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- Publisher
- American Medical Association
- Copyright
- Copyright © 2012 American Medical Association. All Rights Reserved.
- ISSN
- 0098-7484
- eISSN
- 1538-3598
- DOI
- 10.1001/jama.2012.428
- Publisher site
- See Article on Publisher Site
Abstract
Half a century ago, autopsies were routinely performed on about 50% of all patients who died in hospitals. Not only a powerful tool for quality improvement in patient care, the autopsy generates accurate vital statistics, provides a better understanding of diseases, helps in the detection of new infections, and drives progress in medicine. (Photo credit: S Singh/M K Kalra/J R Stone/Massachusetts General Hospital) Virtual autopsies performed with high-resolution imaging may complement traditional autopsies. Postmortem computed tomography scanning (left) shows a large occlusive mass (blue arrowhead) in the left mainstem bronchus extending into the subcarinal region, causing complete collapse of the left lung (yellow arrowhead). A gross pathology image (right) shows the same occlusive mass (blue arrowhead) in the left mainstem bronchus. Despite these many benefits, the hospital autopsy has fallen out of favor and is now used primarily in forensic investigations. But although the traditional autopsy is on life support now, it may yet be revived by high-resolution imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI). A virtual view Over the past decade, imaging techniques began gaining traction in forensics to complement the autopsy. In such cases, before a traditional autopsy is done, the body undergoes a CT scan and sometimes an MRI scan. The postmortem scan of the body—called the virtual autopsy or imaging autopsy—can reveal abnormalities that either can't be seen or might be overlooked in a conventional autopsy, said Anders Persson, MD, PhD, radiologist and director of the Center for Medical Image Science and Visualization (CMIV), Linkoping, Sweden. Persson, a pioneer in imaging autopsy research, noted that scanning is better than the traditional autopsy at finding bone fractures and gas in tissues, as well as in detecting the trajectory a bullet takes through the body. So far imaging technology isn't ready to replace the scalpel, but researchers such as Barry Daly, MD, professor of radiology at the University of Maryland Medical Center, Baltimore, are helping identify the areas in which CT and MR imaging can augment the traditional autopsy. For the last 5 years, Daly has been helping conduct a forensic imaging initiative involving both his department and the office of the chief medical examiner for the state of Maryland. Postmortem imaging is extremely helpful in establishing cause of death in cases of blunt accidental trauma, said Daly. It is also useful for suspected drowning deaths or deaths from burns when the entire body is charred. “We also use it in the investigation of elder or child abuse, where we're trying to identify fractures or intracranial bleeding,” said Daly. Beyond forensics Other researchers are trying to expand the use of postmortem imaging beyond forensics. A recent study on a series of 285 patients who died in the intensive care unit compared findings from imaging autopsy with traditional autopsy in 47 of them. Imaging autopsy confirmed most clinical diagnoses and detected some problems that may have contributed to death but were missed by conventional autopsy—for example, pneumothorax and fractures (Wichman D et al. Ann Intern Med. 2012;156[2]:123-130). However, postmortem imaging missed other diagnoses, including myocardial infarction and pulmonary embolism, which are 2 of the most common causes of death in the United States, noted Elizabeth Burton, MD, deputy director of the autopsy service at Johns Hopkins University School of Medicine, Baltimore, and coauthor of the accompanying editorial (Burton E and Mossa-Basha M. Ann Intern Med. 2012;156[2]:158-159). Burton said she's been interested in the imaging autopsy discussion since the approach came on the scene in the early 2000s. Although she's an advocate, she said it doesn't address one of the major reasons that autopsy rates have declined—cost. “One of the biggest problems with the performance of autopsy is there's no reimbursement,” she said. Despite budgetary constraints, there are good reasons for continuing to do autopsies. “For example, we know that the accuracy of death certificates isn't good,” said Burton. National mortality data are used to determine funding for research in specific areas of disease, she said, so if death certificates are wrong, funds may end up misdirected. Burton also pointed out that autopsy studies provide information about the natural history of disease. “Most of the good autopsy studies looking at disease pathogenesis were done 50 years ago, when people died at younger ages, usually of one disease,” she said. “But now people are dying with multiple diseases, and we don't have any idea how those conditions interact.” Information from an autopsy can even change how medicine is practiced, said Burton. Her laboratory was involved in the first report on cases of rabies that were transmitted through solid organ transplantation (Srinvasan A et al. N Engl J Med. 2005:352[11]:1103-1111). “We knew the virus could be transmitted through corneal tissue, but the autopsy information opened our eyes to the risk with other tissues,” she said. Future directions Experts in postmortem imaging are working toward improving the technology. One recent advance from Persson's group at CMIV is a virtual autopsy table that consists of a large, touch-sensitive LCD screen that displays images of the body. It was designed to manage and visualize the enormous data sets produced by the medical imaging modalities. “It's like a huge iPad, where the imaging data are reconstructed into 3-D images of bone and tissues,” he said. With the swipe of a finger, users can navigate through the body in real time, peeling back layers of muscle, zooming in and out of organs, rotating tissue and “cutting” through it with a virtual knife—almost all the functions of a traditional autopsy. This technology also would be a great addition to medical education, he said. Postmortem imaging is also being used to make imaging safer for living patients. Mannudeep Kalra, MD, and Sarabjeet Singh, MD, radiologists at Massachusetts General Hospital (MGH), Boston, are working on a project in conjunction with Persson and others to study various levels of radiation dosing from CT scans in cadavers in a hospital setting, trying to identify the lowest dose that still provides an accurate diagnosis. Another objective of their research is to create a teaching module that compares premortem and postmortem imaging studies with photographs from gross and microscopic autopsy examinations. The intention is to enhance the understanding of radiological and pathological correlates of different disease processes that have led to a patient's death. Kalra noted that many residents and fellows in radiology at MGH have expressed interest in learning how to correlate postmortem images with pathology. “It may be a bit premature,” he said, “but going forward I could envision a special joint subspecialty in radiology and pathology.”
Journal
JAMA – American Medical Association
Published: Apr 11, 2012
Keywords: autopsy,diagnostic imaging