An Analysis of Autopsy-Radiology Discordance in Cases of Fatal Blunt Force Injury
Learning Overview: After attending this presentation, attendees will learn about the interpretation of Postmortem Computed Tomography (PMCT) in cases of fatal blunt trauma. Impact Statement: PMCT is increasingly used by forensic pathologists in the death investigation setting to augment traditio...
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| Format: | Proceeding |
| Language: | en |
| Published: |
2024
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| Subjects: | |
| Online Access: | http://ir.unimas.my/id/eprint/51908/3/AAFS%202024%20-%20Copy.pdf http://ir.unimas.my/id/eprint/51908/ https://share.google/UZATTTkUeZWOeFUsB |
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| Summary: | Learning Overview: After attending this presentation, attendees will learn about the interpretation of Postmortem Computed Tomography (PMCT) in
cases of fatal blunt trauma.
Impact Statement: PMCT is increasingly used by forensic pathologists in the death investigation setting to augment traditional methods of determining
the cause of death. Blunt force injuries are frequently well-depicted on PMCT, which may enable the forensic pathologist to forgo a full autopsy in nonsuspicious
cases. This presentation will impact the forensic science community by informing attendees that understanding the relative strengths and
weaknesses of autopsy and PMCT in blunt force injury cases is critical for realizing the potential of PMCT to maintain, or even increase, accuracy while
reducing the pathologist's workload.
Background: A previous double-blinded study compared the findings at autopsy, reported by a forensic pathologist, to the findings from whole body
PMCT, reported by a radiologist, for 167 cases of fatal blunt force trauma in adults and 67 cases of pediatric trauma.1 That study concluded that autopsy
and PMCT are both imperfect at detecting injuries, with similar overall sensitivities. Here, we report a detailed analysis of only the discordant findings from
the trauma cohorts of the previous study (i.e., findings observed at autopsy but not PMCT, and findings observed at PMCT but not autopsy).
Methods: The whole body PMCT study for each case was reviewed by a second radiologist, who rated each discordant finding as: (1) CT true miss (injury
found at Autopsy is not visible in CT); (2) CT false miss (injury found at Autopsy is visible in CT but not recorded); (3) CT true find (injury missed at
Autopsy is visible in CT); (4) CT false find (injury not found at Autopsy is not visible in CT); (5) Inconclusive (injury is ambiguous); or (6) Terminology
Issue (same injury was found at both Autopsy and Radiology but described differently).
Results: A total of 2,830 discordant findings were reviewed. In 2,001 instances of autopsy-radiology discordance (71%), the second radiologist agreed
with the first radiologist’s interpretation, comprising 696 CT True Misses (i.e., findings reported at autopsy that were not detectable at CT by either
radiologist) and 1,305 CT True Finds (findings missed at autopsy but detected at CT by both radiologists). In 521 instances of autopsy-radiology discordance
(18%), the second radiologist disagreed with the previous radiologist’s interpretation, comprising 402 CT False Misses (findings reported at autopsy, missed
by the previous radiologist, but seen by the second radiologist) and 119 CT False Finds (findings reported by the first radiologist, but not reported at autopsy
and not seen by the second radiologist). The second radiologist judged 225 previous instances of discordance (8%) to be inconclusive (i.e., the finding was
not sufficiently clear to assign it to another category), and 83 of the previous discordant findings (3%) were judged to be a disagreement in the terminology
used, rather than true discordance. The most common types of injuries that resulted in CT True Misses (findings seen at autopsy but not detected at PMCT
by either radiologist) were external injuries (abrasions, contusions, and lacerations) and lacerations of organs (brain, heart, lung, and other internal organs).
The most common type of injury that resulted in CT True Finds (findings missed at autopsy but seen at PMCT by both radiologists) were fractures. More
than 25% of all discordant findings analyzed were fractures missed at autopsy but found at PMCT by both radiologists, while fractures deemed as CT False
Finds represented <1% of discordant findings. The most common inconclusive findings involved internal organ injuries (hematomas and lacerations),
followed by fractures. Fractures were also the most common injury classified as a “terminology issue.”
Conclusions: Overall, the agreement between the first and second radiologist was 71%. Of 2,830 discordant findings, 46% were findings missed at autopsy,
but detected by both radiologists at PMCT, while 25% were findings observed at autopsy and not detected by either radiologist at PMCT. Inter-rater
agreement cannot be similarly assessed for autopsy. This analysis confirms that in fatal blunt force trauma cases, PMCT detects many fractures that would
be otherwise missed if only an autopsy were performed, while radiologists rarely “overcall” fractures. External injuries were the most common type of
injury confirmed to be undetectable at PMCT, highlighting the importance of the external exam in cases that will not receive an autopsy.
Reference:
1. Lathrop SL, Wiest PW, Andrews SW, Elifritz J, Price JP, Mlady GW, Zumwalt RE, Gerrard CY, Poland VL, Nolte KB. Can computed tomography replace or supplement autopsy? J Forensic Sci. 2023 Mar;68(2):524-535. doi: 10.1111/1556-4029.15217. Epub 2023 Feb 8. PMID: 36752321. |
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