Virtopsy ? Radiology in Forensic Medicine

Virtopsy – Radiology in Forensic MedicineS. Grabherr1, B. A. Stephan1, U. Buck1, S. Nather1, A. Christe1,2, L. Oesterhelweg1, S. Ross1, R. Dirnhofer1,M. J. Thali11Centre for Forensic Imaging, Institute of Forensic Medicine, University of Bern, Bern, Switzerland2Institute of Diagnostic Radiology, University of Bern, Bern, Switzerland

Correspondence to:Silke Grabherr, M.D.Center of Forensic Imaging, Institute of Forensic Medicine, University of Bern, IRM – Buehlstrasse 20, CH – 3012 Bern, SwitzerlandTel: +41 31 631 8411; Fax: +41 31 631 3833; E-mail: [email protected]

Key words: Post-mortem radiology, computed tomography, virtual autopsy, forensic radiology, minimal-invasive autopsy, surface scanning.

Summary

During the last few years, modern cross-sectional imaging

techniques have pioneered forensic medicine. Magnetic

resonance imaging and especially multislice computed

tomography are becoming increasingly implemented into

post-mortem examinations. These non-invasive techniques

can augment and even partially replace a traditional aut-

opsy. Beside the radiological imaging techniques, the

methods of three-dimensional surface scanning and pho-

togrammetry are used for the documentation of the

external findings of the body. To realize the goal of a

minimal-invasive autopsy, other tools like post-mortem

biopsy and post-mortem angiography have been devel-

oped. In analogy to the clinical use of biopsy and angiog-

raphy these techniques will permit post-mortem tissue

sampling for further analyses and enable post-mortem

examinations of the vascular system. With the use of these

methods, a minimally invasive, objective and investigator-

independent documentation of forensic cases can be real-

ized to reach quality improvements in forensic pathological

investigations.

Introduction

Most of the forensic sciences such as forensic genetics and

forensic toxicology have already implemented modern

technologies which have and are revolutionizing these

fields. In contrast, forensic medicine still utilizes the evi-

dence-based methods introduced centuries ago. The gold

standard of examining a deceased person is still the

opening of the corpse with an exact oral description and

a written documentation (1). Important internal and

external findings are also documented by conventional

two-dimensional photography. After this observer-

dependent and subjective observation there is, unfortu-

nately in most of the cases, no way to repeat an

examination because the body has been cremated. Find-

ings that have not been documented are therefore irrev-

ocably destroyed.

Beside the examination of deceased persons, forensic

medicine has another goal, namely to document, analyse

and judge medical findings of living persons. In this field,

the same documentation and description methods utilized

in classic autopsy cases are used. It seems that the rapid

development of modern medicine has passed by forensic

medicine without influencing it relevantly. Although there

have been some authors like Brogdon (2) and Vogel (3)

who mentioned the usefulness of radiology in forensic

medicine, radiological tools did not find their way into the

routine of forensic medicine for a long time.

Only in special cases radiological tools like conventional

radiology and computed tomography (CT) are used in a

forensic context, for example, to demonstrate gunshot

wounds (3) and in order to find hidden drugs in the body

cavities of the so-called body packers (4, 5).

A forensic post-mortem CT-scan was first performed in

1977 to describe a gunshot injury to the head (6). In the

following years, only a few papers appeared in which

autopsy findings were compared to post-mortem CT

findings (7). With the invention of spiral CT in 1989 (8),

a three-dimensional (3D) reconstruction of the data

suddenly became possible. This tool was used for forensic

questions (9–11), but its application did not increase the use

of radiological techniques in forensic medicine much.

Magnetic resonance imaging (MRI) has also been

performed on deceased persons, which made correlations

between autopsy and cross-section imaging possible

(12–18).

Performing whole-body examinations with pre-autopsy

multislice computed tomography (MSCT) and MRI and

the comparison of both cross-sectional imaging techniques

with the findings of the conventional autopsy is part of the

work performed within the Virtopsy� project at the

Institute of Forensic Medicine in Bern, Switzerland

(http://www.virtopsy.com). As the name ‘Virtopsy’ stands

for ‘virtual’ and ‘autopsy’, this project is aimed at

developing and validating new approaches that allow for

a minimally invasive ‘virtual’ autopsy (19–21). The hereby

undertaken studies were approved by the local Justice

IMAGING DECISIONS n 1/2007

Department and the Ethics Committee of the University of

Bern. Due to a close collaboration with the Radiological

Institutes in Bern, a team of forensic specialists and

radiologists is working together and is consequently and

systematically comparing the radiological findings to those

obtained by traditional autopsies.

In collaboration with the police, 3D optical surface

scanning and photogrammetry are performed in certain

forensic cases (21–23) and data of all performed techniques

are matched together to solve forensic questions (24).

Additional applications that have also been implemen-

ted into the Virtopsy� project are post-mortem biopsy

(25), post-mortem angiography (26–29), Micro-MR (30,

31), Micro-CT (32, 33) and MR-spectroscopy (34).

In this article, the most frequently used tools in forensic

medicine, namely MSCT-imaging, MRI, photogrammetry

and 3D surface scanning are described and their indica-

tions mentioned.

Main-Virtopsy tools

CT Imaging

In the Virtopsy� project, MSCT is the most frequently

used tool. As the Institute of Forensic Medicine in Bern

owns a six-detector row scanner (Emotion 6; Siemens

Medical Systems, Erlangen, Germany), this kind of cross-

sectional imaging has found its way into daily routine in

Bern. At present, more than 200 cases have undergone a

pre-autopsy MSCT-scan of which the results were com-

pared to the findings from the subsequently performed

traditional autopsy by board-certified forensic pathologists

and radiologists according to the Armed Forces Institute of

Pathology design (35, 36). To avoid contamination of the

radiology equipment, to facilitate the transport of the body

and to protect the identity of the deceased person during a

post-mortem scan, each body was wrapped in two artefact-

free body bags. Whole-body scans were then performed

with a four- or six-detector row CT-scanner. The section

thickness was generally 1.25 mm and the reconstruction

increment was 0.7 mm in soft-tissue and osseous kernels.

Regions of special interest, like fracture systems or teeth

were scanned with a slice-thickness of 0.63 mm and an

increment of 0.5 mm. According to the thus gained results,

MSCT is an excellent tool to augment traditional autopsy

and may in future even partially replace it in certain cases.

The main advantage of a pre-autopsy MSCT scan is that it

provides additional information to the traditional autopsy.

These can be summarized and divided into the following

three main advantages as follows: (i) detection and

demonstration of fractures; (ii) detection of foreign bodies;

and (iii) detection of gas inside the body.

Detection and demonstration of fractures In analogy to clinical radi-

ology, the diagnosis of a fracture can be performed on cross-

sectional images. The form and pattern of a fracture is

extremely important in forensic medicine, because they can

give clues as to the trauma origin. Regarding a 3D-recon-

struction, it can be very helpful to find out from which side

the impact that led to the fracture occurred. It is also possible

to gather additional information on the injury-causing

instrument. A great advantage of the 3D-fracture models is

that they give a good overview of skeletal injuries and show

them in a way which is easy to understand even for medical

laymen (Fig. 1a,b). This can facilitate the collaboration

between forensic pathologists and the police and justice.

Also, small fractures that can be easily overseen at

autopsy, like fractures of the transversal or costal processes

of the spine can be easily detected by regarding the CT

data (Fig. 1c).

Detection of foreign bodies Metal is easily detected and localized

in a body because it possesses a higher X-ray absorption

compared to bone and soft tissue. In forensic medicine,

this fact is useful for a variety of questions. In cases of

gunshots, a MSCT-scan can easily show remaining pro-

jectiles in the body (Fig. 2a). For the reconstruction of

homicides and suicides, an exact localization of the bullets

is helpful. These are however sometimes difficult to find

with a traditional autopsy, especially if the bullet has

disintegrated inside the body (Fig. 2b). Other foreign

bodies, such as medical implants, are also easily detected

with an MSCT-scan (Fig. 3a). These objects are often of

great forensic interest, for example, to assess the correct

placing of such an implant inside the body in alleged

malpractice cases. Apart from this forensic question, the

localization and detection of implants is frequently used

to identify a body. The data of the MSCT scan can be

compared to radiological X-ray images of the deceased

person which were performed ante-mortem. The most

frequently used medical implants are dental implants

(Fig. 3b). A complete dental profiling with MSCT is also

possible by creating panoramic dental images (Fig. 3b)

which can be compared to the dentist’s data of the

deceased person (37–39).

Detection of air In traditional autopsy, finding an air embolism

or a pneumothorax is fairly difficult. For the latter, a

‘pleural window’ has to be produced by pushing away the

intercostal muscles of the intact thorax after removal of the

skin and the muscles. If the lungs happen to lie at the level

of the rib cage, a pneumothorax can be excluded. The

procedure of confirming the presence of an air embolism is

even more complicated. After opening the pericardium,

the pericardial space is filled with clear water which must

cover the heart entirely. The right ventricle is then punc-

tured with a scalpel which is turned inside the wound. If

this action produces ascending air bubbles, a suspected gas

embolism is confirmed.

With the use of post-mortem MSCT data, gas can be

detected easily due to the fact that it does not absorb

X-rays. Therefore, a pneumothorax can be localized easily

V I R T O P S Y – R A D I O L O G Y I N F O R E N S I C M E D I C I N E n 3

1/2007 n IMAGING DECISIONS

(a) (b)

(c)

j Fig. 1. 3D-reconstructions of the CT-data of a pilot, who died in an airplane crash. (a) Overview of the whole skeletonseen from the front and from behind, showing multiple skeletal fractures: fracture of the right clavicle (yellow arrow), bothhumeri (red arrows), multiple fractures of the pelvis (turquoise arrows), fractures of both femurs (violet arrows) and multiplefractures of both tibiae and fibulae (dotted circle). (b) 3D-model of the skull, showing multiple fractures of the viscerocranium(black arrows) and a fracture that had led to a dislocation of the temporal suture (red arrows). (c) Cross-sectional image at thelevel of the lumbar spine showing the first lumbar vertebra with fractures (arrows) of both transversal processes.

(a) (b)

j Fig. 2. 3D-reconstructions of the CT-data of gunshot victims. (a) Reconstruction of a skull showing the remainingprojectile inside of the head (red arrow). On the forehead a round defect of the bone is visible (yellow arrow), caused by theentrance of the bullet. This defect is surrounded by small metal fragments that are visible as radio-opaque particles (dottedcircle). (b) 3D-reconstruction of the abdomen of a gunshot victim showing metallic particles in blue. Apart from four intactbullets (red arrows), numerous fragments of deformed projectiles are visible in front of the spine.

4 n V I R T O P S Y – R A D I O L O G Y I N F O R E N S I C M E D I C I N E


(19), air embolism can be detected and even quantified (40)

using post-mortem MSCT.

MR imaging

MR imaging of deceased persons is performed on a 1.5-T

system (Signa v5.8; GE Medical Systems, Milwaukee, WI,

USA) at the Institute of Diagnostic Radiology of the

University Hospital in Bern. For this, the bodies are again

wrapped in two artefact-free body bags prior to the scan.

The head, thorax and abdomen, and, depending on the

case, other additional regions (e.g. extremities when

injured) are then scanned. Coronal, sagittal and axial

images are acquired with different contrast weighting

(T1-weighted spin-echo and T2-weigthed fast spin-echo

sequences with and without fat saturation, turbo inversion

recovery sequences and gradient-echo sequences). When

cardiac findings are expected, short-axis, horizontal long-

axis and vertical-axis images are acquired. The acquisition

times range from 1.5 to 3.5 h.

In analogy to clinical MR imaging, forensic medicine is

also using this tool to detect pathological findings of the soft

tissues such as subcutaneous fat (41) and inner organs

(12–19, 42, 43). Also fatal haemorrhage (44) and hypother-

mia (45) can be examined by using MRI in combination

with MSCT. A special indication of MRI is fatal strangu-

lation in hanging (46, 47). As this method is non-invasive

and the examination requires no radiation exposure, it also

used as an additional tool to the external examination of

victims of survived strangulation (Fig. 4a–c) (46).

Digital photogrammetry and 3D surface scanning

Apart from radiological imaging techniques for the docu-

mentation of internal findings in the Virtopsy� project,

digital photogrammetry and the highly precise 3D surface

scanning are employed for the documentation of the

external findings and of injury-inflicting instruments

(21–24).

For this approach in the Virtopsy� project, the GOM

TRITOP/ATOS III system (GOM, Braunschweig,

Germany) is applied. This reliable system reproduces the

geometry of an object in 3D and with a high resolution.

The digitizing of an object consists of two steps. First, the

photogrammetry is performed to predefine discrete points

of the object. Therefore, reference targets and coded

markers as well as coded scale bars are applied to the

object. Then several images are taken from different views.

The photos are transferred to the computer and the

TRITOP software calculates the 3D coordinates of the

reference targets. During the 3D surface scanning, which is

the second step of the digitizing process, these reference

targets serve for merging single scans done from different

views around the object automatically into a complete 3D

data set.

The ATOS III surface scanner consists of one central

projection unit and two digital cameras mounted besides

the projector. A fringe pattern is projected onto the surface

of the object, which is recorded by the two CCD cameras.

The sensor unit is connected to a High End PC. All

captured images are instantly transferred. Based on the

principle of triangulation, 3D coordinates of up to 4 million

surface points per measurement are calculated by the

scanning software ATOS.

Results of these digitizing methods are real-data-based

3D models of the surface of a body, an accident car or a

weapon in real colour. The models display even the tiniest

injuries or defects. In combination with the radiological

data these models are employed for reconstructions of

accidents and homicides.

(a) (b)

(c)

j Fig. 3. Reconstructions of CT-dataused for identifications of bodies. (a)3D-reconstruction of the spine andpelvis showing a metallic implant forthe dorsal stabilization of the spine.Due to its high density, the metal iscoloured blue. (b) 3D-ronconstructionof the skull showing dental prosthesesof the maxilla which appear blue. Afilling of the lower molars (arrow) isalso coloured. (c) Dental panorama,reconstructed from CT-data showingdifferent dental fillings, which appearbright due to their high radio-opacity.



For example, the real-data-based reconstruction can be

used to compare a patterned gunshot injury to a gun which

was found at the crime scene (Fig. 5a–c). The 3D model of

the presumed gun can be merged to the model of the

injury. The morphology of the injury can be compared

with the face of the gun. This can prove that the gun is the

injury causing object and it can also show the exact

position of the gun at the moment of firing (Fig. 5a). This

question is especially important in cases where a suicide is

suspected.

In traffic accidents, reconstructions of the course of an

accident, especially the situation of impact can be

performed by comparing the injuries of the person and

the defects of the inflicted vehicles by the use of the 3D

surface data (Fig. 6). This tool is very helpful for the

reconstruction of complicated traffic accidents (24) where a

traditional autopsy hardly leads to a solution of the case.

Trends in forensic radiology

Since the beginning of the project ‘Virtopsy�’ in 2000, a

large amount of experience could be gained by bringing

radiology into forensic medicine, thus showing the poten-

tial and also the limitations of the project. A vital aspect for

such a project is the close collaboration between foren-

sic pathologists and radiologists. The application of pre-

autopsy CT and MRI scan can bring great advantages. In

most of our cases the cause of death was detected prior to

autopsy using these two tools. At present, it is still necessary

to prove every radiological finding by comparing it with

the results from the traditional autopsy – the currant ‘gold

standard’ – to evaluate the new imaging methods. The

method of photogrammetry and 3D surface scanning has

already found its way into court, where it has been

accepted.

Other Virtopsy� tools have also led to great interest

from police and justice departments, who are willing to

implement these new methods into their case management.

Especially the 3D-reconstructions of MSCT data are

frequently demanded and MRI examinations of survived

strangulation victims are already routinely requested.

Working-groups like Virtopsy� do not exist only in

Switzerland. Actually, other institutes are working on

implementing MRI and MSCT into forensic medicine. For

example, the Office of the Armed Forces Medical Exam-

iner (Washington DC, Dover, Del), the Institute of

Forensic Medicine Copenhagen, Denmark (48) and the

Victorian Institute of Pathology, Sydney, Australia have

already installed their own CT-scanners. In Japan, the

Society for Autopsy Imaging was founded in 2003.

With the further development of radiological techniques

such as total imaging matrix in MRI, which will reduce

examination times for forensic MRI examinations, these

tools will become easier to implement into the daily routine

of forensic medicine. Additional new tools like post-

mortem angiography are also implemented into the

Virtopsy� approach. First studies show promising results

that allow for a demonstration of the vascular system which

is impossible to reach by a traditional autopsy (Fig. 7a–c).

The further development of post-mortem biopsy and post-

mortem angiography together with MRI and MSCT will

set new trends towards a minimal-invasive autopsy. In

contrast to pre-autopsy cross-sectional imaging, a minimal-

invasive autopsy has the potential to replace traditional

autopsy in future. Especially in certain cultural circles

where an autopsy is stigmatized or even forbidden, a

minimal-invasive virtual autopsy could aid the judicial

system without violating religious prohibitions. The great

advantage of MSCT in the identification of bodies is useful

in disaster victim identification (49).

(a) (b)

(c)

j Fig. 4. MR imaging of the headand neck of a victim 1 day after havingsurvived strangulation with the lowerarm. The external examination did notshow any pathological findings. How-ever, the victim declared difficulties inswallowing. (a) This T2-weighted cor-onal cross-sectional image of the headand neck shows a hyperdensity (dot-ted circle) under the mandible on theleft side, indicating a haemorrhage andoedema of the platysma and the sub-cutaneous tissue. (b) T2-weightedcross-sectional image at the level ofthe thyroid cartilage (arrow). The sur-rounding tissue on both sides of thelower horn of the cartilage showshaemorrhage and oedema (dotted cir-cles). (c) A proton-weighted T1 cross-section image at the height of the baseof the buccal cavity shows a restriction(arrow) of the trachea on the left side.



(a)

(b)

(c)

j Fig. 5. Reconstruction of a gunshot in a case of suicide by the use of 3D models from surface-scan and photogrammetrydata. (a) The 3D model of the head with colour information from digital photogrammetry shows a gunshot wound at the righttemple with a muzzle imprint (white arrows). (b) By merging the model of the suspected gun with the muzzle imprint, the exactposition of the weapon can be evaluated. The course of the projectile is demonstrated by the red line. (c) Fusion of theradiological MR image with the surface data. The T2-weighted coronal image depicts the cerebral (yellow arrows) along thebullet course (red line). From this point of view it can be observed that the face of the gun fits exactly to the imprints visible onthe skin (white arrow). The position of the gun is typical for a suicide.

j Fig. 6. Reconstruction of the situ-ation of a traffic accident in which apedestrian was killed by a car. Thisimage shows the resulting reconstruc-ted situation at the moment of theimpact. The external injuries of thebody and the car were documented bysurface scanning, as well as the inter-nal findings by MSCT and MRI. Thegenerated 3D model of the MSCT data(showing the skeleton in the image)and the 3D model of the body’s sur-face (visible at the rear of the person)were compared with the damages ofthe car (arrows), which was also docu-mented by a surface scanning of thecar.



Conclusion

Radiology has already entered the field of forensic medi-

cine. Institutions are working in evaluating MSCT and

MRI application for forensic questions. By combining

radiological imaging with photogrammetry and 3D surface

scanning, an exact objective external and internal docu-

mentation of a body is possible. This datum allows for the

performing of detailed reconstructions. Further develop-

ment and application of additional tools like post-mortem

angiography and biopsy will lead to a minimally invasive

autopsy which has the potential to replace the traditional

autopsy in some cases.

Acknowledgements

This project is financially supported by the Virtopsy

Foundation.

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Virtopsy ? Radiology in Forensic Medicine