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Comparative Study
, 379 (9811), 136-42

Post-mortem Imaging as an Alternative to Autopsy in the Diagnosis of Adult Deaths: A Validation Study

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Comparative Study

Post-mortem Imaging as an Alternative to Autopsy in the Diagnosis of Adult Deaths: A Validation Study

Ian S D Roberts et al. Lancet.

Abstract

Background: Public objection to autopsy has led to a search for minimally invasive alternatives. Imaging has potential, but its accuracy is unknown. We aimed to identify the accuracy of post-mortem CT and MRI compared with full autopsy in a large series of adult deaths.

Methods: This study was undertaken at two UK centres in Manchester and Oxford between April, 2006, and November, 2008. We used whole-body CT and MRI followed by full autopsy to investigate a series of adult deaths that were reported to the coroner. CT and MRI scans were reported independently, each by two radiologists who were masked to the autopsy findings. All four radiologists then produced a consensus report based on both techniques, recorded their confidence in cause of death, and identified whether autopsy was needed.

Findings: We assessed 182 unselected cases. The major discrepancy rate between cause of death identified by radiology and autopsy was 32% (95% CI 26-40) for CT, 43% (36-50) for MRI, and 30% (24-37) for the consensus radiology report; 10% (3-17) lower for CT than for MRI. Radiologists indicated that autopsy was not needed in 62 (34%; 95% CI 28-41) of 182 cases for CT reports, 76 (42%; 35-49) of 182 cases for MRI reports, and 88 (48%; 41-56) of 182 cases for consensus reports. Of these cases, the major discrepancy rate compared with autopsy was 16% (95% CI 9-27), 21% (13-32), and 16% (10-25), respectively, which is significantly lower (p<0·0001) than for cases with no definite cause of death. The most common imaging errors in identification of cause of death were ischaemic heart disease (n=27), pulmonary embolism (11), pneumonia (13), and intra-abdominal lesions (16).

Interpretation: We found that, compared with traditional autopsy, CT was a more accurate imaging technique than MRI for providing a cause of death. The error rate when radiologists provided a confident cause of death was similar to that for clinical death certificates, and could therefore be acceptable for medicolegal purposes. However, common causes of sudden death are frequently missed on CT and MRI, and, unless these weaknesses are addressed, systematic errors in mortality statistics would result if imaging were to replace conventional autopsy.

Funding: Policy Research Programme, Department of Health, UK.

Figures

Figure 1
Figure 1
Protocol for radiology reporting
Figure 2
Figure 2
Post-mortem changes and pathologies (A) Axial CT image through the upper abdomen showing extensive intravascular gas (arrowhead), in keeping with decomposition. Free intraperitoneal gas (arrow) is due to decomposition in this patient, but creates difficulty for exclusion of a perforated intra-abdominal viscus. (B) Axial CT image through the brain showing extensive intracranial gas due to decomposition. Differentiation between grey and white matter is poor. (C) Axial CT image showing rupture of an abdominal aortic aneurysm (arrowhead) with extensive retroperitoneal haemorrhage on the left (arrow). (D) Oblique axial (short-axis view) T2-weighted MRI image showing a haemopericardium (arrowhead) due to rupture of a myocardial infarct (arrow).
Figure 3
Figure 3
Frequency of formulation errors in the general radiologist causes of death for the first six batches Major formulation errors are either unsupported modes of death or sequence errors for which no logical causal relation exists between parts Ia, b, and c of the medical certificate of cause of death.

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