Forensic Science, Medicine and Pathology (2021) 17:10–18

https://doi.org/10.1007/s12024-020-00343-z

ORIGINAL ARTICLE

Comparison of conventional autopsy with post‑mortem magnetic

resonance, computed tomography in determining the cause
of unexplained death
Giuseppe Femia1,2   · Neil Langlois3,4 · Jim Raleigh5 · Belinda Gray2 · Farrah Othman2 · Sunthara Rajan Perumal6 ·
Christopher Semsarian1,2,7 · Rajesh Puranik1,2

Accepted: 16 November 2020 / Published online: 19 January 2021

© Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Conventional autopsy is the gold standard for identifying unexplained death but due to declines in referrals, there is an emerging
role for post-mortem imaging. We evaluated whether post-mortem magnetic resonance (PMMR) and computed tomography
(PMCT) are inferior to conventional autopsy. Deceased individuals ≥ 2 years old with unexplained death referred for coronial
investigation between October 2014 to December 2016 underwent PMCT and PMMR prior to conventional autopsy. Images
were reported separately and then compared to the autopsy findings by independent and blinded investigators. Outcomes
included the accuracy of imaging modalities to identify an organ system cause of death and other significant abnormali-
ties. Sixty-nine individuals underwent post-mortem scanning and autopsy (50 males; 73%) with a median age of 61 years (IQR
50–73) and median time from death to imaging of 2 days (IQR 2–3). With autopsy, 48 (70%) had an organ system cause of
death and were included in assessing primary outcome while the remaining 21 (30%) were only included in assessing secondary
outcome; 12 (17%) had a non-structural cause and 9 (13%) had no identifiable cause. PMMR and PMCT identified the cause of
death in 58% (28/48) of cases; 50% (24/48) for PMMR and 35% (17/48) for PMCT. The sensitivity and specificity were 57%
and 57% for PMMR and 38% and 73% for PMCT. Both PMMR and PMCT identified 61% (57/94) of other significant abnor-
malities. Post-mortem imaging is inferior to autopsy but when reported by experienced clinicians, PMMR provides important
information for cardiac and neurological deaths while PMCT is beneficial for neurological, traumatic and gastrointestinal deaths.

Keywords  Unexplained death · Conventional autopsy · Post-mortem magnetic resonance · Post-mortem computed
tomography

Introduction unexplained death [1, 2]. Unfortunately, due to high costs,

limited availability and some culturally held beliefs, there
Conventional autopsy performed by a trained forensic has recently been a decline in referrals and a shift towards
pathologist is considered the gold standard to identify less invasive examinations [3–5]. Coroners are now in a
structural and biochemical abnormalities in cases of position where they must balance the public interest of

Topical Collection of Images in Forensics

5
* Giuseppe Femia Department of Radiology, Royal Prince Alfred Hospital,
femia82@gmail.com NSW, Camperdown, Australia
6
1 South Australia Health & Medical Research Institute,
Sydney Medical School, Faculty of Medicine and Health,
Preclinical, Imaging & Research Laboratories, Adelaide,
The University of Sydney, NSW 2050 Camperdown,
Australia
Australia
7
2 Agnes Ginges Centre for Molecular Cardiology Centenary
Department of Cardiology, Royal Prince Alfred Hospital,
Institute, The University of Sydney, Sydney, Australia
NSW, Camperdown, Australia
3
Forensic Science South Australia, SA, Adelaide, Australia
4
School of Medical and Health Sciences, University
of Adelaide, SA, Adelaide, Australia

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Forensic Science, Medicine and Pathology (2021) 17:10–18
identifying congenital or inherited abnormalities while
considering specific cultural and religious customs.
In recent years, post-mortem imaging with magnetic
resonance (PMMR) and computed tomography (PMCT)
has been increasingly used in the post-mortem exami-
nation. The current evidence suggests PMMR is more
accurate at identifying the cause of death in younger
individuals with cardiac and intracranial abnormalities
while PMCT is more suitable for traumatic and non-
natural deaths in older individuals [6–12]. Despite these
promising results, post-mortem PMMR and PMCT have
low sensitivity and poor accuracy for diagnosing certain
causes of death such as pulmonary emboli and pneumo-
nia even when reported by trained clinicians [13]. Fur-
thermore, most of these previous studies have focused on
determining the cause of death with limited evidence on
the ability of these modalities to identify other signifi-
cant abnormalities i.e. the overall diagnostic accuracy of
post-mortem imaging. Subsequently, there remains con-
cern about the utility of these modalities with the diverse
cases referred for coronial investigation.
We aimed to assess the accuracy of post-mortem
PMMR and PMCT in a group of ‘all comers’ with unex-
plained death referred for coronial investigation and eval-
uate whether these imaging modalities are non-inferior to
conventional autopsy for identifying the cause of death
and other significant abnormalities.
Methods
Study design and patient population
The study was conducted with the permission of the
Office of the South Australia State Coroners and per-
formed with maintenance of confidentiality in accord-
ance with NHMRC human ethics guidelines. The State
Coroner for South Australia approved a joint initiative
between Forensic Science South Australia and the South
Australian Health and Medical Research Institute (SAH-
MRI) to trial post-mortem PMMR and PMCT imaging
of coronial cases using funding provided by the South
Australian Government.
Deceased individuals 2 years or older referred from
the Adelaide area to the State Coroner for South Aus-
tralia, Australia from October 2014 to December 2016
prospectively underwent brain, neck, chest, cardiac
and abdomen PMMR and PMCT prior to conventional
autopsy as part of the post-mortem examination process
to determine a cause of death. Cases with a coronial
order for conventional autopsy and consent for post-
mortem imaging for whom the scanning would not delay
the time to autopsy by more than 24 h were included.
11
Verbal and/or written consent for the study were obtained
from the next of kin and verbal consent was obtained
from the duty pathologist. Exclusion criteria included
infant deaths (children younger than two years old are
performed at a different facility). Once identified, all
individuals were transported to the imaging facility in
two non-ferrous body bags, one inside the other, covered
with a drape, to undergo post mortem scanning. Once
scanning was complete, the individual was returned to
the mortuary for a conventional autopsy to be performed
the following day.
Imaging acquisition and protocols
All bodies were stored in the mortuary at 4 °C prior to
a morning scanning session. PMCT scanning was per-
formed on a Philips Brilliance 16-slice scanner (Philips
Corporation, Eindhoven, Netherlands). Post-mortem
brain PMCT imaging consisted of contiguous 1.0 mm
axial slices with 0.5  mm gap at 120  kV and variable
mAs. Post-mortem whole-body PMCT was performed in
helical mode in a cranial to caudal direction at 3.0 mm
slices with 1.5  mm gap at 120  kV and variable mAs.
Total time for CT scanning was approximately 15 min.
Contiguous thin slice prospective reconstructions in the
axial plane were generated using both soft tissue and
bone algorithms. Multiplanar images were then generated
in the orthogonal planes through the brain, neck, chest,
abdomen and pelvis with the OsiriX software (Pixmeo
SAR, Geneva).
PMMR imaging was performed on a Siemens Sonata
1.5 T system (Siemens Medical Solutions USA, Inc, Mal-
vern, PA, USA). The deceased individuals were scanned
in the supine position within the bag. Brain, neck, chest
and cardiac PMMR images consisted of 5.0 mm slices
with a 10% interslice gap. For brain and neck PMMR
images the following sequences were acquired: axial
T1, axial T1 inversion recovery (IR), axial T2 turbo spin
echo (TSE), axial T2 fluid attenuated inversion recovery
(FLAIR), sagittal T1, sagittal T2 TSE and sagittal T2
star. For chest and abdomen PMMR images the follow-
ing sequences were acquired: axial T1, coronal 3-dimen-
sional T1 fast field echo (FFE), axial T2 TSE, axial T2
star, sagittal T1, sagittal T2 TSE and axial T2 star. For
cardiac PMMR images, T2 short tau inversion recovery
(STIR) sequence were acquired in multiple long axis car-
diac planes; left ventricular long axis (LVLA), right ven-
tricular long axis (RVLA), four-chamber, left ventricular
outflow tract (LVOT) and right ventricular outflow tract
(RVOT). In addition, T2 TSE and T2 STIR sequences
were acquired according to the cardiac axis in the short
axis plane through the entire cardiac mass from base to
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apex. Total time for MRI scanning was approximately
60 min.
Conventional autopsy
After post-mortem PMMR imaging and PMCT scanning,
the deceased underwent conventional autopsy performed
by a trained pathologist. A conventional autopsy included a
review of clinical history and all relevant ante-mortem infor-
mation. We defined conventional autopsy as a procedure that
included both external and internal examination with ancil-
lary tests (histology, toxicology, biochemistry, microbiol-
ogy) as required and deemed appropriate by the pathologist.
The internal examination required opening and examining
the contents of the cranial vault, neck, chest, abdomen, pel-
vis and any other relevant site such as deep veins of the
legs. Routine microbiology samples were obtained from
cardiac blood, cerebrospinal fluid, lung and spleen when
appropriate. Histological sampling of all major body organs
was performed when indicated as per standard protocols.
Fixed specimens were performed in cases of high suspicion.
Identification of pathology in the subject was as per standard
autopsy criteria.
Image interpretation
De-identified details of the circumstances surrounding the
death and the past medical history of the deceased were
made available to the imaging team. The PMMR and PMCT
images were reported without knowledge of the post-mor-
tem internal examination findings. Image interpretation for
the central nervous, cardiovascular, thoracic (non-cardiac
chest), abdominal and musculoskeletal body systems were
performed by an experienced post-mortem radiologist (JR).
Cardiac PMMR interpretation was performed by an expe-
rienced CMR cardiologist (RP). Following completion of
the written report, the assessors were supplied with the de-
identified post-mortem examination findings.
Clinical data and definitions
The post-mortem examination reports were compared to the
imaging reports by an independent and blinded researcher
(GF). The causes of death were based on the findings of the
conventional autopsy. The primary outcome was the accu-
racy of post-mortem imaging to identify organ system causes
of death (cardiovascular, pulmonary, intracranial and upper
abdominal) as identified by conventional autopsy. Cases with
non-organ system causes of death such as asphyxia, drug and
alcohol toxicity, hyperthermia and diabetes ketoacidosis and
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Forensic Science, Medicine and Pathology (2021) 17:10–18
cases with undetermined cause of death were excluded from
the primary outcome assessment. The secondary outcome
was the accuracy of post-mortem imaging to identify other
abnormalities reported by autopsy as significant but not
associated with the primary cause of death. All cases were
included in the secondary outcome assessment.
Statistical analysis
Statistical analysis was carried out using Microsoft Excel
and SPSS software (Version 21, Armonk, NY: IBM Corp).
Sensitivity, specificity, positive predictive value and negative
predictive value were calculated using standard formulae.
Continuous variables were analyzed using unpaired t-tests.
Difference between PMMR and PMCT were analyzed
using McNamer’s test. A p value was considered significant
if < 0.05.
Results
Case characteristics
Post-mortem imaging and conventional autopsy were per-
formed in 69 individuals (50 males; 72%) with unexplained
death; 43 (62%) individuals were found dead after an unwit-
nessed collapse, 9 (13%) were found unresponsive and died
after unsuccessful resuscitation and 17 (25%) had a wit-
nessed collapsed and died after unsuccessful resuscitation.
The median age at death was 61 years (Interquartile range
(IQR) 50–73) and median time from death to imaging and
autopsy was 2 days (IQR 2–3) and 3 days (IQR 3–4) respec-
tively. The majority of these patients died at their place of
residence (54/69; 78%), five (6%) died while an inpatient in
hospital, six (9%) collapsed and died while driving a car or
bike, two (3%) collapsed and died while shopping and two
(3%) died while swimming.
Post‑mortem examination findings
According to conventional autopsy, 48 (70%) cases had an
organ system cause of death, 12 (17%) had a non-structural
cause of death and 9 (13%) had no identifiable cause. For the
cases with an organ system cause of death, 25 (52%) were
attributed to cardiovascular disease, 14 (30%) to pulmonary
disease, 5 (11%) to intra-cranial pathology and 4 (9%) to
an upper gastrointestinal cause. Amongst the major organ
causes of death cases, the most common were ischemic
heart disease/myocardial infarction (18/48; 38%), pulmo-
nary emboli (9/48; 19%) and intracranial hemorrhage (3/48;
6%). For the patients with non-structural causes of death,

Forensic Science, Medicine and Pathology (2021) 17:10–18 13

Table 1  Organ system causes of death identified by conventional autopsy, post-mortem magnetic resonance and computed tomography
Conventional Autopsy Post-mortem MR Post-mortem CT P value
MR vs. CT

Organ System Causes of Death 48 24/48 (50%) 17/48 (35%) 0.299

Cardiovascular 25/48 (52%) 14/25 (56%) 5/25 (20%) 0.017
Ischemic Heart Disease/Myocardial Infarction 18/25 (72%) 9/18 (50%) 0/18 (10%) 0.001
Haemopericardium 4/25 (16%) 4/4 (100%) 4/4 (100%) 1.000
Cardiomyopathy (non-Hypertrophic) 1/25 (4%) 0 (0%) 0 (0%) 1.000
Ruptured Abdominal Aortic Aneurysm 1/25 (4%) 1/1 (100%) 1/1 (100%) 1.000
Myocardial Fibrosis 1/25 (4%) 0/1 0/1 1.000
Pulmonary 14/48 (29%) 4/14 (29%) 4/14 (29%) 0.427
Pulmonary Emboli 9/14 (67%) 1/9 (20%) 0/9 1.000
Infection 4/14 (27%) 3/4 (20%) 3/4 (100%) 0.048
Malignancy 1/14 (7.1%) 0/1 1/1 (100%) 1.000
Intracranial 5/48 (10%) 5/5 (100%) 5/5 (100%) 1.000
Subarachnoid haemorrhage 3/5 (60%) 3/3 (100%) 3/3 (100%) 1.000
Trauma with Fractures/Haematomas 2/5 (29%) 2/2 (100%) 2/2 (100%) 1.000
Upper Abdominal 4/48 (8%) 1/4 (25%) 3/4 (75%) 0.486
Haemorrhage/Sepsis 4/4 (100%) 1/4 (25%) 3/4 (75%) 0.486

P-value is unpaired T test between MR and CT

Significant P-values (< 0.05) were highlighted in bold

three (3/12; 25%) were due to drug toxicity, three (3/12;
25%) were due to metabolic abnormalities, three (3/12;
25%) were due to asphyxia, two (2/12; 17%) were due to
bacteremia and one (1/12; 8%) was due to complications
from epilepsy (Table 1). In addition, conventional autopsy
identified 94 significant secondary organ abnormalities not
associated with the primary cause of death; 51 (54%) cardio-
vascular, 19 (20%) pulmonary, 8 (9%) intracranial, 13 (14%)
upper gastrointestinal and 3 (3%) other. The most common
abnormalities were left ventricular hypertrophy, left or right
ventricular dilatation, arterial calcification, emphysema with
bullae and pneumonia (Table 2).
Comparison of autopsy and imaging
findings – primary outcome: identification
of organ system cause of death
According to autopsy, 48 (70%) cases had an organ sys-
tem cause of death and were included in the primary out-
come assessment. PMMR or PMCT identified the cause of
death in 58% (28/48) of cases; 50% (24/48) by PMMR and
35% (17/48) by PMCT. PMMR identified 56% (14/25) of
cardiovascular causes of death, 29% (4/14) of pulmonary
causes, 100% (5/5) of intracranial causes and 25% (1/4) of
upper gastrointestinal causes while PMCT identified 20%
(5/25) cardiovascular, 29% (4/14) pulmonary, 100% (5/5)
intracranial and 75% (3/4) upper gastrointestinal (Fig. 1).
PMMR and PMCT agreed on the diagnosis in 29% (14/48)
of cases. The sensitivity and specificity for the primary
outcome were 57% and 57% for PMMR and 38% and 73%
for PMCT; p = 0.451. The positive and negative predic-
tive values were 80% and 31% for PMMR and 85% and
22% for PMCT. Post-mortem PMMR was more accurate
than PMCT in identifying myocardial infarction (50% vs.
0%; p = 0.001) while both modalities correctly identified
all cases with intracranial hemorrhage and hemopericar-
dium (3/3; 100% and 4/4; 100%). The cause of death was
incorrectly diagnosed in twelve cases (eight by PMMR
and five by PMCT) and although both PMMR and PMCT
were able to accurately identify the presence of hemo-
pericardium, both modalities failed to detect aortic dis-
section as the underlying etiology in one case. Overall,
pulmonary emboli and aortic dissection were the (3/12 and
3/12; 25%) the most commonly overcalled cause of death
while myocardial infarction (9/18; 50%) and pulmonary
emboli (8/9; 89%) were the causes of death most com-
monly missed. PMCT did not identify any deaths due to
myocardial infarction or pulmonary emboli (0/27) (Table 3
and 4, and Fig. 2).
In a sub-analysis of the current study based on age, nine
(9/47; 19%) individuals were younger than 50 years of age at
the time of death. Compared to those older than 50 years of
age, all nine individuals had a major organ cause of death on
autopsy (100%; 9/9 vs. 63%; 38/60, p = 0.0489). Although
not statistically significant, PMMR was more accurate in the
younger group (78%; 7/9 vs. 45%; 17/38, p = 0.261). In par-
ticular, PMMR was more accurate for cardiovascular causes

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14 Forensic Science, Medicine and Pathology (2021) 17:10–18

Table 2  Other significant abnormalities identified by conventional autopsy, post-mortem magnetic resonance and computed tomography
Conventional Autopsy Post-mortem MR Post-mortem CT P value
MR vs. CT

Other significant abnormalities 94 57/94 (61%) 57/94 (61%) 1.000

Cardiovascular 51/94 (54%) 25/51 (49%) 23/51 (45%) 1.000
Left or Right 21/51 (41%) 21/21 (100%) 3/21 (14%)  < 0.001
Ventricular Hypertrophy or Dilatation
Myocardial Fibrosis 10/51 (20%) 3/10 (30%) 0/10 0.474
Coronary Artery Calcification 19/51 (37%) 0/19 19/19 (100%)  < 0.001
Atrial Septal Closure Device 1/51 (2%) 1/1 (100%) 1/1 (100%) 1.000
Pulmonary 19/94 (20%) 13/19 (68%) 15/19 (79%) 1.000
Emphysema with bullae 7/19 (36%) 5/7 (71%) 5/7 (71%) 1.000
Pneumonia 7/19 (36%) 4/7 (57%) 5/7 (71%) 1.000
Malignancy 2/19 (11%) 1/2 (50%) 2/2 (100%) 1.000
Pneumothorax 1/19 (5%) 1/1 (100%) 1/1 (100%) 1.000
Hypoplastic Right Lung 1/19 (5%) 1/1 (100%) 1/1 (100%) 1.000
Asbestosis 1/19 (5%) 1/1 (100%) 1/1 (100%) 1.000
Intracranial 8/94 (8.5%) 6/8 (75%) 5/8 (63%) 1.000
Infarction 2/8 (25%) 2/2 (100%) 0/2 0.333
Subarachnoid or 4/8 (50%) 4/4 (100%) 3/4 (75%) 1.000
subdural blood
Skull fracture 2/4 (25%) 0/2 2/2 (100%) 0.333
Upper Gastrointestinal 13/94 (14%) 10/13 (77%) 11/13 (85%) 1.000
Liver Mass 4/13 (31%) 3/4 (75%) 4/4 (100%) 1.000
Fatty Liver/Cirrhosis 4/13 (31%) 4/4 (100%) 4/4 (100%) 1.000
Pancreatic Mass 2/13 (15%) 1/2 (50%) 1/2 (50%) 1.000
Kidney/Adrenal Mass 2/13 (15%) 1/2 (50%) 2/2 (100%) 1.000
Oesophageal Dilatation 1/13 (8%) 1/1 (100%) 0/1 1.000
Other 3/94 (3%) 3/3 (100%) 3/3 (100%) 1.000
Thyroid Mass 2/3 (67%) 2/2 (100%) 2/2 (100%) 1.000
Retropharyngeal Haemorrhage 1/3 (33%) 1/1 (100%) 1/1 (100%) 1.000

P-value is unpaired T-test between MR and CT

Significant P-values (< 0.05) were highlighted in bold

of death (80%; 4/5 vs. 43%; 10/23, p = 0.321); although
again the difference was not statistically significant. There
was no significant difference in the accuracy of PMCT (44%;
4/9 vs 37%; 14/38, p = 1.000) between the two age groups.
Comparison of autopsy and imaging
findings – secondary outcome: identification
of significant abnormalities not associated
with cause of death
vs 75% (3/4), p = 1.000) while PMCT was superior at detect-
ing arterial calcification (100% (19/19) vs. 0%, p < 0.001)
and skull fractures (100% (2/2) vs. 0%, p = 1.000). In addi-
tion, PMMR and PMCT overcalled 27 abnormalities (18
for PMMR and 17 for PMCT) not reported by autopsy i.e.
consistent with false positives. The most common overcalled
abnormalities were aortic pathologies such as aortic dissec-
tion and increased pulmonary signal thought to represent
either chest infection or malignancy.

In the 69 cases, autopsy identified 94 significant abnormali- Discussion

ties not associated with the primary cause of death. With
PMMR and PMCT, both modalities detected 61% (57/94) of
these abnormalities; p = 1.000 (Table 2). PMMR was more
accurate at identifying left or right ventricular hypertro-
phy/dilatation (100% (21/21) vs 14% (3/21), p < 0.001) and
intracranial subarachnoid or subdural bleeding (100% (4/4)
Conventional autopsy is considered the gold standard for
investigating unexplained death but in recent years there
has been a dramatic decline in referrals due to increasing
costs and reluctance for the deceased individual to undergo
an invasive procedure [14]. As a result, there is a growing

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Forensic Science, Medicine and Pathology (2021) 17:10–18 15

Fig. 1  Causes of death correctly identified by post-mortem imag-
ing. A  CMR T2 STIR short axis mid-cavity image – hyper intense
signal in the infero-posterior wall consistent with subacute myocar-
dial infarction (red arrow) B  CMR T2 STIR LVLA image – hyper
intense signal in the infero-septal wall consistent with subacute
myocardial infarction (red arrow) C  CMR T2 STIR transverse
image – large hemopericardium with compression of RA (orange
arrow) D  CT chest – hemopericardium (orange arrow) E  MR brain
T2 image – hypo intense lesion consistent with cerebral hemorrhage
(yellow arrow) F  CT brain – hyper intense lesion consistent with
cerebral hemorrhage (yellow arrow). CMR  cardiac magnetic reso-
nance,  STIR  short tau inversion recovery, LVLA  left ventricular, left
atrium, CT computed tomography

need for non-invasive alternatives. Post-mortem PMMR and
PMCT has been studied and shown to be beneficial in certain
situations for specific abnormalities [15–17]. Unfortunately,
there remain questions about the role of imaging in the
coronial investigation [18]. From this study, there were two
important findings. First, both PMMR and PMCT were infe-
rior to conventional autopsy in detecting the cause of death
and other significant abnormalities. Second, PMMR was
more accurate (50% vs. 35%) than PMCT at detecting the
cause of death in this diverse group of “all comers” referred
for coronial investigation. In cases where a conventional
autopsy cannot be performed, post-mortem imaging can be
useful and provide important information about structural
abnormalities when reported by an experienced specialist
without the need for an invasive procedure [10] (Table 5).
Although post-mortem imaging was not as accurate as
conventional autopsy, there are situations where autopsy
cannot be performed due to cultural and/or religious beliefs
and in these situations, imaging can be used to obtain impor-
tant information to guide the post-mortem examination. For
example, post-mortem PMMR was accurate for diagnosing
cardiac abnormalities such as myocardial infarction, left or

Table 3  Causes of death Post-mortem MR Post-mortem CT bb

overcalled by post-mortem MR vs. CT
magnetic resonance and
computed tomography Total 8 5 1.000
Pulmonary Emboli 2/8 (25%) 1/5 (20%) 1.000
Aortic Dissection 2/8 (25%) 2/5 (40%) 1.000
Myocardial Infarction 1/8 (13%) 0 1.000
Myocarditis 1/8 (13%) 0 1.000
Pneumonia 1/8 (13%) 0 1.000
Arrhythmogenic Right Ventricular 1/8 (13%) 0 1.000
Cardiomyopathy
Aspiration Pneumonia 0 1/5 (20%) 1.000
Upper abdominal Sepsis 0 1/5 (20%) 1.000

P-value is unpaired T-test between MR and CT

Significant P-values (< 0.05) were highlighted in bold

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16 Forensic Science, Medicine and Pathology (2021) 17:10–18

Table 4  Causes of death missed by post-mortem magnetic resonance widely available and less expensive. Overall, we found that
and computed tomography both modalities had low false positive rates suggesting that
Post-mortem MR Post-mortem CT P value in cases where a cause of death is identified, imaging alone
MR vs CT may be sufficient to provide a diagnosis; therefore, avoiding
the need for an invasive procedure and allowing for appro-
Total 23/48 (48%) 29/48 (60%) 0.306
priate counselling of family members.
Ischemic Heart 9/18 (50%) 18/18 (100%) 0.001
Disease/Myocar- As post-mortem imaging was less sensitive than conven-
dial Infarction tional autopsy for identifying both the cause of death and
Cardiomyopathy 1/1 (100%) 1/1 (100%) 1.000 other significant abnormalities, neither modality can replace
Pulmonary 8/9 (89%) 9/9 (100%) 1.000 the current coronial practice at the diagnostic level without
Emboli introducing systematic errors in mortality evaluation. Due
Cancer 2/2 (100%) 0/2 0.333 to sub-optimal resolution and absence of circulating blood
Upper Abdominal 3/4 (75%) 1/4 (25%) 0.486 flow, both modalities have poor accuracy for identifying aor-
Haemorrhage/
tic dissections, discriminating pathological pulmonary throm-
Sepsis
bus from post-mortem clot and differentiating ante-mortem
P-value is unpaired T-test between MR and CT infection from post-mortem pulmonary fluid. Overall, both
Significant P-values (< 0.05) were highlighted in bold modalities had high false negative rates suggesting that in
cases where a cause of death is not identified by post-mortem
imaging, additional investigations should be performed. These
right ventricular hypertrophy/dilatation, cardiac tamponade results are in keeping with a previous study of deceased adults
and neurological abnormalities such as cerebral infarction that found both PMMR and PMCT poorly identified deaths
and intra-cranial hemorrhage, especially in those younger attributed to pulmonary emboli [7]. Although our findings
than 50 years of age. On the other hand, PMCT was accu- have shown specific weaknesses for both imaging modalities,
rate for identifying abdominal gas from bowel perforation, there are also several strengths whereby they can assist with
vascular calcification, skeletal pathologies such as fractures, the post-mortem examination process. For example, if used
cardiac tamponade and intra-cranial hemorrhage. Addition- as a pre-autopsy investigation, post-mortem imaging might
ally, PMCT has important practical advantages compared be able to help the pathologist avoid unnecessary procedures,
to PMMR such as requiring less scanning time, being more fast track dissections by guiding them toward pathology and

Fig. 2  Causes of death overcalled by post-mortem imaging (not
identified on conventional autopsy). A CMR T2 STIR image – hypo
intense region within the left pulmonary artery reported as pul-
monary emboli (red arrow) B  T2 STIR image – hyper intense mass
reported as clot in the RV (red arrow) and pulmonary artery (blue
arrow) C-D  CMR T2 STIR image – focal thickening suggestive of
intra-mural hematoma or aortic dissection (orange arrows) E MR T2
image – hyper intense signal in the both lung bases suggestive of con-
solidation (yellow arrow) F CT chest image – hyper intense signal in
both lung bases suggestive of consolidation (yellow arrow). CMR car-
diac magnetic resonance, STIR short tau inversion recovery, RA right
atrium, CT computed tomography

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Forensic Science, Medicine and Pathology (2021) 17:10–18 17

Table 5  Comparison of conventional autopsy to post-mortem magnetic resonance and computed tomography

Post-mortem MR Post-mortem CT Conventional Autopsy

Availability Limited to Large Centres Good – particularly 16-slice Good

scanners
Acquisition Time (whole body) Long Short Long
 ~ 60–90 min  ~ 15 min  ~ 45 – 90 min
Capital Cost High Moderate High
Cost per Test (EUR) High ~ €400 (EUR) Low ~ €200 (EUR) High ~ €1500 (EUR)
Maintenance Costs Very High High Not applicable
False Positive Rate Low Low Not available
False Negative Rate High High Not available
Causes of death
Myocardial Infarction Yes – Hyperintense signal on T2 No Yes – Histological changes
weighted imaging
Myocarditis Yes – Hyperintense signal on T2 No Yes – Histological changes
weighted imaging
Pericardial Effusion Yes Yes Yes
Intracranial Haemorrhage Yes Yes Yes
Intraabdominal Haemorrhage Yes Yes Yes
Aortic Dissection Limited Accuracy Limited Accuracy Yes
Pulmonary Emboli Limited Accuracy - Limited Accuracy - Yes, but can be difficult to dif-
Difficult to differentiate Difficult to differentiate ferentiate ante-mortem thrombus
from post-mortem clot; from post-mortem clot; from post-mortem clot
No current post-mortem angiog- No current post-mortem angiog-
raphy raphy
Other abnormalities
Left or Right Ventricular Hyper- Yes No Yes
trophy/Dilation
Arterial Calcification No Yes Yes
Pneumonia/Pulmonary Oedema Limited Accuracy - Limited Accuracy - Yes
Difficult to differentiate Difficult to differentiate
from post-mortem fluid from post-mortem fluid
Skeletal System Injuries Limited Yes Yes
Detection of Air/Gas/Fluid Limited Yes Limited
Biochemical or Toxin Induced No No Yes
Death

provide rapid information for referring physicians to inform
families on the need for genetic screening [19].
Before post-mortem imaging can have widespread imple-
mentation, several challenges need to be resolved. First,
post-mortem imaging remains difficult for some mortuaries
due to high running costs, limited access to PMMR scanners
and a small number of trained reporters. Moving forward,
standardized training programs for post-mortem imaging
will need to be established. Second, ante-mortem parameters
are currently being used to report post-mortem pathology
despite significant changes to the structure and composition
of organs from the coronial process and post-mortem putre-
faction. In order to maintain consistency and expand the
accuracy of post-mortem imaging, specific post-mortem def-
initions of normal and abnormal body structures will need
to be established. Third, there is no standardized acquisition
strategy or reporting protocol and as a result, comparing
studies from different centers is difficult. Importantly, these
differences will lead to variable reporting, inconsistent use
of descriptive terms and omission of critical information.
These challenges are important to recognize as we expand
our understanding of post-mortem imaging and develop spe-
cialized sequences necessary to obtain appropriate clinical
information.
Our study has limitations. First, only cases with organ causes
of death were included in the primary outcome as imaging alone
cannot diagnose biochemical or toxicological causes of death
and in our cohort, approximately 30% of deaths had a non-
structural etiology which significantly impacted on the power
of the results. A recent study has shown that supplementing
PMMR with blood samples without dissection or tissue histol-
ogy had excellent concordance with autopsy for detecting major

13
18
pathological abnormalities (89.3%) related to death [7]. Second,
we only included cases with consent for conventional autopsy
and imaging because of difficulties in obtaining timely permis-
sion. Thus, the study population may underrepresent the total
cases referred for coronial investigation. Finally, we considered
conventional autopsy to be the gold standard for identifying the
cause of death, but it is nevertheless subject to intra- and inter-
operator variability. As such, whilst some deaths determined
by PMMR or PMCT were labelled as false positives, it may be
that these abnormalities were present but were not identified by
conventional autopsy.
Conclusions
In cases of unexplained death where conventional autopsy can-
not be performed, post-mortem imaging reported by trained
clinicians can provide important information that can guide
pathologists with the coronial investigation and help referring
physicians make decisions on family screening. Specifically,
post-mortem PMMR can be useful in cases involving younger
individuals where the cause of death is believed to be due to
cardiac or neurological conditions and PMCT is valuable in
cases of neurological, gastro-intestinal and traumatic or non-
natural death.
Key points
1 Conventional autopsy is the gold standard for investigat-
ing unexplained death.
2 Post-mortem PMMR and PMCT are inferior to conven-
tional autopsy.
3 PMMR and PMCT can provide information about the
individual and the cause of death.
4 PMMR is useful in younger individuals with cardiac or
neurological conditions.
5 PMCT is valuable in cases of neurological, gastro-
intestinal and non-natural deaths.
Author contributions  All authors were involved in at least one of
the following: designed study, reported scans or autopsy, data col-
lection,  analysed and interpreted data,  wrote and approved final
manuscript.  tion as a new method in determining the need for autopsy. Foren-
Availability of data availability  The datasets used and/or analysed dur-
ing the current study are available from the corresponding author upon
request.
13
Forensic Science, Medicine and Pathology (2021) 17:10–18
References
1. Mason JK. Forensic medicine for lawyers. 3rd ed. London:
Butterworths; 1995.
2. Peres LC. Post-mortem examination in the United Kingdom:
present and future. Autopsy Case Report. 2017;7:1–3.
3. Friberg N, Ljungberg O, Berglund E, Berglund D, Ljungberg R,
et al. Cause of death and significant disease found at autopsy.
Virchows Arch. 2019;475:781–8.
4. O’Grady G. Death of the teaching autopsy. BMJ. 2003;327:802–3.
5. Femia G, Semarian C, Langlois N, McGuire M, Raleigh J, et al.
Post-mortem imaging adjudicated sudden death: Causes and
controversies. Heart Lung Circ. 2019;28:15–21.
6. Taylor A, Sebire N, Ashworth M, Schievano S, Scott R, et al.
Postmortem cardiovascular magnetic resonace imaging in
fetuses and children: a masked comparison study. Circulation.
2014;129:1937–44.
7. Roberts I, Benamore R, Benbow E, Lee S, Harris J, et al. Post-
mortem imaging as an alternative to autopsy in the diagnosis of
adult death: a validaion study. Lancet. 2012;379:136–42.
8. Thayyil S, Sebire N, Chitty L, Wade A, Chong W, et al. Post-
mortem MRI versus conventional autopsy in fetuses and chil-
dren: a prospective validation study. Lancet. 2013;382:223–33.
9. Arthurs O, Guy A, Thayyil S, Wade A, Jones R, et al. Compari-
son of diagnostic performance for perinatal and paediatric post-
mortem imaging: CT versus MRI. Eur Radiol. 2016;26:2327–36.
10. Puranik R, Gray B, Lackey H, Yeates L, Parker G, et al. Com-
parison of conventional autopsy and magnetic resonance imag-
ing in determing the cause of suddent death in the young. J
Cardiovasc Mag Res. 2014;16:44–55.
11. Ruder T, Thali M, Hatch G. Essentials of forensic post-mortem
MR imaging in adults. Br J Radiol. 2014;87:20130567.
12. Jalalzadeh H, Giannakopoulos G, Berger F, Fronczek J, van
de Goot F, et al. Post-mortem imaging compared with autopsy
in trauma victims - A systematic review. Forensic Sci Int.
2015;257:29–48.
13. Kasahara S, Makino Y, Hayakawa M, Yajima D, Ito H, et al.
Diagnosable and non-diagnosable cases of death by postmortem
computed tomography: A review of 339 forensic cases. Leg
Med. 2012;14:239–45.
14. Davies D, Graves D, Landgren A, Lawrence C, Lipsett J, et al.
The decline of the hospital autopsy: a safety and quality issue
for healthcare in Australia. Med J Aust. 2004;180:281–5.
15. Thayyil S, Chandrasekaran M, Chitty LS, Wade A, Skordis-
Worrall J, et al. Diagnostic accuracy of post-mortem magnetic
resonance imaging in fetuses, children and adults: a systematic
review. Eu J Radiol. 2010;75:142–8.
16. Grabherr S, Egger C, Vilarino R, Campana L, Jotterand M, et al.
Modern post-mortem imaging: an update on recent develop-
ments. Forensic Sci Res. 2017;2:52–64.
17. Smith A, Traill Z, Roberts I. Post-mortem imaging in adults
Diag Histopathol. 2018;24:365–71.
18. Morgan B, Rutty G. How does post-mortem imaging compare
to autopsy, is this a relevant question? J Forensic Radiol Imag.
2016;4:2–6.
19. Bedford P. Routine CT scan combined with preliminary examina-
sic Sci Med Pathol. 2012;8:390–4.
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