Diagnostic accuracy of post-mortem CT with targeted coronary angiography versus autopsy for coroner-requested post-mortem investigations: a prospective, masked, comparison study

Abstract

SummaryBackgroundEngland and Wales have one of the highest frequencies of autopsy in the world. Implementation of post-mortem CT (PMCT), enhanced with targeted coronary angiography (PMCTA), in adults to avoid invasive autopsy would have cultural, religious, and potential economic benefits. We aimed to assess the diagnostic accuracy of PMCTA as a first-line technique in post-mortem investigations.MethodsIn this single-centre (Leicester, UK), prospective, controlled study, we selected cases of natural and non-suspicious unnatural death referred to Her Majesty's (HM) Coroners. We excluded cases younger than 18 years, known to have had a transmittable disease, or who weighed more than 125 kg. Each case was assessed by PMCTA, followed by autopsy. Pathologists were masked to the PMCTA findings, unless a potential risk was shown. The primary endpoint was the accuracy of the cause of death diagnosis from PMCTA against a gold standard of autopsy findings, modified by PMCTA findings only if additional substantially incontrovertible findings were identified.FindingsBetween Jan 20, 2010, and Sept 13, 2012, we selected 241 cases, for which PMCTA was successful in 204 (85%). Seven cases were excluded from the analysis because of procedural unmasking or no autopsy data, as were 24 cases with a clear diagnosis of traumatic death before investigation; 210 cases were included. In 40 (19%) cases, predictable toxicology or histology testing accessible by PMCT informed the result. PMCTA provided a cause of death in 193 (92%) cases. A major discrepancy with the gold standard was noted in 12 (6%) cases identified by PMCTA, and in nine (5%) cases identified by autopsy (because of specific findings on PMCTA). The frequency of autopsy and PMCTA discrepancies were not significantly different (p=0·65 for major discrepancies and p=0·21 for minor discrepancies). Cause of death given by PMCTA did not overlook clinically significant trauma, occupational lung disease, or reportable disease, and did not significantly affect the overall population data for cause of death (p≥0·31). PMCTA was better at identifying trauma and haemorrhage (p=0·008), whereas autopsy was better at identifying pulmonary thromboembolism (p=0·004).InterpretationFor most sudden natural adult deaths investigated by HM Coroners, PMCTA could be used to avoid invasive autopsy. The gold standard of post-mortem investigations should include both PMCT and invasive autopsy.FundingNational Institute for Health Research.

British Neuropathological Society and International Society of Forensic Radiology and Imaging expert consensus statement for post mortem neurological imaging

“…Of the three indication statements that did not achieve consensus (disaster victim identification (DVI), vascular pathogenesis and in all neuropathological examinations), reasons given by the panellists included uncertainty of benefit given lack of experience in DVI reporting, potential lack of ability to diagnose post mortem cerebrovascular accidents on PMCT (without obtaining post mortem CT angiography (PMCTA)) and the fact that post mortem imaging may not need to be performed for all neuropathology cases if an ante‐mortem study had been performed. Recent evidence from a large cohort of 210 subjects where PMCTA was performed , has shown that this imaging modality was better than autopsy for assessment of haemorrhage and trauma ( P = 0.008), although the cases were not specific to neuropathology and none of the subjects were found to have suffered from a cerebrovascular incident. Nevertheless, a cause of death was established by imaging in 92% of coroner referred cases.…”

Postmortem imaging as a complementary tool for the investigation of cardiac death

“…Targeted coronary artery methods [32,33] allow detailed visualization of the coronary arteries by selected filling of the ascending aorta and the coronary arteries through the insertion of a catheter via a carotid artery [5]. A recent study has hypothesized that this technique could avoid invasive autopsy in cases of cardiac death [34].…”

Targeted coronary post-mortem CT angiography, straight to the heart

“…3 A lot of effort has been put into the development, use, and validation of multiphase wbPMCTA and good results have been shown with a dedicated wbPMCTA system. 4,5 In the Lancet, Guy N Rutty and colleagues 6 report a prospective study about the value of PMCTA in natural sudden death. For this post-mortem imaging study, the primary outcome for large prospective series was the accuracy of cause of death, if identifiable on PMCTA compared with the autopsy (which they class as gold standard).…”

“…In a Series of papers [5][6][7][8] and Comments 9,10 in The Lancet, Vikas Saini and colleagues provide a framework for such a change of thinking. The Right Care Series examines the areas and extent of overuse and underuse of health and medical services around the world.…”

“…It defines overuse as "the provision of medical services that are more likely to cause harm than good", 5 and underuse as "the failure to use effective and affordable medical interventions". 6 The Series authors argue that both overuse and underuse happen side-by-side in different countries, within countries, among populations, within institutions, and even for a single person. This situation offers an enormous (and currently poorly recognised) opportunity to tackle underuse and overuse together to achieve the right care for health and wellbeing.…”