can be seen in the synchondroses between these bones and in the pelvic apophyses. The fragmented appearance of these centers can be confused with pathology. OBJECTIVE: To examine development of pelvic ossification centers by CT and determine normal appearance throughout childhood. MATERIALS AND METHODS: Three pediatric radiologists reviewed 325 pelvic CT scans in children and young adults 5-18 years old and graded 6 pelvic ossification centers to evaluate maturational changes in critical structures. RESULTS: Rate and progression of ossification and age at complete fusion vary with gender at the different ossification centers in the growing pelvis. CONCLUSION: Knowledge of the normal CT appearance of ossification centers throughout childhood is important to differentiate the normal appearance from pathology.

Pulmonary embolus as cause of death in an adolescent: demonstration on postmortem CT.

Computed tomography (CT) is widely accepted in adult forensic death investigations (determination of cause and manner of death) but is only beginning to play a larger role in the cause of death determination in infants and children. We present a case of an adolescent with nephrotic syndrome who sustained cardiac arrest and died in the emergency department. A postmortem CT was requested by the state Office of the Medical Examiner as part of the medicolegal death investigation. Postmortem CT showed a saddle pulmonary embolus that was confirmed on conventional autopsy, demonstrating a natural manner of death.

Aneurysmal bone cysts and pathologic fracture associated with supernumerary ring chromosome 6 in two unrelated patients.

Small supernumerary ring chromosome 6 (sSRC[6]) is a rare chromosomal abnormality characterized by a broad clinical phenotype. The spectrum of this disorder can range from phenotypically normal to severe developmental delay and congenital anomalies. We describe two unrelated patients with small SRCs derived from chromosome 6 with a novel bone phenotype. Both patients presented with a complex bone disorder characterized by severe osteopenia, pathologic fractures, and cyst-like lesions within the bone. Imaging revealed decreased bone mineral density, mutiple multiloculated cysts and cortical thinning. Lesion pathology in both patients demonstrated a bland cyst wall with woven dysplastic appearing bone entrapped within it. In patient 1, array comparative genomic hybridization (CGH) detected a tandem duplication of region 6p12.3 to 6q12 per marker chromosome. Cytogenetic analysis further revealed a complex patient of mosaicism with some cell lines displaying either one or two copies of the marker indicative of both tetrasomy and hexasomy of this region. Patient 2 was mosaic for a sSRC that encompassed a 26.8 Mb gain from 6p21.2 to 6q12. We performed an in-depth clinical analysis of a phenotype not previously observed in sSRC(6) patients and discuss the potential influence of genes located within this region on the skeletal presentation observed.

Intraosseous vascular access defect: fracture mimic in the skeletal survey for child abuse.

Two infants were transferred to the emergency department for injuries suggestive of child abuse. Skeletal surveys showed cortical bone defects in the proximal tibiae that were initially interpreted as healing fractures. Further investigation, however, revealed that intraosseous (IO) vascular access needles had been placed at these sites in both infants. In the appropriate clinical setting, a cortical lesion in the proximal tibia corresponding to the site of IO needle insertion should not be mistaken for a radiographic sign of child abuse.