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Forensic Science International 280 (2017) 8186

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Forensic Science International


journal homepage: www.elsevier.com/locate/forsciint

Comparative radiologic identication with standardized single CT


images of the paranasal sinusesEvaluation of inter-rater reliability
Cdric N. Bruna , Angi M. Christensenc , Milan Kravarskid,e , Guillaume Gorincourf ,
Wolf Schweitzera , Michael J. Thalia , Dominic Gaschoa , Gary M. Hatchg,
Thomas D. Rudera,b,*
a
Institute of Forensic Medicine, Department of Forensic Medicine and Imaging, University of Zurich, CH-8057 Zurich, Switzerland
b
Institute of Diagnostic, Interventional, and Pediatric Radiology, University Hospital Inselspital, University of Bern, CH-3010 Bern, Switzerland
c
Federal Bureau of Investigation Laboratory, Quantico, VA 22135, USA
d
Department of Orthopedic Surgery and Traumatology, Spital Tiefenau, CH-3004 Bern, Switzerland
e
Department of Orthopedic Surgery and Traumatology, Burgenspital Solothurn, CH-4500 Solothurn, Switzerland
f
LiiEEA 4264 (Experimental and Interventional Imaging Laboratory), CERIMED (European Center for Medical Imaging Research), Aix-Marseille University, F-
13005 Marseille, France
g
Center for Forensic Imaging, Departments of Radiology and Pathology, University of New Mexico School of Medicine, Albuquerque, NM 87102, USA

A R T I C L E I N F O A B S T R A C T

Article history:
Received 3 November 2016 The aim of this study was to assess the reproducibility of a standardized image for personal identication
Received in revised form 11 April 2017 (SIPI), used in the comparative analysis of paranasal sinuses, and test the effect of inaccurate reformation
Accepted 28 August 2017 of the SIPI on suitability for comparative identication.
Available online 2 September 2017 Five raters with different professional backgrounds independently reformatted SIPIs from ten post-
mortem head CTs. Inter-rater, intra-rater agreement as well angular deviations between reformatted SIPI
Keywords: images and reference SIPI images were calculated. Second, raters assessed the suitability of 70 accurately
Forensic radiology and inaccurately reformatted SIPIs for identication with a 4-point Likert scale. Inter-rater agreement as
Personal identication
well as levels of signicance regarding image suitability were calculated.
Radiologic identication
Inter-rater agreement regarding reproducibility of SIPI reformation was excellent (inter-rater
Paranasal sinuses
Standardized image for personal correlation coefcient (ICC) 0.9995, intra-rater ICC 0.9983). Deviation between the angular dimensions
identication of the reformatted SIPIs and the reference SIPIs was 1 in 94% of all 300 measurements. Inter-rater
agreement regarding the effect of inaccurate SIPI reformation on suitability for comparative
identication was fair (ICC 0.6809). There was no statistically signicant difference between raters
evaluation of image suitability (p = 0.9755).
This study shows that the standardized image for personal identication can be accurately reformatted
by different raters with varying professional backgrounds. In addition, raters agree that inaccurately
reformatted SIPIs are still suitable for comparative identication in the majority of cases.
2017 Published by Elsevier Ireland Ltd.

1. Introduction Technological developments in medical imaging and the subse-


quent ascent of cross-sectional imaging in forensic sciences
There are several established and reliable methods to identify uncovered an enormous potential of radiologic images, especially
the dead, including DNA samples, ngerprints or radiologic images computed tomography (CT) for personal identication [24].
[1]. The process of identication depends on the scenario or Irrespective of the medical imaging modality used for identica-
circumstances of death, the availability of experts [2], and the tion, an identication is performed through careful comparison of
availability and quality of antemortem records for comparison. ante-mortem (AM) images to post-mortem (PM) images, which
may include both macroscopic (visual) assessment as well as the
use of population frequency data for traits being compared [5].
* Corresponding author at: Forensic Medicine and Imaging, Institute of Forensic Radiologic images of osseous structures are well suited for this
Medicine, University of Zurich, Winterthurerstrasse 190/52, CH-8057 Zurich, purpose because of their durability [6].
Switzerland. Fax: +41 44 635 68 51.
E-mail addresses: thomas_ruder@hotmail.com, thomas.ruder@irm.uzh.ch
The rst published report on a positive identication with
(T.D. Ruder). radiologic images of the paranasal sinuses was published as early

http://dx.doi.org/10.1016/j.forsciint.2017.08.029
0379-0738/ 2017 Published by Elsevier Ireland Ltd.
82 C.N. Brun et al. / Forensic Science International 280 (2017) 8186

as 1927 [7]. The paranasal sinuses are fully developed by the age of description of the anatomical landmarks is provided in Fig. 1.
20 and their morphology remains unchanged throughout adult life They propose that this image plane is well suited for the purpose of
unless affected by pathologies [811]. In the late 1980s, Harris et al. radiologic identication for the following reasons: (1) the selected
observed that the morphology of the frontal sinus features a high anatomical landmarks are covered in the scan volume of standard
inter-individual variability and hence offered a reliable means of head-CTs, which means that any existing clinical head-CT should
radiologic identication [12]. This conclusion was afrmed in be suitable for comparison with a corresponding PMCT; (2) clinical
studies by Kullmann et al. and later by Christensen who used head-CT (i.e. potential AM reference material) is traditionally
Elliptical Fourier Analysis to demonstrate that the outline of the acquired in the orbito-meatal plane, which means that the in-
frontal sinus is highly variable between individuals [1315]. A plane resolution of an old non-isotropic CT image of the head will
signicant step towards modern radiologic identication was be highest in the orbito-meatal plane and thus image quality
taken in the early 1990s by forensic anthropologist Kathleen Reichs should be sufcient for comparative identication regardless of the
who successfully identied a decedent based on her comparison of scan date of the AMCT; (3) all elements used for anatomical
ante-mortem CT (AMCT) and post-mortem CT (PMCT) of the orientation, reformation and identication are osseous, which
paranasal sinuses [16]. Since then, a number of publications have means that they should remain unchanged even after a long
demonstrated the utility and reliability of radiologic identication postmortem interval; and (4) the selected anatomical landmarks
based on CT images of the paranasal sinuses [2,6,17]. are thought to be unambiguous and easy to recognize, which
Today, there is general agreement that CT offers two funda- means that the reformation of the SIPI should be a straightforward
mental advantages over conventional radiographs: First, CT images and simple task [18]. There is an abundance of published evidence
are cross-sectional images and thus allow for a more detailed to support the authors rst three reasons for selecting the SIPI for
comparison of the morphology of the paranasal sinuses than radiologic identication [2,17,2123]. However, the publication by
conventional radiographs. Second, the use of multi-planar Ruder et al. does not provide any evidence to conrm the
reformation (MPR) tools enables investigators to reformat PMCT supposedly straightforward and simple task of creating the SIPI.
images to match nearly any radiographic ante-mortem image [2]. The aim of this study is to (1) assess the reproducibility of the
Typically, alignment between PMCT and AMCT is achieved through SIPI by multiple raters with different professional backgrounds,
individual reformation of PMCT images to the axial AMCT images. and (2) test the effect of inaccurate reformation of the SIPI on
A recent publication proposed the use of a single standardized suitability for comparative identication.
image of the paranasal sinuses and orbit for identication [18]. The
use of standards in forensic sciences, particularly in comparative 2. Methods
identication can increase the accuracy of identications both in
individual cases as in mass disasters (quantitative identication Ethical approval for this study was waived by the responsible
instead of qualitative visual comparison), decrease the time Ethics Committee of the Canton of Zurich, Switzerland (Waiver
needed to perform individual identications, and also improve Number: KEK Zurich 22-2015). PMCT images used in this study were
the evidentiary value of an identication in court (e.g. Daubert scanned between March 1 and March 4, 2016 as part of the judicial
Standard) [19,20]. investigation into the manner and cause of death of the deceased.
In their article, Ruder et al. detail the method to create the
standardized image for personal identication (SIPI) from both 2.1. Study population
AMCT and PMCT data [18]. The SIPI is reconstructed parallel to the
orbito-meatal plane, using the inner ear and inferior margin of the In this study, 10 postmortem head CT datasets were analyzed.
left frontal bone as anatomical landmarks [18]. A detailed The population consisted of 7 males and 3 female with a mean age

Fig. 1. Axial and sagittal CT images of a skull. Fig. 1a corresponds to the standard image for personal identication (SIPI). The image plane of the SIPI (red dotted line in b) is
parallel to the orbito-meatal plane (blue dotted line in b) using the inner ear (yellow circles in a) and the inferior orbital margin of the left frontal bone (red arrows in b and a)
as anatomical landmarks. The center of cross-hairs on the axial image (Fig. 1a) is positioned over the small bone between the lateral semilunar canal and the vestibule The
anterio-posterior cross-hair line (red dotted line in b) is positioned just below the inferior left orbital margin of the frontal bone (red arrow in b). Note the numbers in the
lower left corner of the images (blue circles in a and b) which are used to document the angular position of the images within the x-, y-, and z-axis of the CT coordinate system.
(For interpretation of the references to colour in this gure legend, the reader is referred to the web version of this article.)
C.N. Brun et al. / Forensic Science International 280 (2017) 8186 83

of 62.8 years (minimum 44 years; maximum 85 years; median 64.5 forensic pathologist, one forensic anthropologist, one orthopedic
years). None of the cases featured traumatic or non-traumatic surgeon, and one medical student) on a digital picture archiving
pathologies of the sinuses or skull. Raters were blinded to all and communication system (PACS) viewer using a dedicated
patient information. visualization software (MM Reading, Syngo. Via VB10, Siemens
Healthcare, Erlagen, Germany). All raters underwent the same
2.2. PMCT scan protocol training provided by the study supervisor (a board certied
radiologist) on how to operate the PACS viewer and the multi-
PMCT of the head was performed on a 128-slice Dual Source CT planar reformation (MPR) tool in three training cases. The study
scanner (Somatom Denition Flash, Siemens Healthcare, Erlangen, supervisor did not participate in the study as a rater.
Germany). Scan parameters of data used in this study were
(adapted from [24]):120 kVp; automatic dose modulation (CARE 2.4. Reproducibility of the SIPI
Dose4D, Siemens Healthcare, Erlangen, Germany); 128  0.6 mm
collimation. PMCT image reconstruction was performed with a To test the reproducibility of the SIPI, raters were asked to
slice thickness of 0.6 mm in increments of 0.4 mm in an adjusted separately and independently reformat each head CT with the
eld of view using soft tissue and bone-weighted tissue kernels in MPR tool and recreate an accurate SIPI according to the method
all cases. For this study, only bone-weighted tissue kernel images described by Ruder et al. in each of the 10 cases [18]. The
were evaluated. The viewing window was set to center of goniometry application of the MPR tool was used to document the
1000 Hounseld Units (HU) and width of 4000 HU. exact angular position of each reformatted SIPI with six angular
dimensions within the x-, y-, and z-axis of the CT coordinate
2.3. Image reformation and analysis system (two angular dimensions for each axis) (Fig. 1). Consis-
tency of angular dimensions was assessed between all ve raters
PMCT reformation and analysis was performed by ve raters as well as between all reformatted SIPIs and a set of 10 reference
with different professional backgrounds (one radiologist, one SIPIs, previously reconstructed by the study supervisor. The time

Fig. 2. Sample case of inaccurately reformatted SIPI images. To assess the effect of inaccurate reformation of the SIPI on suitability for personal identication, the study
supervisor reformatted series of SIPI with lateral, cranial, and caudal rotation and three different degrees of angular deviation from the orbito-meatal plane.
84 C.N. Brun et al. / Forensic Science International 280 (2017) 8186

needed to reformat the SIPIs was documented for each rater. All identication). The evaluations were examined for inter-rater
raters completed their individual image reformations in one agreement as well as signicant levels of differences between
single session. In addition, the study supervisor who created the raters. The effect of in-plane rotation (i.e. lateral, cranial, and
reference SIPSs (and who is not included as one of the ve study caudal rotation) and the effect of angular deviation (in steps of 1,
raters) repeated the reformation of all 10 SIPIs after an interval of 3 , and 5 ) were separately assessed.
several months to assess the intra-rater agreement of the SIPI
reformation. 2.6. Statistical analysis

2.5. Effect of inaccurate reformation of the SIPI on suitability for Continuous variables are expressed as means  standard
identication comparison deviations or medians and ranges. Categorical variables are
expressed as frequencies (%). Inter-rater agreement regarding the
To assess the effect of inaccurate image reformation on the angular position of the reformatted SIPIs in the CT-coordinate
suitability of the SIPI for comparative identication, raters were system (i.e. reproducibility of SIPI) as well as inter-rater
independently asked to evaluate as series of 70 reformatted SIPIs agreement regarding the effect of inaccurate reformation of the
which included both accurately and inaccurately reformatted SIPI on suitability for comparative identication was assessed
images. Each stack of 70 images consisted of 7 accurately with the intra-class correlation coefcient (ICC). Intra-rater
reformatted SIPIs (taken from the reference SIPIs) as well as agreement regarding the reproducibility of the reference SIPI
63 inaccurately reformatted SIPIs with either a lateral, cranial, or was also assessed with ICC. According to Landis and Koch, ICC
caudal rotation in predetermined angular degrees of 1, 3 , and 5 , values of 1.0 indicate absolute, 0.80.99 excellent, 0.60.79 fair,
respectively (Fig. 2). Raters used a 4-point Likert-scale to rate their 0.20.59 moderate, and 0.00.19 slight agreement [25]. The
visual assessment of the effect of in-plane rotation and angular KruskallWallis test was used to assess signicant levels of
deviation on image quality as compared to the reference SIPI differences between the raters evaluation of image suitability. A
(adapted from [1]): (1) no deviation from SIPI (excellent suitability p value <0.05 indicates statistical signicance. Consistency
for comparative identication); (2) minor deviation from SIPI between angular dimensions of the 10 reference SIPI and the
(good suitability for comparative identication); (3) moderate reformatted SIPI was calculated in differences of angular degrees.
deviation from SIPI (fair suitability for comparative identication); Data analysis was performed using an online statistical software
(4) major deviation from SIPI (image not suitable for comparative tool (StatsToDo, Brisbane, Australia).

Fig. 3. Comparison of one case of reformatted SIPI images as reformatted by the study supervisor (reference SIPI) and all ve raters. The anatomical details of the paranasal
sinuses of all six images are perfectly aligned.
C.N. Brun et al. / Forensic Science International 280 (2017) 8186 85

Fig. 5. Bar chart to visualize the effect of inaccurate SIPI reformation on suitability
for comparative identication.

The fact that there was excellent inter- and intra-rater


agreement regarding SIPI reformation, regardless of the varying
professional background and experience with CT of all raters,
supports the claim that the landmarks selected by Ruder et al. for
the SIPI are easy to recognize. The fact that the deviation between
the angular dimensions of all reformatted SIPIs and the reference
SIPIs was 1 in 94% of all 300 measurements further indicates that
the SIPI is a highly reproducible image. Moreover, the time needed
Fig. 4. Bar chart to visualize the high consistency regarding angular dimensions to reformat a single SIPI ranged from only 2 to 4.5 min, which in
between the reformatted SIPIs and the reference SIPIs. Angular dimensions some of the authors experience is shorter than the time needed to
between the reformatted SIPIs and the 10 reference SIPIs were consistent (0 match a non-standardized MPR reformation of the head with
deviation) in 70% (211/300) of all angular measurements. Angular dimensions of the
AMCT images. In other words, the SIPI can be accurately and
reformatted SIPIs deviated from the reference SIPIs by 1 in 24% (71/300), by 2
in 4% (11/300), by 3 in 2% (6/300), and by 4 in 0.3% (1/300) (Fig. 4). rapidly reformatted following the step-by-step instructions
published by Ruder et al. [18].
3. Results High reproducibility of accurately reformatted images and
short reformation time are also two important features of the SIPI
Inter-rater agreement regarding the angular position of the with regard to the work ow in disaster victim identication (DVI).
reformatted SIPI in the CT-coordinate system (reproducibility of The high consistency of angular dimensions between the
SIPI) was excellent (ICC 0.9995) (Fig. 3). Intra-rater agreement reformatted SIPIs and the reference SIPI is relevant in view of the
regarding the reproducibility of the SIPI was also excellent (ICC assessment of image quality: raters agreed that image suitability of
0.9983). Angular dimensions between the reformatted SIPIs and incorrectly reformatted SIPIs with an angular deviation of 1 (in
the 10 reference SIPIs were fully consistent (0 deviation) in 70% any direction) was still adequate in 95% of all cases. In cases with an
(211/300) of all angular measurements. Angular dimensions of the angular deviation of 3 (in any direction), the SIPI was considered
reformatted SIPIs deviated from the reference SIPIs by 1 in 24% suitable for comparative identication in 62%. Although this
(71/300), by 2 in 4% (11/300), by 3 in 2% (6/300), and by 4 in nding clearly shows that angular deviations of 3 (and more) have
0.3% (1/300) (Fig. 4). Mean time to reformat the SIPI was 3.3 min a considerable effect on the potential suitability of the SIPI for
per case (range 2.0 to 4.5 min, median 3.1 min). Inter-rater comparative identication, one has to keep in mind that angular
agreement regarding the effect of inaccurate SIPI reformation on deviations 3 occurred in only 6 of all 300 angular measurements
suitability for comparative identication was fair (ICC 0.6809). The (2%). This means that the high reproducibility of the SIPI
KruskallWallis test revealed that there was no statistically compensates for the apparent susceptibility of image suitability
signicant difference between raters evaluation of image suitabil- to angular deviations. In addition, a closer look at the data shows
ity (p = 0.9755). Regarding in-plane rotation, SIPIs were rated that the effect of angular deviation on suitability of the SIPI is
suitable for comparative identication (i.e. Likert scores of 13) in different depending on the direction of in-plane rotation: there is
92% (97/105) of all images with a lateral rotation, 59% (62/105) of agreement among the raters that the effect of a lateral rotation on
all images with a cranial rotation, and 53% (56/105) of all images image suitability is smaller than that of cranial or caudal rotation.
with a caudal rotation. Regarding angular deviation, SIPIs were Therefore, inaccurate SIPI reformation is nearly always tolerated if
rated suitable for comparative identication (i.e. Likert score of the deviation from a technically accurate reformatted SIPI either
13) in 95% (100/105) of images with an angular deviation of 1 (in occurs as lateral in-plane rotation or is 1 angular deviation in any
any image plane), 62% (65/105) of images with an angular image plane.
deviation of 3 , and 48% (50/105) of images with an angular This study has several limitations which deserve discussion.
deviation of 5 (Fig. 5). The variable professional background may be seen as limitation
with regard to the second aim of the study (i.e. test the effect of
4. Discussion inaccurate reformation of the SIPI on image quality): the fact that
only two of the ve raters had practical experience with
This study shows that the standardized image for personal comparative identication may have caused a greater heterogene-
identication can be accurately reformatted by different raters ity regarding the assessment and rating of image quality. However,
with a varying professional background. In addition, raters agree it remains speculative if a more homogeneous group of raters with
that inaccurately reformatted SIPIs are still suitable for compara- respect to the extent of their practical experience in identication
tive identication in the majority of cases. would have rated the effect of inaccurate reformation on image
86 C.N. Brun et al. / Forensic Science International 280 (2017) 8186

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