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IMPROVING PATIENT CARE

Virtual Autopsy With Multiphase Postmortem Computed Tomographic Angiography Versus Traditional Medical Autopsy to Investigate Unexpected Deaths of Hospitalized Patients: A Cohort StudyVirtual Autopsy Versus Traditional Medical Autopsy

Dominic Wichmann, MD, DTM*; Axel Heinemann, MD*; Clemens Weinberg, MSc; Hermann Vogel, MD, PhD; Wilhelm Wolfgang Hoepker, MD, PhD; Silke Grabherr, MD, PhD; Klaus Pueschel, MD, PhD; and Stefan Kluge, MD
[+] Article and Author Information

* Drs. Wichmann and Heinemann contributed equally to this work.


From the University Medical Center Hamburg–Eppendorf, Hamburg, Germany, and Centre Universitaire Romand de Médecine Légale, Centre Hospital Universitaire Vaudois, Lausanne, Switzerland.

Acknowledgment: The authors thank the medical staff of the Department of Intensive Care Medicine for their unfailing commitment to quality control when asking relatives for informed consent to do this study. Furthermore, they thank the technicians of the Department of Legal Medicine for their help in doing the CT scans.

Financial Support: By the University Medical Center Hamburg–Eppendorf. Dr. Grabherr had personal academic funding from the Fondation Leenaards. Fumedica provided consumables for multiphase PMCT angiography.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2211.

Reproducible Research Statement: Study protocol, statistical code, and data set: Available from Dr. Wichmann (e-mail, d.wichmann@uke.de).

Requests for Single Reprints: Dominic Wichmann, MD, DTM, Department of Intensive Care Medicine, University Medical Center Hamburg–Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.

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

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

Dr. Hoepker: Department of Pathology, University Medical Center Hamburg–Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.

Dr. Grabherr: Centre Universitaire Romand de Médecine Légale, Centre Hospital Universitaire Vaudois, Rue du Burgnon 21, CH-1011 Lausanne, Switzerland.

Author Contributions: Conception and design: D. Wichmann, A. Heinemann, W.W. Hoepker, K. Pueschel, S. Kluge.

Analysis and interpretation of the data: D. Wichmann, A. Heinemann, H. Vogel, K. Pueschel, S. Kluge.

Drafting of the article: D. Wichmann, S. Grabherr, S. Kluge.

Critical revision of the article for important intellectual content: D. Wichmann, A. Heinemann, H. Vogel, W.W. Hoepker, S. Grabherr, K. Pueschel, S. Kluge.

Final approval of the article: D. Wichmann, A. Heinemann, H. Vogel, W.W. Hoepker, K. Pueschel, S. Kluge.

Provision of study materials or patients: D. Wichmann, A. Heinemann, C. Weinberg, H. Vogel, W.W. Hoepker, K. Pueschel.

Statistical expertise: D. Wichmann, S. Kluge.

Obtaining of funding: A. Heinemann, S. Grabherr.

Administrative, technical, or logistic support: D. Wichmann, A. Heinemann, W.W. Hoepker, S. Grabherr, K. Pueschel, S. Kluge.

Collection and assembly of data: D. Wichmann, A. Heinemann, C. Weinberg, H. Vogel, W.W. Hoepker, K. Pueschel


Ann Intern Med. 2014;160(8):534-541. doi:10.7326/M13-2211
Text Size: A A A

Background: “Virtual” autopsy by postmortem computed tomography (PMCT) can replace medical autopsy to a certain extent but has limitations for cardiovascular diseases. These limitations might be overcome by adding multiphase PMCT angiography.

Objective: To compare virtual autopsy by multiphase PMCT angiography with medical autopsy.

Design: Prospective cohort study. (ClinicalTrials.gov: NCT01541995)

Setting: Single-center study at the University Medical Center Hamburg–Eppendorf, Hamburg, Germany, between 1 April 2012 and 31 March 2013.

Patients: Hospitalized patients who died unexpectedly or within 48 hours of an event necessitating cardiopulmonary resuscitation.

Measurements: Diagnoses from clinical records were compared with findings from both types of autopsy. New diagnoses identified by autopsy were classified as major or minor, depending on whether they would have altered clinical management.

Results: Of 143 eligible patients, 50 (35%) had virtual and medical autopsy. Virtual autopsy confirmed 93% of all 336 diagnoses identified from antemortem medical records, and medical autopsy confirmed 80%. In addition, virtual and medical autopsy identified 16 new major and 238 new minor diagnoses. Seventy-three of the virtual autopsy diagnoses, including 32 cases of coronary artery stenosis, were identified solely by multiphase PMCT angiography. Of the 114 clinical diagnoses classified as cardiovascular, 110 were confirmed by virtual autopsy and 107 by medical autopsy. In 11 cases, multiphase PMCT angiography showed “unspecific filling defects,” which were not reported by medical autopsy.

Limitation: These results come from a single center with concerted interest and expertise in postmortem imaging; further studies are thus needed for generalization.

Conclusion: In cases of unexpected death, the addition of multiphase PMCT angiography increases the value of virtual autopsy, making it a feasible alternative for quality control and identification of diagnoses traditionally made by medical autopsy.

Primary Funding Source: University Medical Center Hamburg–Eppendorf.

Figures

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Appendix Figure 1.

Study flow diagram.

CT = computed tomography.

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Appendix Figure 2.

Proportional Venn diagrams for each disease group, showing the concordance of VA, MA, and CR in identifying diagnoses.

Values represent the numbers of diagnoses identified by the respective method. Values in overlapping areas of the circles represent the numbers of diagnoses made by the methods sharing in the overlap. For simplification, the labeling is displayed only for overall diagnoses. Diagrams for each disease group are displayed in proportional size to their contribution to the overall diagnoses. Myocardial infarctions or pulmonary embolisms are examples of cardiovascular diseases; pleural effusion or calcification are examples of pulmonary diseases; cerebral hemorrhage or brain infarction are examples of cerebral diseases; infectious endocarditis or pneumonia are examples of infectious diseases; and rib fractures, residual changes after surgery, gallstones, and nephrolithiasis are examples of the miscellaneous conditions. CR = clinical records; MA = medical autopsy; VA = virtual autopsy.

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Figure 1.

Type B aortic dissection.

Case 8 of Table 2. A. Dissection of the descending aorta identified after multiphase postmortem computed tomographic angiography; the arrow shows the flap dividing the true from the false vascular lumen (Table 2 [case 8] and Supplement Video 1). B and C. Histologic section of a longitudinal section through the dorsal wall of the abdominal aorta (original magnification, ×5; each with adapted magnification). Elastica van Gieson stain (panel B) showing dissection zones (1) with 2 interruptions (2a and 2b) and splicing flap from the cranial part of the vessel encountering the outer third of the media, surrounding hyperemic vessels (3), adventitia (4), media (5), fibrotic intima (6), and large atheroma with cholesterol crystals (7). Hematoxylin–eosin stain (panel C) showing vital reaction and fresh hemorrhage from vasa vasis into the wall (8).

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Figure 2.

Pulmonary embolism in the artery of the right upper lobe (blue circle), identified by multiphase PMCT angiography.

Case 5 of Table 2. Bilateral fluid accumulation in the dorsal parts of the lung and adjacent pleural space is also shown (red asterisks), which probably resulted from postmortem changes due to the 5-day interval between the patient's death and PMCT angiography. PMCT = postmortem computed tomography.

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Figure 3.

Three-dimensional reconstruction of the multiphase PMCT angiography data set showing stenosis of the left descending coronary artery in a patient with fatal myocardial infarction.

Case 4 of Table 2. The angiographic filling distal to the stenosis is a result of collateral filling during the venous and dynamic phases of the contrast medium application. PMCT = postmortem computed tomography.

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Figure 4.

Fatal thoracic hemorrhage in a patient who had left-sided pneumonectomy for lung cancer in a 3-dimensional reconstruction of the multiphase PMCT angiography data set in 2 perspectives.

The hemorrhage, visualized by contrast medium in white and gray (yellow and blue circles), was caused by the displacement of a clip (not visible) on a branch of the left internal thoracic artery (1) (Table 2 [case 9] and Supplement Video 2). A central venous catheter (2) and Celestin tube inserted into the esophagus because of a bronchioesophageal fistula caused by the tumor (3) are shown. PMCT = postmortem computed tomography.

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Figure 5.

Three-dimensional reconstruction of the multiphase PMCT angiography data set showing perforation of the superior vena cava by a dialysis catheter (blue arrow) introduced via the left internal jugular vein.

Case 3 of Table 2. The inset shows the 4-cm-long dissection of the vessel disruption (yellow arrows) documented during medical autopsy. The right atrium (blue asterisk) is also shown (Supplement Video 3). PMCT = postmortem computed tomography.

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