Death following cylindrical battery ingestion associated with toxic manganese levels.

Cases of battery ingestion are well documented in the scientific literature, especially concerning button cell battery ingestion in children. In this instance, the authors present an atypical case of a young man who voluntarily ingested a cylindrical alkaline battery containing manganese. The patient died approximately a week later, despite not exhibiting any specific symptoms. The battery was found in the cecum during the autopsy, showing deterioration at its positive pole. The cecal mucosa exhibited two ulcerations without perforation. Histological analysis revealed intestinal ischemia in the cecum, with no microscopic lesions in other organs. Toxicology reports indicated high levels of manganese in both cardiac and peripheral blood. Considering all the results from the additional analyses, the experts concluded that the death was likely of multifactorial origin, associated with a toxic blood concentration of manganese. To the best of our knowledge, this is the first recorded death following the ingestion of a cylindrical battery, and the first instance of manganese intoxication resulting from the ingestion of an alkaline battery. The authors will present the case and provide a literature review to assess the extent to which the presence of manganese may have contributed to the fatality.

Hidden lesions: a case of burnt remains.

One of the many challenging cases that forensic pathologists, anthropologists, and forensic imaging experts have to face are burnt human remains. Perpetrators frequently attempt to hide/destroy evidence and make the body unidentifiable by exposing it to fire. We present a case of a partially burnt body found in an apartment after an explosion. First, multidetector computed tomography (MDCT) images and the following autopsy revealed several lesions on the cranium. Forensic anthropologists were involved in order to specify the aetiology of the lesions observed on the cranium. Through an interdisciplinary approach bringing together MDCT scans, 3D surface scans, and anthropological analysis, it was possible to answer the questions raised during the autopsy. Analyses demonstrated that there were signs of blunt force trauma on the cranium vault that the perpetrator likely attempted to hide by exposing the body to fire. This case demonstrates the importance of close collaboration between forensic anthropologists, imaging experts, and forensic pathologists. This multidisciplinary approach allows for a better, more complete reconstitution of forensic cases. Key points: The analyses of burnt human remains are one of the many challenging tasks that forensic pathologists and anthropologists have to face.We present an occurrence of a partially burnt body after an explosion and forensic anthropologists were asked whether the nature of the lesions observed on the cranium could be further specified.Anthropological analyses of the skull were consistent with the radiological and autopsy report. It was possible to reconstruct the various lesions on the dry bone.The case demonstrates the importance of an interdisciplinary approach and the close collaboration between forensic anthropologists, imaging experts, and forensic pathologists.

A forensic case of hydranencephaly in a preterm neonate fully documented by postmortem imaging techniques.

The authors present a medico-legal autopsy case of hydranencephaly in a male preterm newborn, fully documented by postmortem unenhanced and enhanced imaging techniques (postmortem computed tomography and postmortem magnetic resonance imaging). Hydranencephaly is a congenital anomaly of the central nervous system, consisting in almost complete absence of the cerebral hemispheres and replacement of the cerebral parenchyma by cerebrospinal fluid, rarely encountered in forensic medical practice. A premature baby was born during the supposed 22nd and 24th week of pregnancy in the context of a denial of pregnancy without any follow-up. The newborn died a few hours after birth and medico-legal investigations were requested to determine the cause of death and exclude the intervention of a third person in the lethal process. The external examination revealed neither traumatic nor malformative lesions. Postmortem imaging investigations were typical of hydranencephaly, and conventional medico-legal autopsy, neuropathological examination, and histological examination confirmed a massive necrotic-haemorrhagic hydranencephaly. This case represents in itself an association of out-of-the-ordinary elements making it worthy of interest. Key Points: Postmortem unenhanced and enhanced imaging techniques (computed tomography and magnetic resonance imaging) were performed as complementary examination to conventional medico-legal investigations.Postmortem angiography of a preterm newborn is possible with catheterization of the umbilical blood vessels.Hydranencephaly is a congenital anomaly of the central nervous system, consisting in almost complete absence of the cerebral hemispheres and replacement of the brain by cerebrospinal fluid, for which several aetiologies have been postulated.

Application of postmortem imaging modalities in cases of sudden death due to cardiovascular diseases-current achievements and limitations from a pathology perspective : Endorsed by the Association for European Cardiovascular Pathology and by the International Society of Forensic Radiology and Imaging.

Postmortem imaging (PMI) is increasingly used in postmortem practice and is considered a potential alternative to a conventional autopsy, particularly in case of sudden cardiac deaths (SCD). In 2017, the Association for European Cardiovascular Pathology (AECVP) published guidelines on how to perform an autopsy in such cases, which is still considered the gold standard, but the diagnostic value of PMI herein was not analyzed in detail. At present, significant progress has been made in the PMI diagnosis of acute ischemic heart disease, the most important cause of SCD, while the introduction of postmortem CT angiography (PMCTA) has improved the visualization of several parameters of coronary artery pathology that can support a diagnosis of SCD. Postmortem magnetic resonance (PMMR) allows the detection of acute myocardial injury-related edema. However, PMI has limitations when compared to clinical imaging, which severely impacts the postmortem diagnosis of myocardial injuries (ischemic versus non-ischemic), the age-dating of coronary occlusion (acute versus old), other potentially SCD-related cardiac lesions (e.g., the distinctive morphologies of cardiomyopathies), aortic diseases underlying dissection or rupture, or pulmonary embolism. In these instances, PMI cannot replace a histopathological examination for a final diagnosis. Emerging minimally invasive techniques at PMI such as image-guided biopsies of the myocardium or the aorta, provide promising results that warrant further investigations. The rapid developments in the field of postmortem imaging imply that the diagnosis of sudden death due to cardiovascular diseases will soon require detailed knowledge of both postmortem radiology and of pathology.

Contribution of the use of clavicle bone density in age estimation.

Age estimation is an essential element in the field of forensics and is also of judicial interest in forensic medicine of the living. Despite all the methods, age estimation is often imprecise with many biases, especially in mature individuals. The main objective of our study is to assess the correlation between age and computed tomography bone mineral density of the medial end of the clavicle. A sample of 180 chest multi-slice computed tomography scans without contrast injection performed in living individuals, with suspected respiratory infection, aged 15 to 100 years was used. Bone density measurement was performed on the medial meta-epiphyseal region of the clavicles. A significant negative correlation was found between bone density and age of individuals (p-value < 0.05). The mean absolute error was calculated for men at 13.4 years and 13.1 years for women, which was associated with an absence of bias. Good precision of the estimate for both sexes was also calculated on a subgroup of individuals whose age was greater than 40 years, with average absolute errors of about 12 years, which was associated with an absence of relative error. In view of our preliminary results, the study of bone density of the medial end of the clavicle could be of interest in the estimation of age. Several studies will be necessary to evaluate the reproducibility of these results on independent bone samples and in the estimation of age in the living individual.

Pictorial review of the postmortem computed tomography in neonaticide cases.

Neonaticide is defined by the deliberate killing or homicide of a child within 24 h of its birth. In this context, three fundamental questions are generally asked of the forensic pathologist: what is the cause of death of the neonate? Was the child viable (i.e., what is the gestational age of the neonate)? Finally, was the neonate stillborn or liveborn?Postmortem imaging can help answer these questions by conducting (1) a complete lesional analysis of the body and the placenta, (2) an estimation of the gestational age by measuring the lengths of the diaphyseal long bones, and (3) an analysis of the aeration of the lungs and intestines. Using the details of 18 cases, we illustrate aspects of neonaticide cases in postmortem computed tomography (PMCT), offering detailed examples of notable postmortem changes and abnormalities, especially in the analysis of the pulmonary parenchyma. This article presents a useful iconography for the radiologist confronted with this rare yet complex forensic situation.

Age estimation based on computed tomography exploration: a combined method.

Despite an extensive number of existing methods, age estimation of human remains is still an unsolved matter in the field of forensic anthropology, especially when it comes to mature adults. The specific aim of this work was to propose a combined method for age estimation, for forensic purposes, by coupling the Suchey-Brooks method and the measure of the pubic bone density. For this purpose, we used an independent test sample comprising 339 CT scans of living individuals aged 15 to 99 years old. Measurement of bone density and staging according to the Suchey-Brooks phases were performed, followed by estimation of ages based on a combined method and an existing virtual reference sample. Results highlighted a significant negative correlation between bone density and age. Good accuracy was obtained for the measurement of pubic bone density for age estimation of men and women, especially concerning mature adults, with an absolute error ranging from 9 to 16 years for all individuals. The authors propose a practical combined method consisting of, first, allocating phases according to the scannographic approach of the Suchey-Brooks method. For phases I to IV, the age estimation is given using the Suchey-Brooks method. For phases V to VI, the pubic bone density measurement is used. Further study will be needed to assess the reproducibility of these results on cadavers and dry bones, as the post-mortem process could interfere with the measurement of mineral bone density.

Postmortem coronary artery calcium score in cases of myocardial infarction.

Sudden cardiac death (SCD) related to atherosclerotic coronary artery disease (ACAD) resulting in myocardial infarction is the most prevalent cause of death in western countries. In clinical practice, coronary artery calcium score (CACS) is considered an independent predictor of coronary events, closely related to atherosclerotic burden and is quantified radiologically by the Agatston score being calculated through computed tomography. Postmortem computed tomography (PMCT) allows the visualization and quantification of coronary calcifications before the autopsy. However, it was reported that some patients who died from severe ACAD had a zero CACS in PMCT. In this study, a retrospective evaluation of CACS in adult's myocardial infarction cases related to ACAD, with available CACS and histological slides of coronary arteries, was performed in order to gain a deeper understanding of coronary calcifications and their role in myocardial infarction cases. The CACS was calculated by using the software Smartscore 4.0 after the radiological examination on a 64-row CT unit using a specific cardiac protocol. Thirty-six cases were identified out of 582 autopsies, recorded during a 2-year study period (29 men, 7 women; age 56.3 ± 11.7). CACS was 0-10 in 5 cases (5 men, 44.8 ± 13.7), 11-100 in 8 cases (6 men, 2 women, 53.1 ± 7.7), 101-400 in 13 cases (11 men, 2 women, 57.4 ± 9.6), and > 400 in 10 cases (9 men, 1 woman, 63.1 ± 11.9). Coronary thrombosis was found in 28 cases, histologically identified as plaque erosions in 6 cases and as plaque ruptures in 22 cases. Statistical analyses showed that CACS increases significantly with age (p-value < 0.05) and does not show significant correlation with gender, body weight, body mass index, and heart weight. CACS was significantly higher in plaque ruptures than in plaque erosions (p-value < 0.01). Zero or low CACS on unenhanced PMCT cannot exclude the presence of myocardial infarction related to ACAD. This paradoxical discrepancy between imaging and autopsy findings can be explained considering the histological aspect of fatal coronary plaques.

Homicide by unusual-edged weapons: Forensic considerations of two cases.

Homicide by stab wound is common worldwide. However, the use of unusual edged weapons is rarely reported in the forensic literature. Here, we report two cases of homicide involving a Japanese sword, or katana, and a sickle. Both of these weapons can create either stab or incised wounds with some particularities. In our cases, characteristics of the external wounds, internal injuries, and the depth of penetration raised the possibility of an unusual weapon. Meticulous forensic examination of these injuries (morphological characteristics, depth of penetration, trajectories, and cut marks in the bone) may allow the forensic expert to determine the type of weapon used.

Neck-MRI experience for investigation of survived strangulation victims.

For the medicolegal evaluation of victims of survived strangulation, a neck-magnetic resonance imaging (MRI) can be performed for assessing lesions in the inner soft tissues (fat, muscles or lymph nodes, for example). In our institute, such MRI examinations have been performed for a test period of 4 years with the aim of evaluating the use of this tool by forensic pathologists and identifying medicolegal indicators for the performance of neck-MRI in surviving victims of strangulation. We retrospectively reviewed medicolegal reports from all victims examined during the test period. We extracted objective lesions (e.g. petechiae, bruising and abrasions) and reported clinical symptoms (e.g. vision disorder, dysphasia) from the reports. These findings were compared to those reported from the neck-MRI. In total, 112 victims were clinically examined after suspected strangulation. Eleven of these victims underwent an MRI examination of the neck. Eighty-four of the victims presented objective lesions during the clinical examination, with eight showing signs of both petechiae and bruising. Neck-MRI was performed in four of these eight victims and three of them showed lesions visible in MRI. Of 76 victims with bruising as the only objective finding, 66 victims described clinical symptoms. Of those 66 victims, seven were examined by MRI and two demonstrated lesions in MRI. When MRI was performed, relevant findings were detected in 45% of the cases. This leads to the suspicion that many more findings could have been detected in the other victims, if an MRI had been performed in those cases. Our results lead us to the conclusion that an MRI examination of victims of suspected strangulation is useful, and strict indications for its application should be established.

Oleic Acid (OA), A Potential Dual Contrast Agent for Postmortem MR Angiography (PMMRA): A Pilot Study.

Choosing proper perfusates as contrast agents is an important aspect for postmortem magnetic resonance angiography (PMMRA). However, in this emerging field, the number of suitable kinds of liquid is still very limited. The objective of this research is to compare MR images of oleic acid (OA) with paraffin oil (PO) in vitro and in ex situ animal hearts, in order to evaluate the feasibility to use OA as a novel contrast agent for PMMRA. In vitro, OA, PO and water (control) were introduced into three tubes separately and T1weighted-spin echo (T1w-SE) and T2w-SE images were acquired on a 1.5T MR scanner. In the second experiment, OA and PO were injected into left coronary artery (LCA) and left ventricle (LV) of ex situ bovine hearts and their T1w-SE, T2w-SE, T1w-multipoint Dixon (T1w-mDixon) and 3DT2w-mDixon images were acquired. The overall results indicate that OA may have a potential to be used as a dual (T1 and T2 based) contrast agent for PMMRA when proper sequence parameters are utilized. However, as the pilot study was based on limited number of animal hearts, more researches using OA in cadavers are needed to validate our findings.

Blended learning of radiology improves medical students' performance, satisfaction, and engagement.

PURPOSE: To evaluate the impact of blended learning using a combination of educational resources (flipped classroom and short videos) on medical students' (MSs) for radiology learning. MATERIAL AND METHODS: A cohort of 353 MSs from 2015 to 2018 was prospectively evaluated. MSs were assigned to four groups (high, high-intermediate, low-intermediate, and low achievers) based on their results to a 20-MCQs performance evaluation referred to as the pretest. MSs had then free access to a self-paced course totalizing 61 videos based on abdominal imaging over a period of 3 months. Performance was evaluated using the change between posttest (the same 20 MCQs as pretest) and pretest results. Satisfaction was measured using a satisfaction survey with directed and spontaneous feedbacks. Engagement was graded according to audience retention and attendance on a web content management system. RESULTS: Performance change between pre and posttest was significantly different between the four categories (ANOVA, P = 10-9): low pretest achievers demonstrated the highest improvement (mean ± SD, + 11.3 ± 22.8 points) while high pretest achievers showed a decrease in their posttest score (mean ± SD, - 3.6 ± 19 points). Directed feedback collected from 73.3% of participants showed a 99% of overall satisfaction. Spontaneous feedback showed that the concept of "pleasure in learning" was the most cited advantage, followed by "flexibility." Engagement increased over years and the number of views increased of 2.47-fold in 2 years. CONCLUSION: Learning formats including new pedagogical concepts as blended learning, and current technologies allow improvement in medical student's performance, satisfaction, and engagement.

Geometric morphometric study of the early shape of the hip bone (os coxae): variations with age and sex.

Data regarding sexual dimorphism in children are sparse with contradictory results. Recently, geometric morphometric analysis has shown that the pubis and ilium have both sexual shape dimorphism and shape differences that increase during ontogeny, but little is known about the entire pelvic (os coxae) bone shape in very young children. The goal of this study was to show pelvic bone age-related and sex-related shape changes using 3D geometric morphometric analysis in very young children. Geometric morphometric analysis was carried out on CT scans of the pelvic bone of 96 children aged from 3 to 24 months. Eleven landmarks were defined on the left pelvic bone. Geometric morphometric analyses were carried out to identify trends in bone shape in sex-based and age-based subgroups. Age-related differences in shape were statistically significant (Goodall's F = 3.68; p < 0.001) but there were no sex-related differences in shape (Goodall's F = 1.95; p = 0.065). Overall, the superior part of the pelvic bone becomes narrower with age. This study has shown that geometric morphometric analysis of the pelvic bone is feasible in very young children and revealed changes in shape with age but not differences with sex.

The antiquity of the spondyloarthritides: Presentation of one of the oldest Neolithic cases in Western Europe.

In humans, little is yet known about the origins of the inflammatory rheumatisms of the spondyloarthritides group, especially regarding the period of their emergence. However, a better knowledge of their history would help to clarify their aetiology. We report a paleopathological case of European origin, dated from the late Neolithic (3621-3023 cal BC), consisting of an isolated vertebral block combining erosion, ossification and severe anterior and posterior ankylosis. The lesional presentation is very suggestive of a severe form of axial spondyloarthritis. This specimen and some other rare cases from the same period found in Western Europe suggest that these diseases appeared, in this geographical region, in evolving groups of humans as part of the demographic and epidemiological transition that constituted the Neolithic period. The emergence of infectious agents and the profound dietary changes that occurred during this period of human history may have favoured the appearance of the spondyloarthritides.

Postmortem CT Angiography Compared with Autopsy: A Forensic Multicenter Study.

Purpose To determine if postmortem computed tomography (CT) and postmortem CT angiography help to detect more lesions than autopsy in postmortem examinations, to evaluate the strengths and weaknesses of each method, and to define their indications. Materials and Methods Postmortem CT angiography was performed on 500 human corpses and followed by conventional autopsy. Nine centers were involved. All CT images were read by an experienced team including one forensic pathologist and one radiologist, blinded to the autopsy results. All findings were recorded for each method and categorized by anatomic structure (bone, organ parenchyma, soft tissue, and vascular) and relative importance in the forensic case (essential, useful, and unimportant). Results Among 18 654 findings, autopsies helped to identify 61.3% (11 433 of 18 654), postmortem CT helped to identify 76.0% (14 179 of 18 654), and postmortem CT angiography helped to identify 89.9% (16 780 of 18 654; P < .001). Postmortem CT angiography was superior to autopsy, especially at helping to identify essential skeletal lesions (96.1% [625 of 650] vs 65.4% [425 of 650], respectively; P < .001) and vascular lesions (93.5% [938 of 1003] vs 65.3% [655 of 1003], respectively; P < .001). Among the forensically essential findings, 23.4% (1029 of 4393) were not detected at autopsy, while only 9.7% (428 of 4393) were missed at postmortem CT angiography (P < .001). The best results were obtained when postmortem CT angiography was combined with autopsy. Conclusion Postmortem CT and postmortem CT angiography and autopsy each detect important lesions not detected by the other method. More lesions were identified by combining postmortem CT angiography and autopsy, which may increase the quality of postmortem diagnosis. Online supplemental material is available for this article.

Study of a seventeenth-century French artificial mummy: autopsical, native, and contrast-injected CT investigations.

BACKGROUND: A lead coffin was fortuitously discovered in a church called "Eglise des Toussaints" in Rennes (French Brittany). A collaborative taskforce investigated this extraordinary discovery. A multi-disciplinary team of experts from the National Institute for Preventive Archeological Research (INRAP) and Rangueil University Hospital of Toulouse was created, including anthropologists, archeologists, forensic pathologists, radiologists, and pathologists. The inscription on the lead coffin specified that the body belonged to "Messer Louys de Bruslon, Lord of Plessis," a nobleman who died on November 1, 1661. Multiple holes were visible in the lead coffin, and deterioration threatened the mummy. We opened the lead coffin and discovered an excellently preserved mummy, except for mostly skeletonized upper and lower limbs. The mummy was conserved in several layers of shrouds. Vegetal embalming material covered the head and filled the face, the thorax, and the abdomen. The embalmers had removed all thoracic and abdominal organs and conserved some pelvic organs (e.g., the bladder). METHODS: Multi-slice computed tomography (MSCT) scanner evaluated the mummy, at each step of our analysis. The excellent preservation of abdominal vascular axes led us to perform a CT angiography using Angiofil®, an oily contrast agent developed for postmortem imaging, before an autopsy. RESULTS: Sub-diaphragmatic arteries, including the abdominal aorta and iliac arteries, were excellently preserved. The vascular contrast agent filled all arteries. The native CT, CT angiography, and autopsy did not detect any vascular lesion. CONCLUSION: Our study, based on rare archeological material, allowed a complete examination of an excellently preserved seventeenth-century mummy, using MSCT, angiography, and an autopsy. We did not detect any arterial lesion and proposed a comprehensive description of the embalmment process.

Visualization of Myocardial Infarction in Postmortem Multiphase Computed Tomography Angiography: A Feasibility Study.

Recent studies have indicated that multiphase postmortem computed tomography angiography (MPMCTA) allows detection of a pathological enhancement of the myocardium in regions that correlate with the localization of the infarction at histology. The aim of this study was to verify this hypothesis by examining MPMCTA images in cases of myocardial infarction. Therefore, we investigated 10 autopsy cases where death was attributed to myocardial infarction or which showed cardiovascular pathology. As a control group, we selected 10 cases of non-natural (namely, not cardiac) death. The MPMCTA was performed in both groups to ascertain whether a pathological enhancement could be observed. We detected a myocardial enhancement in all cardiac death cases, in the same region that showed infarction at histology. No enhancement was observed in control cases. These results have important implications in the routine management of sudden cardiac death cases. In fact, MPMCTA can not only orient about the cause of death before autopsy, but can especially help to identify affected regions for guiding and improving the sampling for microscopic examination.

Sudden aortic death-proposal for a comprehensive diagnostic approach in forensic and in clinical pathology practice.

BACKGROUNDS: Aortic rupture or dissection as immediate cause of sudden death is encountered in forensic and clinical autopsy practice. Despite a common denominator of 'sudden aortic death' (SAD), we expect that in both settings the diagnostic workup, being either primarily legal or primarily disease related, differs substantially, which may affect the eventual diagnoses. METHODS: We retrospectively reviewed case records of deceased persons who fitted a diagnosis of SAD in the continuous autopsy cohorts in a forensic (Suisse) and a clinical setting (The Netherlands). Clinical characteristics, data from post-mortem imaging, tissue blocks for histological analysis and results of ancillary studies were reviewed for its presence and outcome. RESULTS: SAD was found in 7.7% in the forensic versus 2.2% in the clinical autopsies. In the forensic setting, autopsy was always combined with post-mortem imaging, showing variable outcome on detection of aortic disruption and/or pericardial bleeding. Histology of aorta was performed in 12/35 cases, mostly in the natural deaths. In the clinical setting, histology of the aorta was available in all cases, but post-mortem imaging in none. In both settings, underlying aortic disease was mostly cystic medial degeneration, atherosclerosis or a combination of both, with occasional rare unexpected diagnosis. Also in both, a genetic cause of aortic dissection was revealed in a minority (three cases). CONCLUSION: Sudden aortic death (SAD) is more commonly encountered in a forensic than in a clinical setting. Major differences in the approach of SAD between these settings coincide with similarities in causes of death and underlying diseases. To ensure a correct diagnosis, we recommend that the investigation of SAD includes a study of the medical history, a full autopsy with histology of major organs including aorta, and storage of material for toxicological and genetic testing. Post-mortem radiological examination, useful for documentation and screening purposes, is feasible as non-invasive alternative when autopsy is not possible, but cannot substitute a full autopsy.