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Forensic Magazine® | Articles | The Virtual Autopsy: The Doctor Will Scan You Now

The Virtual Autopsy: The Doctor Will Scan You Now

Douglas Page
August/September 2008

Advanced imaging tools such as MDCT are being used more and more in forensic medicine,
sometimes beyond morgue walls.

It may be too soon for a television series titled CSI: Radiology, but advanced imaging devices like
multidetector computed tomography (MDCT) scanners are already accelerating changes in forensic
medical science.

MDCT technology is important to forensic investigators because it is fast, non-invasive, can obtain
images without destroying the artifact, and can be used when conventional autopsy may not be
feasible or where families may forbid conventional autopsy based on religious beliefs.

(Multidetector CT scanners are similar in concept to original single-ring CT devices, except MDCT
scanners have between 4 and 64 detector rings.)

The technology even has wheels.

In the first use of mobile MDCT for a mass fatality incident, researchers in England recently found that
MDCT can be operational in temporary mortuaries within 20 minutes of arrival.

Depending on the nature of the incident, three different imaging modalities may be required at
conventional disaster morgues: fluoroscopy to screen victims prior to autopsy; plain x-ray for bone
examination; and dental x-ray units to document dentition. MDCT provides an alternative or
replacement for fluoroscopy and plain film x-ray within temporary morgues.

“Our data suggest that CT may be adequate as the sole imaging investigation within a mass fatality
mortuary,” said Guy N. Rutty, MD, of the Forensic Pathology Unit, University of Leicester. Rutty’s unit
is the world leader in the area of mobile MDCT.

Rutty recently used a mobile MDCT scanner in a disaster mortuary established after a five vehicle
fatal traffic incident. Five out of six bodies were successfully imaged by MDCT in about 15 minutes per
body, compared to subsequent full radiological analysis of about one hour per case. (1 of 5)6/12/2009 2:31:32 PM

Forensic Magazine® | Articles | The Virtual Autopsy: The Doctor Will Scan You Now

Rutty’s mobile scanner was powered by diesel generators, but can also be plugged into the electrical
grid. A truck transported the scanner and imaging suite, which included air conditioning,
telecommunications facilities for remote radiology reporting, hard film printing, and CD burners for
data storage.

Usually, in the primary reception stage in a disaster morgue, fluoroscopy is used first to screen bodies
and body parts, followed by further fluoroscopy or x-ray during identification, autopsy, or
anthropological stages.

“These can be time-consuming, rate-limiting procedures often requiring manual handling of both the
bodies and equipment to insure adequate imaging,” Rutty said. Rutty demonstrated that a single CT
modality can undertake both of these roles in a single stage, generating both soft tissue and bony
images in antero-posterior, lateral, axial, and 3D views within a short time period.

The scanner can examine single body bags or multiple fragment bags all at the same time without the
bags being opened, which not only shields radiology technicians from disturbing sights, but also tends
to maintain evidence continuity.

“Since radiation dose is not relevant for the deceased, scanned images were obtained at the highest
possible resolution to achieve the narrowest possible reconstructed slice thickness,” Rutty said. High
resolution however introduces two potential problems. First, increasing resolution correspondingly
increases heat load on the scanner, which can delay imaging while the unit cools. Secondly, high
resolution increases the number and size of the image file, which can be an issue if the images are to
be transmitted offsite to obtain a remote radiology report.

Radiological findings in this incident followed a newly designed forensic CT reporting form that
includes review of the muscular-skeletal system, cranium, facial bones, spine, axial, appendicular
skeleton, central nervous system, cardiovascular system, respiratory system, airway, abdomino-pelvic
organs, including upper GI tract, foreign bodies, and personal effects. “We identified the location of
personal possessions and could even collect data related to articles of clothing, such as shoe tread
patterns,” Rutty said. “We identified debris both on and in the bodies, which could be of evidentiary

Rutty said MDCT correctly identified the potential causes of death in all victims. Fractures were well
seen and could be reconstructed in 3D.

“In many cases, CT showed additional information not easily obtained by autopsy, such as stable
fractures and nonhemmorrhagic brain injury,” he said.


A 2007 military study found MDCT can also be used either to facilitate or reduce the need for
conventional autopsy when drowning is the suspected cause of death.

“Determining whether a person found dead in the water has actually drowned is imperative in forensic
investigation because becoming submerged in water may be a secondary rather than primary event,” (2 of 5)6/12/2009 2:31:32 PM

Forensic Magazine® | Articles | The Virtual Autopsy: The Doctor Will Scan You Now

said COL. Angela D. Levy, MD, of the Department of Radiology, Uniformed Services University of the
Health Sciences in Bethesda, Maryland.

In Levy’s study, whole-body MDCT was performed immediately prior to routine autopsy in 28 male
subjects who died of drowning. The control group was 12 male subjects who died of sudden death
from coronary artery disease.

Digital images were evaluated for such indications as the presence of fluid and sediment in the
paranasal sinuses and airways, mastoid air cell fluid, frothy fluid in the airways, and pulmonary
opacity. Image findings were then compared with findings from autopsy reports and photographs.

The researchers concluded that MDCT finding of frothy airway fluid or high-attenuation airway
sediment is highly suggestive of drowning, and that MDCT findings of pan sinus fluid, mastoid cell
fluid, subglottic tracheal and bronchial fluid, and ground-glass opacity within the lung are supportive of
drowning in the appropriate scenario.

Levy said MDCT may provide support for the diagnosis of drowning when other causes of death have
been excluded by a limited autopsy or external examination of the body.

In addition to the MDCT-drowning paper, Levy has published studies of the utility of MDCT in gunshot
wounds and fire deaths, work that has led many medical examiners to consider adding MDCT to their

“MDCT speeds recovery of projectile and bullet fragments through precise localization of metallic
fragments and aids in the detection of occult trauma,” Levy said.

Certain areas of neck and deep pelvis are difficult to dissect. MDCT helps guide the forensic
pathologist through these areas.

“Also, MDCT is very helpful in the depiction and classification fractures in severe skull trauma,” Levy

MDCT has also been shown to be effective in localizing gunshot wound tracks and to aid in forensic
autopsies of gunshot wound victims.

In forensic investigations of death by suspected projectile injury, plotting the projectile’s entry and exit
locations, path, and associated tissue trauma can be important in determining the cause and manner
of death.

The Armed Forces Institute of Pathology has used MDCT as a non-invasive method to enhance
forensic investigation in this area.

“MDCT may guide, direct, or limit forensic autopsy in projectile injury cases, thereby eliminating the
need for a complete invasive autopsy,” said H. Theodore Harcke, MD, of the Institute’s Department of (3 of 5)6/12/2009 2:31:32 PM

Forensic Magazine® | Articles | The Virtual Autopsy: The Doctor Will Scan You Now

Radiologic Pathology.

In a 2007 study, Harcke compared MDCT to full-body digital radiography (DR) in the postmortem
evaluation of gunshot wound victims. Thirteen consecutive male victims had full-body DR and MDCT
prior to routine autopsy. According to Harcke, DR successfully identified all metallic fragments, but
MDCT was superior in its ability to precisely determine location because it provided 3D anatomic
localization. In all cases, MDCT more accurately assessed organ injuries and wound tracks.

MDCT is even finding forensic uses outside of forensic medicine. Swiss researchers, for instance,
have devised a way to detect smuggled dissolved cocaine using MDCT scanners.

Smuggled dissolved drugs, particularly cocaine, in bottled liquids, is an ongoing problem at

international borders. Common fluoroscopy of packages cannot detect contaminated liquids.
Smugglers dissolve the drug and hide it in a few bottles of, say, wine, filling the remainder with
uncontaminated liquid, making it easier to go undetected since border checks perform only random

“Our screening method can test all bottles rapidly and noninvasively,” said Silke Grabherr, MD, of the
Institute of Forensic Medicine, University of Lausanne. Grabherr said the technique is suitable for the
examination of large cargos or to confirm suspicions without compromising the packaging.

Cocaine is a candidate contraband because it shows x-ray attenuation. Attenuation is the reduction in
amplitude and intensity of a signal, such as an x-ray.

“When a carton of wine bottles contains the same wine, the bottles will have more or less the same
mean attenuation on cross-sectional images,” Grabherr said. “It should be considered suspicious
when the attenuation of some bottles differs from the rest.”

Grabherr said MDCT is applicable to other sorts of smuggling, such as contraband hidden inside small
sculptures and hollowed fruit.

“Using CT and measuring the mean opacity of the content, differences in hidden drugs can be
detected without destroying the carrier,” she said.

Grabherr isn’t necessarily recommending that expensive MDCT units be deployed at all border

“To employ our method, collaboration between police or customs officials and a medical department is
necessary,” she said. Scanning can be performed at any facility with a CT scanner.

“If a forensic chemistry department must analyze a confiscated shipment suspected of containing
dissolved cocaine or other drug, the screening scan can be helpful to get a first overview to sort our
suspicious vessels so more expensive quantitative chemical analysis can be performed on selected
items,” Grabherr said. (4 of 5)6/12/2009 2:31:32 PM

Forensic Magazine® | Articles | The Virtual Autopsy: The Doctor Will Scan You Now

Douglas Page writes about forensic science and medicine from Pine Mountain, California. He can be
reached at

Copyright © 2009 Vicon Publishing, Inc. (5 of 5)6/12/2009 2:31:32 PM