Application of Targeted Coronary Angiography in the Diagnosis of Sudden Cardiac Death.

OBJECTIVES: To diagnose coronary artery stenosis by using the postmortem computed tomography angiography (PMCTA), and to explore the diagnostic value of PMCTA in sudden cardiac death. METHODS: Six death cases were selected, and the contrast medium iohexol was injected under high pressure through femoral artery approach with 5F pigtail catheter to obtain coronary image data and then the data was analyzed. The results of targeted coronary imaging and coronary artery calcium score (CaS) were compared with the results of conventional autopsy and histopathological examination. RESULTS: The autopsy and histopathological examination of cases with coronary artery stenosis obtained similar results in targeted coronary angiography, with a diagnostic concordance rate of 83.3%. Targeted coronary angiography could effectively show coronary artery diseases, and the CaS was consistent with the results of conventional autopsy and histopathological examination. CONCLUSIONS: Targeted coronary angiography can be used as an effective auxiliary method for conventional autopsy in cases of sudden cardiac death.

Application of Targeted Coronary Angiography in the Diagnosis of Sudden Cardiac Death / 法医学杂志

OBJECTIVES@#To diagnose coronary artery stenosis by using the postmortem computed tomography angiography (PMCTA), and to explore the diagnostic value of PMCTA in sudden cardiac death.@*METHODS@#Six death cases were selected, and the contrast medium iohexol was injected under high pressure through femoral artery approach with 5F pigtail catheter to obtain coronary image data and then the data was analyzed. The results of targeted coronary imaging and coronary artery calcium score (CaS) were compared with the results of conventional autopsy and histopathological examination.@*RESULTS@#The autopsy and histopathological examination of cases with coronary artery stenosis obtained similar results in targeted coronary angiography, with a diagnostic concordance rate of 83.3%. Targeted coronary angiography could effectively show coronary artery diseases, and the CaS was consistent with the results of conventional autopsy and histopathological examination.@*CONCLUSIONS@#Targeted coronary angiography can be used as an effective auxiliary method for conventional autopsy in cases of sudden cardiac death.

Histomorphological assessment of isolated abdominal organs after targeted perfusion with the contrast agent Angiofil® in postmortem computed tomography angiography.

The current literature about histological alterations and artefacts associated with postmortem computed tomography angiography (PMCTA) is scarce and limited to qualitative research. The aim of this study was to describe and quantify histological alterations and artefacts in histologic specimens of the inner organs. The spleen, the liver, the kidneys and the pancreas were eviscerated in the course of standard forensic autopsy, followed by manual arterial and venous perfusion of the organs with the lipophilic contrast agent Angiofil®. Computed tomography (CT) of the organ packages was executed to evaluate if the perfusion with Angiofil® was sufficient. The CT scans revealed a good delineation of the vessel trees up to the organ periphery, suggesting a sufficient perfusion. Tissue samples were taken before and after perfusion, stained with hematoxylin-eosin (H&E) and examined by using microscopy. Native and perfused specimens were assessed on the basis of a qualitative rating scale in regard to the integrity of the cells, the tissue architecture and induced alterations. Subsequently the observed differences before and after perfusion with Angiofil® were analyzed quantitatively. While the liver, spleen and kidneys could be evaluated, further microscopic examinations of the pancreatic tissue were not possible due to vast autolytic changes. On the cellular level no changes in the liver, spleen and kidneys were observed after administering Angiofil®. While the tissue architecture of these organs remained intact, a significant blood volume displacement occurred. As a consequence, tissue with hypoemic or normal blood state demonstrated congestion. Further, optically empty spaces emerged regularly in the vessels and the parenchyma of each organ as a surrogate for the lipophilic contrast agent. With a few exceptions an adequate perfusion up to the microscopic level was observed. Following the results of this investigation, CT-controlled manual injection of Angiofil® into isolated organs may be an alternative to the generalized in situ application of contrast agents in the course of PMCTA. It is of eminent importance to know the artefacts induced by an Angiofil® injection in order to avoid a misinterpretation or a masking of findings. Thus, a collection of native tissue specimens has to be done before contrast agent application.

Evaluation of an acetated Ringer-based contrast material mixture for postmortem computed tomography angiography.

PURPOSE: The purpose of this study was to compare an established postmortem contrast medium mixture based on polyethylene glycol (PEG) to an isotonic crystalloid with acetated Ringer solution (AR) as the base, both mixed with water-soluble iodinated contrast medium for postmortem computed tomography angiography (PMCTA) with the aim to avoid alterations of the corpse during autopsy. MATERIALS AND METHODS: The study included 20 cadavers; 10 had PMCTA with AR and 10 with PEG. PMCTA images were analyzed with respect to image quality, vascular contrast patterns and artifacts. Autopsy was evaluated for visual, organ, vessel and haptic alterations. The Wilcoxon rank sum test was used to search for differences in image quality between the two groups. Statistical significance was set at P<0.05. RESULTS: AR provided excellent contrast within the right coronary artery (P<0.001) but a lack of contrast within the left coronary artery (P=0.008) whereas PEG showed the opposite. A better image quality was observed in the PEG group by comparison with the AR group for right common carotid artery (P=0.03), left common carotid artery (P=0.01) and left coronary artery (P=0.008). No differences were found for ascending aorta (P=0.65), aortic arch (P=0.09), right circle of Willis (P=0.17), left circle of Willis (P=0.08), inferior vena cava (P=0.07) and abdominal aorta (P=0.08). Severe extravasation occurred in all (10/10; 100%) cadavers in the AR group but in none (0/10; 0%) in the PEG group (P<0.001). At autopsy, visual alteration with lilac discoloration of the face was observed in 4/10 cadavers (40%) in the AR group and in 9/10 cadavers (90%) in the PEG group (P=0.057). Haptic alterations were observed in 3/10 cadavers (30%) in the AR group and 10/10 cadavers (100%) in the PEG group (P=0.003). CONCLUSION: AR results in contrast medium mixture extravasation in all cadavers, but PEG altered the autopsy more severely. Both carrier substances result in specific substance-related artifacts and dependent opacification of the coronary arteries, but PEG is recommended for PMCTA exclusively with regard to diagnostic imaging.

Medico-Legal Aspects of Pulmonary Thromboembolism.

Pulmonary ThromboEmolism (PTE) is an important disease for legal medicine. Because of their sudden lethal onset, generally medicolegal autopsies show few clinical information when PTE is the cause of death. During medicolegal autopsies, the autopsy operator must answer to important questions. For example, autopsy operator can need to assess the casual relationship between PTE and recent accident, such as trauma or long air travel. Furthermore, the autopsy operator needs to investigate the pathology of PTE as a cause of sudden cardiovascular death. It is relatively simple to confirm a fatal massive thromboembolus in the initial stage of thoracic investigations, but sometimes it might be difficult to distinguish this from postmortem clot. In such cases histopathological examination can help in the differentiation. Histological examination is also required for observation of chronological changes of the thrombi. Chronological evaluation is an important factor especially to determine whether the death coincides with the date of a specific accident/event or instead there is an earlier onset of PTE. In addition, histological sections sometimes show additional information, such as tumor fragments in cases of malignancy or small fragments of bone marrow in cases of active resuscitation, that can be useful in a medicolegal scenario. Furthermore, new diagnostic tools are arising, which they can be very helpful in the individuation of this frequently underdiagnosed disease. The goal of our work is to investigate these aspects through the review of the recent literature.