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Virtual Autopsy as an Alternative to Traditional Medical Autopsy in the Intensive Care Unit: A Prospective Cohort Study

Dominic Wichmann, MD, DTM; Frieder Obbelode; Hermann Vogel, MD; Wilhelm Wolfgang Hoepker, MD; Axel Nierhaus, MD; Stephan Braune, MD, MPH; Guido Sauter, MD; Klaus Pueschel, MD; and Stefan Kluge, MD
[+] Article, Author, and Disclosure Information

From University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Grant Support: By University Medical Center Hamburg-Eppendorf.

Reproducible Research Statement:Study protocol: Available to approved individuals through written agreements with research sponser. Statistical code: Available from Dr. Kluge (e-mail, s.kluge@uke.de). Data set: Not available.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1201.

Requests for Single Reprints: Dominic Wichmann, MD, DTM, Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany; e-mail, d.wichmann@uke.de.

Current Author Addresses: Drs. Wichmann, Nierhaus, Braune, and Kluge and Mr. Obbelode: Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.

Drs. Vogel and Pueschel: Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.

Drs. Hoepker and Sauter: Department of Pathology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.

Author Contributions: Conception and design: D. Wichmann, G. Sauter, S. Kluge.

Analysis and interpretation of the data: D. Wichmann, F. Obbelode, H. Vogel, W.W. Hoepker, S. Braune, K. Pueschel, S. Kluge.

Drafting of the article: D. Wichmann, S. Braune, G. Sauter, S. Kluge.

Critical revision of the article for important intellectual content: D. Wichmann, A. Nierhaus, S. Braune, S. Kluge.

Final approval of the article: D. Wichmann, H. Vogel, W.W. Hoepker, A. Nierhaus, S. Braune, S. Kluge.

Provision of study materials or patients: D. Wichmann, W.W. Hoepker, S. Braune, G. Sauter.

Statistical expertise: S. Kluge.

Administrative, technical, or logistic support: D. Wichmann, F. Obbelode, S. Braune, G. Sauter, S. Kluge.

Collection and assembly of data: D. Wichmann, F. Obbelode, H. Vogel, W.W. Hoepker, A. Nierhaus, S. Braune.

Ann Intern Med. 2012;156(2):123-130. doi:10.7326/0003-4819-156-2-201201170-00008
Text Size: A A A

Background: Autopsy is an important educational and quality-control tool in the intensive care unit (ICU), but rates of traditional medical autopsies have declined worldwide. “Virtual” autopsy involving only advanced radiographic techniques might provide an alternative approach to postmortem examinations.

Objective: To assess the value of postmortem multidetector computed tomography as an alternative to medical autopsy.

Design: Prospective cohort study. (ClinicalTrials.gov registration number: NCT01040520)

Setting: 9 ICUs in a single academic medical center. Consent for both medical and virtual autopsies was sought from the families of all consecutive patients who died in the ICU between 1 January and 30 June 2010. Clinical records were reviewed to determine whether unsuspected autopsy findings would have altered care if known (major diagnosis) or would not have altered care (minor diagnosis).

Results: Of 285 patients, 47 underwent both virtual and medical autopsy. Of 196 clinical diagnoses made before death, 173 (88%) were identified by virtual autopsy and 183 (93%) by medical autopsy. Fourteen new major and 88 new minor diagnoses were detected by any autopsy method. The main diagnoses missed by virtual autopsy were cardiovascular events (9 of 72) and cancer (12 of 30). In contrast, medical autopsy missed 13 traumatic fractures and 2 pneumothoraces. Among 115 additional patients in whom only virtual autopsy was performed, 11 new major diagnoses were made.

Limitation: Virtual autopsy was performed in only 57% of patients (n = 162); among this group, consent for traditional medical autopsy was obtained for only one third.

Conclusion: Virtual autopsy may be useful for identifying diagnoses that traditionally have been identified by medical autopsy. This may also hold true, at least in part, for the educational aspect of medical autopsy (confirming antemortem clinical diagnoses). Further studies are required to confirm these preliminary results.

Primary Funding Source: University Medical Center Hamburg-Eppendorf, Germany.


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Appendix Figure.
Worldwide changes in autopsy rates in recent decades.

Autopsy rates are decreasing consistently in all developed countries. Data obtained from references 2 and 6–9.

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Figure 1.
Study flow diagram.

CT = computed tomography; ICU = intensive care unit.

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Figure 2.
Virtual autopsy images from case 1.

A. Three-dimensional surface reconstruction obtained by using volume rendering software. B. Surface reconstruction with a partial view to the intra-abdominal cavity. A large area of retroperitoneal bleeding (asterisk) detaching the peritoneum from the left abdominal flank and bleeding in the pancreatic area (arrowhead) are visible. C. Semiluminescent reconstruction provides additional information on anatomical landmarks for orientation.

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Figure 3.
Virtual autopsy images from case 3.

A. Three-dimensional surface reconstruction obtained by using volume rendering software. The central venous catheter (asterisk) and the Shaldon catheter (arrowhead) were inserted during a resuscitation procedure. B. Soft tissue is subtracted; the catheters are displayed in blue. A small part of the lower jaw is removed digitally to demonstrate the misplacement of the distal tip of the central venous catheter (arrow), entering the base of the skull via the foramen jugulare after being inserted via the right subclavian vein. Contralaterally, the Shaldon catheter is inserted correctly via the left internal jugular vein.

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Submit a Comment/Letter
Misplacement of Central Venous Catheters
Posted on January 30, 2012
Carl M.Kirsch, Physician
Santa Clara Valley Medical Center
Conflict of Interest: None Declared

The concept of a "Virtual Autopsy" is interesting, but there are some "abnormalities" which may be detected but are of minor clinical significance. Figure #3 is said to show a right subclavian venous catheter placed, inadvertently, into the neck. The image shows that the course of the right-sided catheter is totally above the clavicle, thus suggesting that it is actually a right-sided internal jugular venous catheter. The fact that the distal tip of the catheter has been placed into the cervical portion of the internal jugular vein, is not surprising or particularly dangerous and should not be considered a "major finding". Such a placement can be easily detected with ultrasound, at the time of the procedure, rather than rely on CT imaging.

Conflict of Interest:

None declared

Author's Response to Kirsch
Posted on March 7, 2012
DominicWichmann, MD, DTM, Stefan Kluge, MD
University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Conflict of Interest: None Declared

We appreciate the comment of Kirsch and agree that especially for cervical central lines, ultrasound is an easy to perform non-invasive method to control the correct positioning of the device. Thus this case once more underscores the value of virtual and classic autopsy forms for quality control (1), because obviously in this case control mechanisms were not sufficient to prevent the displacement of the device. That's why we disagree with Kirsch in classifying the event as minor. In a patient with septic shock, measuring central venous pressure, providing adequate volume and vasopressor therapy is held to be crucial (2). Since this can not be assured we classified the central venous line placed into the sigmoid sinus as "new major finding."


1. De Vlieger GY, Mahieu EM, Meersseman W. Clinical review: What is the role for autopsy in the ICU? Crit Care. 2010;14:221.

2. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. The New England journal of medicine. 2001;345:1368-77.

Conflict of Interest:

None declared

Submit a Comment/Letter

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