Can virtual autopsy with postmortem CT improve clinical diagnosis of cause of death? A retrospective observational cohort study in a Dutch tertiary referral centre

Abstract

ObjectiveTo investigate whether virtual autopsy with postmortem CT (PMCT) improves clinical diagnosis of the immediate cause of death.DesignRetrospective observational cohort study. Inclusion criteria: inhospital and out-of-hospital deaths over the age of 1 year in whom virtual autopsy with PMCT and conventional autopsy were performed. Exclusion criteria: forensic cases, postmortal organ donors and cases with incomplete scanning procedures. Cadavers were examined by virtual autopsy with PMCT prior to conventional autopsy. The clinically determined cause of death was recorded before virtual autopsy and was then adjusted with the findings of virtual autopsy. Using conventional autopsy as reference standard, we investigated the increase in sensitivity for immediate cause of death, type of pathology and anatomical system involved before and after virtual autopsy.SettingTertiary referral centre.Participants86 cadavers that underwent conventional and virtual autopsy between July 2012 and June 2016.InterventionPMCT consisted of brain, cervical spine and chest–abdomen–pelvis imaging. Conventional autopsy consisted of thoracoabdominal examination with/without brain autopsy.Primary and secondary outcome measuresIncrease in sensitivity for the immediate cause of death, type of pathology (infection, haemorrhage, perfusion disorder, other or not assigned) and anatomical system (pulmonary, cardiovascular, gastrointestinal, other or not assigned) involved, before and after virtual autopsy.ResultsUsing PMCT, the sensitivity for immediate cause of death increased with 12% (95% CI 2% to 22%) from 53% (41% to 64%) to 64% (53% to 75%), with 18% (9% to 27%) from 65% (54% to 76%) to 83% (73% to 91%) for type of pathology and with 19% (9% to 30%) from 65% (54% to 76%) to 85% (75% to 92%) for anatomical system.ConclusionWhile unenhanced PMCT is an insufficient substitute for conventional autopsy, it can improve diagnosis of cause of death over clinical diagnosis alone and should therefore be considered whenever autopsy is not performed.

Clinical Relevance of Unexpected Findings of Post-Mortem Computed Tomography in Hospitalized Patients: An Observational Study

“…These studies confirmed that PMCT has a significantly higher agreement on the cause of death than the clinical assessment alone [ 11 , 12 ]. Additionally, it was stated that the detection of cardiovascular diseases (e.g., coronary occlusion or stenosis, pulmonary embolism) is the major limitation of non-enhanced PMCT [ 7 , 10 , 12 ]. This limitation also explains why post-mortem angiography is a promising technique in the field of post-mortem research [ 4 , 13 ].…”

“…Among these possibilities, post-mortem computed tomography (PMCT) is considered to be the most feasible imaging modality because it is fast and widely available. So far, three clinical studies have shown that PMCT is in agreement with autopsy on the cause of death of hospitalized patients in 64–74% of all cases [ 10 , 11 , 12 ]. These studies confirmed that PMCT has a significantly higher agreement on the cause of death than the clinical assessment alone [ 11 , 12 ].…”

“…So far, three clinical studies have shown that PMCT is in agreement with autopsy on the cause of death of hospitalized patients in 64–74% of all cases [ 10 , 11 , 12 ]. These studies confirmed that PMCT has a significantly higher agreement on the cause of death than the clinical assessment alone [ 11 , 12 ]. Additionally, it was stated that the detection of cardiovascular diseases (e.g., coronary occlusion or stenosis, pulmonary embolism) is the major limitation of non-enhanced PMCT [ 7 , 10 , 12 ].…”

“…However, its implications for daily use in addition to autopsy are not yet fully known. Multiple studies have reported on the agreement with autopsy on the cause of death, but no studies have been published on the clinical relevance of unexpected findings reported by PMCT [ 10 , 11 , 12 ]. PMCT and autopsy are fundamentally different examinations, thus PMCT has a different way of visualizing pathological processes.…”

Performance of the minimally invasive autopsy tool for cause of death determination in adult deaths from the Brazilian Amazon: an observational study

“…In high-income countries, imaging-based methods have been proposed as an alternative to the CDA, but the high costs and the high level of expertise required are major drawbacks for their implementation, particularly in low- and middle-income countries (LMIC). Moreover, these imaging-based methods could be insufficient for the identification of infectious CoD [10], presumably more frequent in LMIC. Therefore, innovative methods are necessary in LMIC, where most premature deaths occur, and robust mortality data are poor [1].…”