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Ultrasonography on the non-living. Current approaches.

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Ahead of print Med Ultrason 2021:0, 1-10  Online first
DOI: 10.11152/mu-3490

Ultrasonography on the non-living. Current approaches.

Thomas Thomsen1, Michael Blaivas2, Paulo Sadiva3, Oliver D. Kripfgans4, Hsun-Liang
Chan5, Yi Dong6, Maria Cristina Chammas7, Beatrice Hoffmann8, Christoph F. Dietrich9,10

1Department of Internal Medicine, Westküstenkliniken, Brunsbüttel, Germany, 2University of South Carolina School

of Medicine, Columbia, South Carolina, USA, 3Department of Pathology, Faculty of Medicine, University of
São Paulo, Brazil, 4Department of Radiology, Michigan Medicine, University of Michigan, USA, 5Department of
Periodontology and Oral Medicine, School of Dentistry, University of Michigan, USA, 6Department of Ultrasound,
Zhongshan Hospital, Fudan University, Shanghai, China, 7Department of Radiology, Hospital das Clínicas – School
of Medicine, University of São Paulo, Brazil, 8Beth Israel Deaconess Medical Center, Boston MA, USA, 9Department
Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permancence, Bern, Switzerland,
10Johann Wolfgang Goethe Universitätsklinik Frankfurt, Germany.

Abstract
The vast majority of clinicians associate diagnostic ultrasound with a tool that is designed for the living patient. However,
it is of course possible to apply this imaging technology to evaluate the recently deceased patient for postmortem diagnosis,
or even just examine postmortem tissue. We describe several cases in which ultrasound-enabled providers obtain answers in
postmortem examinations and discuss potential future strategies and applications. In addition, we will also illustrate the use of
sonography in minimally invasive post-mortem tissue sampling (MITS), an approach that can be used in post-mortem mini-
mally invasive autopsies as well as for establishing ultrasound diagnostic parameters in new medical fields such as periodontal
and dental implant specialties.
Keywords: postmortem ultrasound; autopsy; imaging; cause of death; validation

Introduction Clinical autopsies are important to determine a pre-

Imaging for postmortem diagnostics, for instance
in forensic medicine, has been used since 1895, and in-
clude conventional X-rays, computed tomography (CT)
and magnetic resonance imaging (MRI). Generally, ul-
trasound (US) was never considered to be of particular
value for postmortem torso imaging because of tissue gas
formation [1]. However, as US is a readily available and
inexpensive imaging modality, it might be of value for
specific postmortem evaluations.
Received 10.08.2021  Accepted 05.10.2021
Med Ultrason
2021:0 Online first, 1-10
Corresponding author: Prof. Dr. Christoph F. Dietrich
Department Allgemeine Innere Medizin (DAIM),
Kliniken Hirslanden Beau Site,
Salem und Permancence, Bern, Switzerland
Phone: +41798347180
E-mail: c.f.dietrich@googlemail.com
cise cause of death but have been declining worldwide
[2]. Several factors contributed to this shift, including
increasing accuracy of modern imaging and molecular
diagnostic procedures, rising costs of autopsies, cultural
or religious beliefs prohibiting autopsies.
Aside from macroscopic evaluations, post-mortem
microscopic tissue examination also has an important
role in medical diagnosis and research. Few examples are
tissue sampling from organs that would be problematic
in living patients (brain, heart, large vessels); evaluation
the effects of medical interventions, such as end-organ
lung damage as a consequence of mechanical ventilation
or therapeutic agents; studying oral anatomy and diseas-
es by comparing imaging and histology of post-mortem
samples; investigating new infectious diseases; or im-
proving the accuracy of cause of death determination in
areas devoid of advanced diagnostic systems.
In this paper we review the literature published on US
postmortem examinations and we describe several cas-
2 Thomas Thomsen et al
es in which US enabled physicians to obtain answers to
open diagnostic questions in postmortem examinations.
In addition, we will illustrate how US can assist in mini-
mally invasive post-mortem tissue sampling (MITS) and
how several investigators used cadavers to evaluate diag-
nostic accuracy of certain ultrasound indications.
Review of the literature
A review of the available literature showed that US
appears to be particularly important in fetal and neonatal
postmortem diagnostics [3,4]. However, overall CT and
MRI or X-ray dominate the forensic literature. Heine-
mann et al reported on the use of postmortem CT and
CT angiography between 2004 and 2014 [5]. CT is con-
sidered the standard method in postmortem imaging. It
is less susceptible to interference from postmorten gas
formation than US. The biggest advantage over clinical
autopsy is the detection of free air. Skeletal changes and
retained foreign bodies can also often be better detected.
The strength of CT angiography lies primarily in the
detection of bleeding sources, even in postmortem ex-
aminations that are lacking an intrinsic blood pressure.
Agreement between postmortem CT (PMCT) and clini-
cal autopsy is nearly 90% if the reporting radiologist has
sufficient experience in post-mortem imaging [5].
Grabherr et al [6] reported on the use of X-ray in fo-
rensic medicine dating back to 1896, the year an X-ray
of a hand was performed on a mummified Egyptian prin-
cess. Today, many forensic departments have mobile X-
ray machines to examine corpuses for radiopaque foreign
bodies or bony lesions. X-rays are also used to identify
unknown deceased with the help of dental findings or lo-
cating osteosynthetic material. The most common tech-
niques used today are PMCT, CT angiography and MRI.
A new development is the 3-D surface scanner. Blood
and fluids can be well visualized in CT, even postmor-
tem, using this technique. Free air is also imaged without
difficulty. However, interpretation is complicated by gas
formation, which begins a few hours after death. Free air
can therefore only be detected up to a few hours after
death. The value of CT in cases of natural death is lim-
ited. For example, ischemic heart disease in acute cardiac
arrest cannot be detected by CT without angiography [6].
MRI is also used in post-mortem imaging. Limita-
tions include the occurrence of gas, lack of circulation
and low body temperature, which influences the behavior
of MR contrast agents. Gas leads to a complete loss of
signal in MR. Gases formed by autolysis can significantly
interfere with imaging. On the other hand, the detection
of myocardial infarction is as good in postmortem MRI
as in living patients [7]. MRI is currently the method of
Ultrasonography on the non-living. Current approaches.
choice for postmortem imaging of neonates and paediat-
ric cadavers [3]. By contrast, Roberts et al consider CT to
be the method of choice in postmortem imaging because
discrepancies between autopsy and MRI are more com-
mon than between PMCT and autopsy [8].
Simonds et al [9] reported on the use of conventional
radiography in cadavers to detect fractures and foreign
bodies, positron emission tomography to detect tissue
changes especially in Alzheimer’s disease and Lewy
body dementia and various uses of CT with stationary
and mobile equipment. The working group reported that
US has so far been underrepresented in cadaver diagnos-
tics. MRI provides excellent images, but its availability
and expense are significant limiting factors. The vastly
superior imaging provided by MRI has placed post-
mortem US in a subordinate status in forensic medicine,
despite cost and availability advantages. This is mainly
due to the formation of gas on the corpus after few hours
and the resultant limitation to US wave propagation in
the body.
Egger et al [10] examined 119 cadavers for gas for-
mation. They found gas formation mainly in the heart
and liver. Gas was initially detectable after 5-84 hours
after death. In all cases of natural death, gas was found in
the liver vessels and the heart simultaneously; in cases of
death by gas embolism, gas was noted only in the heart.
Spaienza et al [11] reported on seven victims of a flood
whom they examined with CT for postmortem intrahe-
patic gas formation. They found that gas first formed in
the portal vessels and then appeared in the hepatic veins.
Fischer et al [12] analyzed intrahepatic gas formation in
five male cadavers with non-traumatic causes of death
using a longitudinal study with CT scans at hourly in-
tervals over a 24 hour period. They found an increase in
gas formation between the fourth and seventh hour after
death, after which conditions remained constant until the
end of the study period. Intrahepatic gas is predominant-
ly caused by mesenteric gas formation [13]. Detection
is possible by both CT and US. The first description of
portal venous gas was made in 1955 by Wolfe et al in six
newborns that had died of intestinal necrosis [14].
The interference by gas formation and its rapid de-
velopment raises questions regarding what potential
significance post-mortem US could have in clinical
adult medicine. A search of the literature on this topic
revealed a paucity of publications to date. Duarte-Neto
et al [15] described ten US-guided multiorgan punctures
in patients with COVID-19 induced death. The first pub-
lished description of this method was in 2002 by Farina
et al [16]. They compared US-guided puncture biopsies
with conventional autopsies on 100 cadavers and found
a concordance rate of 83% for final diagnosis. An easily

overlooked location and timing for postmortem US per-
formance is in the emergency department, where deaths
may occur suddenly and unexpectedly. Even in older,
chronically ill patients, immediate postmortem US evalu-
ations can provide vital clues as to the cause of death
and critical education to clinicians. Some catastrophic
etiologies can be assessed with US and include proxi-
mal thoracic aortic dissections, pericardial effusion and
pneumothorax. Abdominal aortic aneurysm presence can
raise its potential role in a death, even if intraabdominal
or retroperitoneal fluid is not detected. US examination
so quickly after death is unlikely to be encumbered by
gas formation. Evaluation of pleural cavities is easily
performed in search of fluid collections and assessment
of the lower extremity deep venous system may reveal
the presence of deep venous thrombosis, thus suggesting
pulmonary embolism as a potential cause of death if the
clinical scenario is supportive. However, more direct evi-
dence of massive pulmonary embolism is unlikely to be
reliable as blood can quickly gel in the cardiac chambers
and lack of intracardiac pressure means acute signs of
right heart strain will not be identified [5].
Postmortem US in the pathology department has been
used to validate US findings in 20 patients to delineate
small organ structures, e.g., the adrenal glands [17] and
perihepatic lymph nodes [18,19].
Recently three cases in which post-mortem US within
three hours of death enabled the clarification of a previ-
ously unclear cause of death have been reported [20]. In
all three cases, an autopsy could not be performed for
various reasons. The examinations were performed with
the GE S7 (GE Medical Systems Information Technolo-
gies, Freiburg i. Breisgau, Germany). Multifrequency
transducers were used: a phased array (3-5 MHz), a mul-
tifrequency linear array (6-15 MHz) and a sector trans-
ducer (2-4 MHz). A Mindray M7 with a phased array
(2-5 MHz) transducer was also utilized for evaluation.
Fig 1. Postmortem a) echocardiography, after resuscitation was stopped: right atrium slightly dilated, the other cardiac cavities are of
normal width; b) US, after resuscitation was stopped: lower caval vein of normal width and c) left femoral vein perfusion detectable
after compression.
Med Ultrason 2021; 0: 1-10 3
The transducers were protected during the examination
with sterile probe covers from Civco Medical Solutions.
The US device and the transducers were reprocessed af-
ter use according to the local hygiene recommendations.
Use of US in postmortem diagnosis
Case 1
An 87-year-old female patient presented via para-
medics due to a one-day increase in dyspnea, now at
rest. She denied thoracic pain, cough, fever or chills, as
well as sweating and palpitations. The patient had been
discharged from the geriatric ward only 5 days ago. On
physical examination the patient was alert and oriented,
Glasgow Coma Scale 15, reduced general status body
habitus was obese, slight bilateral leg oedema. Her res-
pirations were equal on both lungs, percussion sound so-
norous; heart sounds were regular and rhythmic without
murmurs, rub or gallops, norm frequent. Hemoglobin
and white blood cell count, inflammatory parameters,
renal values, electrolytes and urine status were unre-
markable. The patient was diagnosed with heart failure,
treated conservatively and monitored overnight. After a
stable course, the patient was transferred to the ward the
following day. That next evening, the patient rapidly de-
teriorated and had to be resuscitated. Cardiac resuscita-
tion was unsuccessful. A post-mortem US was performed
given the lack of clinical diagnosis and the unsuspected
clinical course. There were no signs of pulmonary embo-
lism (fig 1).
Case 2
A 71-year-old male undomiciled and living alone in
the woods is brought in by the ambulatory emergency
service for decreased responsiveness. Prehospital trans-
port time was approximately 40 minutes and the patient
expired on the way, despite aggressive and constant re-
suscitative efforts by paramedics. The family and the lo-
4 Thomas Thomsen et al
cal coroner both declined an autopsy by phone, with the
coroner planning to list the death as natural. The deceased
patient was placed in an empty patient room shortly after
EMS arrival and a point of care US was performed show-
ing an 8.1 cm abdominal aortic aneurysm with retroperi-
toneal fluid (fig 2).
Case 3
An 81-year-old patient with multiple medical comor-
bidities including prior cerebrovascular accident with
residual dysphagia, dementia was admitted to the hospi-
tal for several days of gradual decrease in mental status,
high fevers, and hypotension. The clinical team felt the
most likely diagnosis was urosepsis and started treatment
with broad-spectrum antibiotics. Her inflammatory pa-
rameters improved, but the patient’s condition continued
to deteriorate. Five days after hospitalization the patient
died due to cardiovascular failure. Since the exact cause
of death was unclear, an immediate postmortem US was
performed and clear evidence of significant pulmonary
artery embolism was detected (fig 3).
Use of ultrasound for minimally invasive
post-mortem tissue sampling
Minimally invasive post-mortem tissue sampling
(MITS) may be an alternative to overcome the obstacles
to conventional autopsy. This type of procedure has been
employed since the mid 1930’s in Brazil, when infectious
diseases were extensively studied by post-mortem tissue
sampling with the use of a simple viscerotome [21,22].
MITS possibilities were substantially expanded under
imaging guidance [23]. In 2015, one medical institution
built a minimally invasive autopsy (MIA) facility com-
posed of a 7T MRI, a 16 channel CT, as well as diagnos-
tic US devices (PISA project at the Faculty of Medicine,
Universisty of São Paulo https://pisa.hc.fm.usp.br/). Over
time, it was noted that US became the most frequently
used instrument to guide MIAs because of its low cost
and transportability, allowing the conduction of MIAs in
other institutes of the medical complex [15,24,25].
Fig 3. Postmortem echocardiography, showing signs of massive acute pulmonary embolism. Subxiphoid (a) and four-chamber view (b).
Ultrasonography on the non-living. Current approaches.
Fig 2. Postmortem ultrasound, transverse scan of an abdominal
aortic aneurysm (a), with retroperitoneal fluid (b, arrow).
MIAs played a major role in COVID-19 from March
2020 up to submission of the paper and São Paulo was
the epicenter of the present pandemic, allowing a team of
examiners to investigate more than 200 cases of a highly
contagious disease in an autopsy facility without level
three biosafety needs [15,24-26]. In the course of the
present pandemic, over 180 autopsies were performed,
including on COVID-19 patients and patients admitted
to the intensive care units for other causes. A portable
SonoSite M-Turbo R (Fujifilm, Bothell, WA, USA) ultra-
sound equipment with a C60x (5-2 MHz Convex) multi-
frequency broadband transducers and DICOM® standard
images has been used. Tissue sampling was performed
either using Tru-Cut semi-automatic coaxial needles of
14G, 20 cm long or by doing scalpel dissections guided
by US, through small incisions over the area of interest
(mainly lungs and heart). Some illustrative cases are pre-
sented.
Case reports demonstrating the use of US
in MIAs
Case 4
A 71-year-old male patient with a history of HIV di-
agnosed in 2014 and poor adherence to anti-retroviral
 Med Ultrason 2021; 0: 1-10 5

Fig 4. Lung ultrasound showing irregular, discontinuous pleural artefact, small supleural condensations and diffuses pulmonary
infiltration (a). Focus of acute pulmonary hemorrhage (hematoxylin-eosin stain, magnification 200 X) (b). Larva of Strongyloides
stercoralis in the alveolar lumen (c) (hematoxylin-eosin stain, magnification 400 X).

therapy was admitted in 2017 to investigate an episode
of fever, dyspnea and diarrhea. Investigation for tuber-
culosis was negative, but patient received treatment for
syphilis and hepatitis B. In late 2019 the patient com-
pletely abandoned anti-retroviral therapy. Following
medication cessation, he lost 12 kg and in October 2020
was admitted for progressive dyspnea and diarrhea.
X-ray revealed diffuse bilateral pulmonary infiltrates and
CT showed ground glass infiltrates with predominance
in basal portions of the lungs. The patient’s respiratory
status worsened, and he was intubated requiring progres-
sively higher levels of inspired oxygen. The patient rap-
idly deteriorated with worsening hemodynamic param-
eters despite broad-spectrum antibiotics and vasoactive
drugs. The patient then developed massive respiratory
hemorrhage, which leads to cardiac arrest refractory to
resuscitation efforts. The autopsy service received the
patient’s body with evident signs of weight loss. US of
the lungs revealed an irregular, discontinuous pleural
artefact, small supleural consolidations and diffuse pul-
monary infiltration (white lung). Bowel US examination
showed marked thickening of intestinal walls. Needle
pulmonary tissue sampling revealed foci of pulmonary
hemorrhage and the presence of larvae of Strongyloides
stercoralis perforating the pulmonary capillaries in the
lungs and intestinal mucosa (fig 4). The final diagnosis
was established as systemic angioinvasive Strongyloi-
diasis in a patient with acquired immune deficiency syn-
drome and COVID-19 was excluded.
Case 5
A 52-year-old female with a history of type I diabetes
and immunosuppression due to a kidney pancreas double
transplantation performed in 2008, now back on hemo-
dialysis after renal transplant rejection, presented to the
hospital with progressive dyspnea and one episode of
haemorrhagic diarrhea. She eventually developed respir-
atory failure and was intubated and placed on mechani-
cal ventilation. CT scans revealed bilateral ground glass
opacities affecting more than 50% of the lungs. RT PCR
for Sars-CoV-2 was positive in material sampled from
her trachea. She rapidly developed multiple organ failure
and septic shock refractory to broad-spectrum antibiot-

Fig 5. Ultrasound image showing thickened pleural line with irregularities next to areas of lung parenchyma in which is still possible
to identify A lines. Photomicrography showing alveolar septa thickening by fibrosis (arrow, hematoxylin-eosin stain, magnification
200 X) (b). Scattered epithelial cells with nuclear alterations compatible with viral infection (arrow) and foci of fibrin thrombi in
alveolar capillaries (dashed arrow, hematoxylin-eosin stain, magnification 200 X) (c).
6 Thomas Thomsen et al
ics. During MIA, US imaging disclosed discontinuous
thickened pleural line and small sub pleural consolida-
tions. US guided Tru-Cut tissue sampling was conducted
from different organs, evidencing acute fibrin thrombi in
alveolar capillaries, fibrotic foci suggestive of organiza-
tion of previous acute pulmonary damage and rare cells
with aberrant nuclei, compatible with SARS-CoV-2 cy-
topatic effects. Final diagnosis was COVID-19 in fibro-
proliferative phase in a patient with immunosuppression
due to pancreas kidney double transplantation (fig 5).
Case 6
A 46-year-old male was admitted due to an episode
of loss of consciousness while in the outpatient thoracic
surgery offices. Family reported severe weight loss dur-
ing the preceding 4 months (14 kilograms) and the ap-
pearance of enlarged lymph nodes in the supraclavicular
and cervical regions. He was immediately transported
to the emergency ward, where he had a sudden cardiac
arrest refractory to resuscitative efforts. Postmortem US
images confirmed the presence of diffuse cervical lym-
phadenopathy. Pulmonary images were not adequate
because the massive loss of weight promoted a retrac-
tion of intercostal spaces, making proper transducer ap-
position on thoracic surfaces difficult. An irregular mass
was identified in the abdomen in the area corresponding
to the transverse colon. US guided right pneumectomy
was performed, through a 3 cm incision in the right in-
tercostal space. Macroscopic evaluation of the resected
lung showed massive pulmonary thromboembolism and
microscopic examination showed the presence of multi-
ple foci of undifferentiated adenocarcinoma in the pul-
monary lymphatics (fig 6), lymph nodes and in the mass
adjacent to the transversal colon. Final diagnosis was
pulmonary thromboembolism due to diffuse carcinoma-
tosis secondary to advanced intestinal (probably colonic)
cancer.
Fig 6. Ultrasound image of enlarged cervical lymph node (a); macroscopic view of a pulmonary embolus in a large branch of pulmo-
nary artery (embolus shown by an arrow) (b); microscopic view of pulmonary parenchyma, showing perivascular lymphatics dilated
by the presence of emboli of neoplastic epithelial cells exhibiting atypical nucleim cellular pleomorphism, organized as rudimentary
glandular acini. hematoxylin-eosin stain, 400 X magnification) (arrows points towards neoplastic emboli (c).
Ultrasonography on the non-living. Current approaches.
Postmortem US imaging to establish
new diagnostic approaches for US use
Dental US is a virtually non-existing field except for
research efforts. There is no widespread clinical use of
US imaging technology other than for oral surgery. Im-
aging technology has recently seen an increase in center
frequency and also an increase in point of care solutions,
i.e., smaller and more portable systems [27]. This sets
the stage for an attempt on the initiation of facilitating
ultrasonic imaging with proper spatial resolution, practi-
cal scan head size and meaningful clinical applications
[28]. These technological advancements could be espe-
cially helpful to monitor oral wound healing and evalu-
ate periodontal (gum) and peri-implant tissues longitudi-
nally. The presented images here were recorded in human
cadavers and were compared to cone-beam CT (CBCT)
as well as to direct caliper measurements to validate den-
tal US as proof of principle studies when we piloted US
imaging in dentistry a few years ago. These efforts and
materials significantly enhanced our understanding of
US imaging of various anatomical structures in the oral
cavity, enabling us to comfortably scan live humans with
an off-the-shelf US imaging system at the University of
Michigan Graduate Periodontal Clinic now. The images
were not taken with the intent of performing an autopsy.
Since dental procedures currently do not involve US, it
is not surprising that forensic investigations also do not
involve US.
Case 7
In a study in 2015 to 2016 we have investigated the
ability of US to depict soft and hard-tissue structures in
the oral cavity [29] (fig 7). A Zonare/Mindray scanner
(ZS3) with off-the-shelf imaging transducers (L14-5w
and L14-5sp) was employed for scans in human cadaver
specimens (Study ID: HUM00107975). Findings were
 Med Ultrason 2021; 0: 1-10 7

Fig 7. Example for underlying curvature of the oral hard-tissue

anatomy. Ultrasonic images are composed of scattered and
reflected waves. While soft-tissue scattering is often omnidi-
rectional, reflections from hard-tissues, such as bones, roots,
crowns, are angle dependent and may require more adjustment Fig 8. Comparison of ultrasound and cone beam CT images.
and alignment to obtain satisfactory images. A second-harmonic imaging mode SH12 was used here, with
an approximately 170 µm axial resolution and 0.5 mm lateral
compared to CBCT and photographs. The intent was to resolution, assuming a f-number of 3. Displayed is tooth #9.
The employed US scanner allows for automatic speed of sound
seek US as an additional imaging modality, i.e., to com- correction. Here a Speed Index (ZSI) of 20 was selected, i.e.,
plement CBCT, X-ray and optical scans, among others, +20 m/s.
to harness the power of US soft tissue contrast and its
spatial resolution. Soft- and hard-tissue imaging is of in-
terest. While soft-tissues mostly provide omnidirectional
visualization, due to mostly angle independent scatter-
ing, hard-tissues predominantly show strong angle de-
pendence and thus require specific spatial adjustment of
the ultrasound transducer for satisfactory visualization.
In Figure 8 tooth #9 is shown by means of CBCT and
US. The former has excellent hard-tissue contrast though
lacks soft-tissue contrast. For US a second harmonic
imaging mode, i.e., SH12, was used here. The Mindray
scanner offers an optimize function/button which adjusts
the assumed speed of sound. In the presented case a speed
of sound correction of +20 m/s resulted and is indicated
as Zonare Speed Index (ZSI): 20. The overlay of the
CBCT and US in panels (c) and (d) illustrates the spatial
resolution that can be obtained with off-the-shelf imag-
ing technology. In addition, one may appreciate the soft
tissue contrast of the gingiva in panel (b), left side of the
ultrasound scan, which is not obtainable via CBCT. The
left-most thickest gingiva is 4.4 mm from the jawbone to
the epidermis. Relevance to forensics is not straightfor-
ward. But subdermal tissue changes may be visible on Fig 9. Ultrasonic visualization of the greater palatine foramen.
ultrasound and not be apparent visually or visually evi- The arrow in panel (a) points to the foramen opening located
dent yet quantified ultrasonically, both in geometry and under a mucosal soft-tissue layer. Panel (b) is the equivalent
gray scale appearance. Figure 9, shows the greater pala- cone beam CT image, where the arrow also points to the fora-
men, yet in a different image orientation. Thus, ultrasound and
tine nerve. Morphometric parameters have been defined
cone beam CT are not co-registered.
for the dimensions of the greater palatine foramen, which
differ between male and female gender [30,31]. It may to also find either gender differences or other forensic in-
therefore be possible that similar features can be found formation. It should be noted that with the introduction
for ultrasonographic assessment of the greater palatine of the L30-8 linear array by Mindray, three classes of US
8 Thomas Thomsen et al
transducers exist that might be helpful in the oral cavity.
At first the forward looking endocavitary probe, second
the sideways looking (transducer cable in the lateral di-
rection), often intra-operatively used, hockey stick probe,
as well as third, the also sideways looking but transducer
cable in the elevational direction L30-8 array. This al-
lows the transducer to image sagittal, transverse and cor-
onal slices in the oral cavity (fig 8, fig 9).
Case 8
The above mentioned soft-tissue imaging qualities
were demonstrated in a study concerned with posterior
mandible pertinent to clinical dentistry, e.g. oral, peri-
odontal and implant surgery [32]. While oral surgeons
Fig 10. Labeled soft tissue structures demonstrating the wide
range of possible soft-tissue imaging and their locations, i.e.,
as far posterior as molar. (a) Image at right maxillary molar
showing muscle attachement (arrow) to jawbone. (b) Image at
mandibular left premolar showing the mental (nerve) foramen.
Fig 11. Gas bubble or other hyperechoic formation in cadaver
tissue. Image frames shown are picked from an elevational
sweep from the left retro-molar to molar region.
Ultrasonography on the non-living. Current approaches.
may need to be informed about soft-tissue, so may need
to be a forensic investigator or a forensic clinician. Fig-
ure 10 demonstrates how well connective tissue, muscle,
nerve, and glands can be distinguished by US. While
such is known for medical US, it has previously been
a challenge in dental due to probe dimensions and spa-
tial resolution. Of note is also the observed gas bubble
formation in cadaver tissues. Figure 11 shows frames re-
corded during an elevational sweep from retro-molar to
molar region. A significant number of bubbles are seen,
most dominantly in the muscle tissue. These might either
be the result of previous freezing of the specimen or are
originating from the known postmortem gas formation
during the process of decomposition [1] (fig 10, fig 11).
Discussion
We presented the use of postmortem US under very
different conditions. Postmortem US has been compared
with CT/CBCT and MRI in forensic medicine reference.
In previous studies, US was considered to be of limited
value because of gas formation due to tissue autolysis and
the regular occurrence of pneumatosis intestinalis due to
bacterial transmission [33]. The advantages of post-mor-
tem imaging include potentially valuable findings that
may help determine cause of death at low cost [34]. In
paediatrics, there are increasing reports of post-mortem
echocardiography and US after stillbirths with meaning-
ful findings [35]. In adult medicine, too, postmortem US
can yield further findings. Advantages are the ubiquitous
availability and the low organizational and financial costs
compared to CT or MRI. Postmortem gas formation in
the abdomen and tissue maceration present known chal-
lenges for US. This has been described as a major limit-
ing factor for use of US in forensic medicine. Fetal US,
on the other hand, can be performed weeks postmortem
without these impediments and shows good results. We
performed the first three described examinations in the
first three hours after death and found good conditions.
The last two were performed at 20 and 10 minutes after
death and also yielded valuable information that would
have otherwise been undiscovered. It was even possible
to provoke flows in the leg veins by compression. In all
cases, sonography made it possible to clarify the cause of
death. The next two examinations were performed at 20
and 10 minutes, respectively, after death and also yielded
valuable information that would have otherwise been
lost, as neither patient would have entered the hospital
nor had an autopsy. We therefore recommend that post-
mortem US be performed as soon as possible after death.
Developments in high-frequency US as well as minia-
turization allow for visualization of regions previously

not of interest due to poor spatial resolution or poor ac-
cess, such as the oral cavity. The last two cases were not
recorded with the intent of autopsy, but rather technology
development and for dental imaging and should be seen
as feasibility demonstration for future autopsies. Other
cases would include difficult to reach abdominal or en-
docavitary spaces where a side-looking ultrasound array
would be advantageous.
US-guided post-mortem tissue sampling played a
pivotal role in the study of infectious and non-infectious
diseases and significantly helped our group to produce
information about the pathogenesis of COVID-19. In a
situation in which conventional open autopsies were for-
bidden in Brazil, US-guided minimally invasive autop-
sies made it possible to obtain tissue samples from dif-
ferent organs such as lungs, heart, kidneys, liver spleen,
gastrointestinal tract, testis, salivary glands, thyroid and
lymph nodes. In addition, US imaging guided tissue dis-
section and sampling conducted via small incisions in the
thoracic and abdominal cavities. Finally, US-guided tis-
sue sampling increased the acceptance of post-mortem
studies by families and clinicians, opening new possibili-
ties to investigate diseases in which in vivo tissue sam-
pling is not possible. MITS has been long recognized as
a technique that could substitute or even offer the unique
option to perform autopsies in low- and middle-income
countries, where the shortage of resources makes con-
ventional open autopsy very rare. MITS has also been
used to orient public health policies, such as occurs in
Africa, with a special emphasis on the diagnosis of in-
fectious diseases, to improve efforts on the investigation
of child mortality [36]. In our series, US guidance ex-
panded the accuracy and possibilities of targeting differ-
ent organs at low cost. Indeed, although we have in our
pathology office a 16 channel CT and a 7T MRI, US was
the imaging modality of choice to plan tissue sampling
because it facilitates multiple samplings within a short
period of time. In addition, in some circumstances, US
guided MITS allowed us to conduct autopsies outside our
autopsy office in the Intensive Care Units of our Insti-
tution, minimizing time and increasing the efficiency of
post-mortem studies.
Currently dental US is at an early stage and has not
been used routinely for forensics. Intra-oral US is an
emerging technology that has been validated using hu-
man cadaver specimens as a transition and learning tool
to patient care. In the near future, it may be used to ex-
plore cause of death that may be related to oral diseases,
e.g., intraoral infection leading to sepsis.
Acknowledgment: The authors thank the Bad Mer-
gentheimer Leberzentrum e.V. for support.
Med Ultrason 2021; 0: 1-10 9
Conflict of interest: none
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