Accuracy of targeted post-mortem computed tomography coronary angiography compared to assessment of serial histological sections

Abstract

Post-mortem computed tomography with coronary angiography (PMCTA) could have a role in the investigation of sudden natural death. This study assesses the accuracy of targeted coronary PMCTA, using both air and iodinated contrast media, to provide sensitivity and specificity for critical stenosis (CS) on a segmental basis, based on a gold standard of 3-5 mm serial sections of the coronary arteries using macroscopic and histological techniques. Assessment of stenosis at 1 mm intervals on PMCTA was compared with the data from pathological analysis. Stenosis was defined as "critical" when the stenotic region reaches ≥75 %. Regions were defined every 20 mm or by a clear change in stenosis. Discrepancies were defined as significant if only one test showed CS. Five cases with 25 vessels with 124 regions were assessed. PMCTA was unable to identify plaque hemorrhage or dissection (but this was normally associated with CS). Eighteen segments had significant discrepancies, giving a sensitivity and specificity of 50 and 91.5 %. When an alternative gold standard was constructed by excluding regions beyond a CS (five cases), taking PMCTA as correct where a heavily calcified vessel opens under contrast injection (four cases), and correcting for misregistration of distance (one case), the sensitivity rose to 85.7 %. There was complete agreement when the right or left coronary arteries are assessed as a whole. This study shows that PMCTA is not a perfect replacement for histological examination of coronary vessels, but may have a role in routine post-mortem investigation.

Postmortem CT Angiography Compared with Autopsy: A Forensic Multicenter Study

“…Consequently, various postmortem angiographic techniques have been developed (10)(11)(12)(13)(14)(15)(16)(17)(18)(19). Probably the most widespread single approach for postmortem angiography today is multiphase postmortem CT angiography (20)(21)(22)(23)(24)(25)(26)(27), first described in 2011 (14).…”

How does post-mortem imaging compare to autopsy, is this a relevant question?

“…Coronary vascular imaging has been stated as a weakness of PM imaging [17,25], but this is another area where the techniques of angiography in the dead [26--29] are changing the technical performance of imaging, which may even lead to greater effectiveness than standard autopsy techniques [30].…”

Measuring pressure during coronary artery angiography in ex-vivo hearts

“…The introduction of angiography to the post-mortem evaluation of CAD has allowed coronary artery disease to be assessed accurately in the deceased [1,2]. This was a significant advance and has increased the possibility of using PMCT to replace autopsy for adult natural death [3,4]. Imaging is important to the clinical evaluation of patients with CAD and traditional angiography has been the 'gold standard' for decades [5].…”

“…The improvements PMCTA has made to the diagnosis of CAD have been widely discussed [9,10,11,12] and its accuracy verified against histological studies [13]. Using pressurised injections in PMCTA in order to replicate physiological conditions has been described [11,12].…”