Review Paper

VIRTUAL AUTOPSY: A NEW TREND IN FORENSIC INVESTIGATION

1 2
Ahmad M , Rahman FN

Abstract
Introduction: The modern high-resolution imaging difficult forensic cases; body length and Individual
has been used as a well described aid in the decedent feature identification; identifying distinct
setting of post-mortem investigations. In developed foreign bodies retained bullets, blades, etc.;
countries Computed Tomography (CT) and identification of injuries and forensic
Magnetic Resonance Imaging (MRI) are now being reconstructions three dimensional
evaluated as complementary means for reconstructions, bullet tract identification;
cause-of-death determination. education and clinical performance improvement
process; and research.
Objective: This paper explores the implication of
virtual autopsy from ethical and technical point of Conclusion: Due to its minimal invasive
view. procedure, virtual autopsy is very much acceptable
to the society. In USA and European countries
Methods: Published literature with strict inclusion virtual autopsy is likely to replace conventional
and exclusion criteria were extensively reviewed autopsies in future. We can also utilize this modern
through use of general and Meta search engines technology to upgrade the century old investigation
to elucidate the applications and implications of system in our country.
virtual autopsy.
Key-words: Virtual autopsy, Conventional post
Discussion: Virtual autopsy introduces a new era mortem examination, Future aspect.
in autopsy examination. It utilizes the
technological innovation of modern imaging
system to obtain high quality 3 Dimensional
images of the body in multiple plains without Introduction
mutilation of the human body. The Virtual Autopsy
can be applied in a broad number of forensic The modern high-resolution imaging has been used
situations, such as thanatological investigations; as a well described aid in the setting of
carbonized and putrefied body identifications; post-mortem investigations. In developed countries
mass disaster cases; age estimation; Computed Tomography (CT) and Magnetic
anthropological examinations and skin lesion Resonance Imaging (MRI) are now being evaluated
analyses, determining cause of death as complementary means for cause-of-death
determination; decedent gender, identification in determination.

1. Lt Col Mushtaq Ahmad, MBBS, DFM, MCPS, Associate Professor & Head, Dept of Forensic Medicine and
Toxicology, Armed Forces Medical College, Dhaka; 2. Dr. Farial Naima Rahman, MBBS, DMU. Lecturer, Dept of
Forensic Medicine and Toxicology, Armed Forces Medical College, Dhaka.

JAFMC Bangladesh. Vol 9, No 2 (December) 2013 100

 Objective In most countries, clinical autopsies are performed
This paper explores the implication of virtual with permission from the family of the deceased.
autopsy from ethical and technical point of view. In As a consequence of its invasiveness, permission
6-8
this article the history of autopsy and the reasons to conduct a clinical autopsy is often not given .
for the gradual decrease in conventional autopsy In ancient Egypt and Mesopotamia postmortem
rates over the last two decades have been briefly dissections were frequently performed during the
described. An overview on advantages and process of embalming. In India, autopsy and
limitations of modern imaging autopsy techniques dissection were practiced by Sushruta, an early
is also presented and potential future applications pioneer of ayurveda (the Indian art of medicine) in
of modern imaging techniques in postmortem the sixth century B.C. In the third century B.C.,
analysis are also discussed. Greek scholars used autopsy for the purpose of
enhancing their understanding of anatomy and
Materials and Methods disease. Similar approaches re-emerged in Europe
Published literature with strict inclusion and during the middle Ages and the Renaissance with
exclusion criteria were extensively reviewed the work of Vesalius and others. The first
through use of general and Meta search engines organized treatise on pathological findings at
to elucidate the applications and implications of autopsy was The seats and causes of diseases
virtual autopsy. Articles containing information investigated by anatomy, published in 1761 by
regarding the history of virtual autopsy, its Giovanni Batista Morgagni when he was 79 years
application in different cases, and gradual old. This book, describing nearly 700 autopsies
development of the procedures in western performed by the author, is the foundation of
countries and future aspects of this method have modern post-mortem science. At the end of the
been taken into count for collection of data and nineteenth century, Osler established autopsy as
references. one of the cornerstones of his approach to both
9-11
medical training and clinical method . In the first
Discussion half of the twentieth century autopsy rates steadily
The word autopsy has come from the Greek increased. In the 1960s and 1970s, many of the
words Autos- which means self and opis advances in cardiovascular surgery developed by
which means view or to see for one self. It is also DeBakey and his team were pioneered using
called necropsy. (Necros means- dead body) or cadaveric testing. The second half of the 20th
post mortem examination (post- means after, century and the beginning of 21st century saw
1
mortem means death) . Autopsy is a special type continued decline in autopsy rates. This was
of scientific examination of a dead body carried out largely a global phenomenon, with only a few
under the law of state. A model autopsy procedure countries where autopsy rates remained relatively
has been produced by United Nations within the constant or decreased less dramatically, including
12-13
context of investigation of human rights abuses Sweden and Finland . Over the past three
called the-Minnesota Protocol (The United decades, there has been a 40-50% drop in
14
Nations Manual on the Effective presentation and autopsy rates across the world . In the United
investigation of extra legal, arbitrary and summary States, autopsy rates fell from the reported high of
execution). It can be used to deal with difficult, 41% in the 1960s to between 5% and 23% at
2 15-16
controversial or sensitive cases . The first medico present . The most commonly cited factors
legal autopsy was done by Bartolomio De accounting for this phenomenon include physician
3
Varignana in Italy in 1302. In this Subcontinent the discomfort in requesting permission from the
first medico legal autopsy in India was performed family, cost containment measures, risk of blood
4
by Dr Edward Bulkley on 28th August 1693. borne pathogen transmission, as well as the
Mainly autopsy are of three types: medico legal, perceived absence of the curricular/educational
5 17-21
pathological or clinical or hospital and anatomical . value of autopsies .

JAFMC Bangladesh. Vol 9, No 2 (December) 2013 101

 30
One report from Australia demonstrated a sharp sponsored programs in the USA , and the
drop in autopsies from nearly 40% in the year CATopsy program at St Luke's Hospital in
2000 to just over 10% in 2001 which was attributed Bethlehem, Pennsylvania, USA. R A L Bisset et
22 31
to a significant increase in autopsy refusals . The al studied 53 cases at Manchester, UK in the year
Virtopsy, or "virtual autopsy" was developed by 1997, using MRI where the findings were
Richard Dirnhofer, former Director of Forensic confirmed by conventional autopsy. According to
Medicine, Berne, which was then continued by his their study, the findings were more or less similar
successor, Michel Thali and his colleagues at the in both the methods. In their study, they could
University of Berne's Institute of Forensic detect cardiac ischemia, pneumonic
Medicine, Switzerland. During autopsy the 3-D consolidations, pleural effusion or pulmonary
geometry of human body is destroyed but using oedema etc apart from the other cases. In Japan,
the cross-section imaging technique, it is possible postmortem computed tomography (PMCT) is
to document the same findings in a noninvasive widely applied for three major roles screening the
way. A multi-slice computed tomography (MSCT) cause of death, screening candidates for autopsy,
and magnetic resonance imaging (MRI) visualize and for guidance and/or supplemental information
the interior of the body for collection of all the data for autopsy.
in details in regards to condition of different
organs. Specific software (e.g. Tera Recon In a study conducted in Japan, questionnaire sheets
Aquarius NET, Foster City, California, United were distributed, regarding the use of PMCT, to
States of America) allowed for 3D reconstructions 183 major medical establishments having
of the computed tomography images from the Emergency Rooms. Of these, 67% responded and
observed structures. Another part of the it was found that 89% of the respondents used
documentation concerns the body surface PMCT. This high rate was likely because the
recording, performed by forensic photogrammetric number of CTs in Japan was greater than 10,000
and 3D optical scanning. One can examine the units, constituting more than one-third of those
32
part of the body slice by slice in different planes world wide . Since 2005, United States Army
according to the requirement of the situation. Apart Forces Institute of Pathology has scanned and
from these, using the magnetic resonance imaging analyzed about 800 bodies killed in war zones in
spectroscopy, time since death can also be order to determine cause of death and examine the
33-35
estimated by measuring metabolites in the brain, injuries . This information will eventually be
emerging during postmortem decomposition. The used to improve head and body armor and to
samples for histopathological examination if improve combat casualty care. The Virtual
required can be collected more precisely using CT Autopsy can be applied in a broad number of
guided needle biopsy. Postmortem angiography is forensic situations, such as thanatological
23-26
used to visualise the cardiovascular system . investigations; carbonized and putrefied body
identifications; mass disaster cases; age
In 1980, Flodmark et al performed a comparison estimation; anthropological examinations and skin
study of premortem computed tomographic lesion analyses, determining cause of death and
findings and subsequent autopsy results in decedent gender, identification in difficult forensic
27
neonates who suffered perinatal asphyxia . cases, body length and Individual decedent feature
Kalender et al followed in 1990 by developing identification; identifying distinct foreign bodies
acquisition and processing of three-dimensional retained bullets, blades, etc.; identification of
28
digital radiographic imaging data . The 1990's saw injuries and forensic reconstructions three
the inception of large-scale research programs dimensional reconstructions, bullet tract
dedicated to imaging autopsy. The most prominent identification; education and clinical performance
of those programs is the Virtopsy Project at the improvement process; and research from
36
University of Bern, Switzerland. Other programs medical to historical (i.e., mummies, etc) .
29
include those headed by Donchin et al , military-

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 37
Thali et al have shown that virtual autopsy in Imaging autopsies in that study were able to point
gunshot wound victims is useful to localize the to the cause of death in 14 of 15 decedents when
bullet in three dimensions, document the bullet radiographic information was combined with
51
path, visualize fracture patterns associated with premortem clinical and laboratory data . In 2007,
gunshot wounds, and evaluate internal organ Levy et al published a series of postmortem CT
injury prior to autopsy. In 1977, Wullenweber et al examinations of military air mishap victims. In that
reported one of the earliest forensic applications of study, pockets of ectopic air in various anatomic
computed tomography to describe radiographic areas were found in 24% of victims. They also
38
patterns of gunshot injuries to the head . In mass noted that detection of solid organ injury and
39
disaster cases Dirnhofer et al describe for human superficial traumas were significantly worse on CT
identification purposes the use of adapted vehicles than on a traditional autopsy, corroborating the
52
(e.g. Oshkosh Specialty Vehicles, Clearwater, complementary character of IA studies . In
Florida, United States of America) with imaging hanging cases the CT images of the injuries of the
machines allowing for PM data collection on the neck obtained by CT scan clearly showed the
disaster field. The author states that mobile CT ligature mark, the hemorrhagic suffusion in the soft
imaging could provide a high level of positive tissue (thickening of derma) and in the muscles
identifications. In the odontology field (sternocleidomastoid) of the neck. Furthermore,
40
Oesterhelweg et al described a case where the CT 3-dimensional reconstruction showed brain
victim was struck by respiratory obstruction from a edema, fracture of the left posterior horn of the
41-42
foreign body (food bolus). Birngruber et al hyoid bone, and a grade 1 retrolisthesis of C5 on
reported a positive identification case based on the C6. In drowned bodies the CT information about
superimposition of post-mortem CT reconstructed the volume, density, size of the lungs and the
images on ante-mortem radiographies. Dedouit et amount of liquid observed in them is helping in
43 53
al stressed the importance of the presence of diagnosing the cause of death .
dentists in the forensic identification team in
particular to determine the age of charred bodies.
44-47
Other studies also relates the role the forensic
odontologist on age estimations. The data is stored in digital format, so can be
transmitted to any part of the world and easily
transferred to courtrooms and because they offer a
In one study over 40% of postmortem CT studies less gruesome alternative to traditional autopsy
revealed clinically significant findings that were not photographs, less time consuming and body can
identified on traditional autopsy. IA offers excellent be released immediately after the scanning, better
accuracy, including very close estimation of solid acceptance for the relatives of the diseased and
48
organ weights . Imaging autopsies provide also by the religious customs as incisions are not
visualization of soft tissue patterns in cases of used. The disadvantages of this procedure
severe putrefaction. Aghayev et al described the includes: insufficient data base of comparative
use of both MSCT and MRI to document herniation study of virtopsy and conventional autopsy. It is
of cerebellar tonsils prior to traditional autopsy in not possible to distinguish all the pathological
49
patients with blunt head injuries . The same conditions with this technique, cannot give the
group also advocated postmortem imaging as a infection status, difficult to differentiate antemortem
good forensic visualization tool for documentation or the postmortem wounds, difficult to appreciate
and examination of traumatic injuries and other the postmortem artifacts, difficult to appreciate the
50
pathologic findings in a broad range of scenarios . colour changes, small tissue injury may be missed
Oyake et al conducted an IA study to help and in our scenario, it is not possible to provide
determine the etiology of sudden death due to these types of investigations to all the living
non-traumatic causes in infants and children. persons.

JAFMC Bangladesh. Vol 9, No 2 (December) 2013 103

 Conclusion
Virtual autopsy introduces a new era in autopsy 8. Scholing M. , Saltzherr T. P. , Fung Kon Jin P.
examination. It utilizes the technological H. P. , Ponsen K. J. , Reitsma J. B. , Lameris J. S.
innovation of modern imaging system to obtain , Goslings J. C. . The value of postmortem
high quality 3Dimensional images of the body in computed tomography as an alternative for
multiple places without mutilation of the human autopsy in trauma victims: a systematic review
body. It also incorporates other minimally invasive Eur Radiol. 2009 October; 19(10): 233341.
techniques such as image guided biopsy, MR
spectroscopy, postmortem angiography etc. 9. Rodin AE. Oslers autopsies: their nature and
followed by data analysis to give a postmortem utilization. Med Hist 1973;17:37-48.
diagnosis. Due to its minimal invasive procedure,
it is very much acceptable to the society. In USA 10. Hill RB, Anderson RE. The recent history of the
and European countries virtual autopsy is likely to autopsy. ArchPathol Lab Med 1996;120:702-712.
replace conventional autopsies in future. We can
also utilize this modern technology to upgrade the 11. Rutty G. Are autopsies necessary? The role of
century old investigation system in our country. computed tomography as a possible alternative to
invasive autopsies. Rechtsmedizin 2007;17:21-8.

References 12. Saukko P. Medicolegal investigative system

1. Biswas G. Review of Forensic Medicine & and sudden death in Scandinavia. Nihon Hoigaku
Toxicology. 2nd ed. New Delhi :Jaypee : 2012. p Zasshi 1995;49:458-65.
83-5.
13. Lindstrom P, Janzon L, Sternby NH. Declining
2. James JP, Jones R, Karch SB, Manlove J. autopsy rates in Sweden: a study of causes and
Simpsons Forensic Medicine 13th ed.London: consequences in Malmo, Sweden. J Intern Med
Arnold: 2011. p31-4. 1997;242:57-165.

3. Reddy KSN. The Essentials of Forensic 14. Loughrey MB, McCluggage WG, Toner PG.
Medicine & Toxicology. 31st ed. Hyderabad : The declining autopsy rate and clinicians attitudes.
Medical Book Coy :2012. p 1-7. Ulst Med J 2000;69:83-9.

4. Mathiharan K, Patnaik AK. Modi;s Medical 15. Burton EC, Phillips RS, Covinsky KE, Sands
Jurisprudence and Toxicology. 23rd ed. : LP, Goldman L, Dawson NV, Connors AF Jr,
Butterworts :. 2005. p1-8. Landefeld CS. The relation of autopsy rate to
physicians beliefs and recommendations
5. Rao NG. Text book of Forensic Medicine & regarding autopsy. Am Journal Med
Toxicology. 2nd ed. New Delhi :Jaypee: 2010. 2004;117:255-61.
p162-4.
16. Corona T, Rembao D, Sotelo J. Improving the
6. Burton JL. A bite into the history of the autopsy. autopsy rate in a teaching hospital. Arch Pathol
Forensic Science, Medicine, and Pathology Lab Med 2003;127:1408-1409.
2005;1: 277-84.
17. Grossman MD, Stawicki SP. The impact of
7. Pathology. Wikipedia. Available at: human immunodeficiency virus (HIV) on outcome
http://en.wikipedia.org/wiki/ Pathology#_note-0. and practice in trauma: Past, present, future. Injury
Last accessed on June 21, 2013. 2006;37:1117-24.

JAFMC Bangladesh. Vol 9, No 2 (December) 2013 104

 18. Lundberg GD. Medicine without the autopsy. 27. Flodmark O, Becker LE, Harwood-Nash DC,
Arch Pathol Lab Med 1984;108:449-54. Fitzhardinge PM, Fitz CR, Chuang SH. Correlation
between computed tomography and autopsy in
19. OGrady G. Death of the teaching autopsy. BMJ premature and full-term neonates that have
2003;237:802-3. suffered perinatal asphyxia. Radiology.
1980;137:93 -103.
20. Welsh TS, Kaplan J. The role of postmortem
examination in medical education. Mayo Clin Proc 28. Kalender WA, Seissler W, Klotz E, Vock P.
1998;73:802-5. Spiral volumetric CT with single-breath-hold
technique, continuous transport, and continuous
21. Combes A, Mokhtari M, Couvelard A, Trouillet scanner rotation. Radiology 1990;176:181-183.
JL, Baudot J, Hnin D, et al. Clinical and autopsy
diagnoses in the intensive care unit: a prospective 29. Donchin Y, Rivkind AI, Bar-Ziv J, Hiss J, Almog
study. Arch Intern Med. 004;164:389-92. J, Drescher M. Utility of postmortem computed
tomography in trauma victims. J Trauma
22. Ward HE, Clarke BE, Zimmerman PE, Cleary 1994;37:552555.
MI. The decline in hospital autopsy rates in 2001.
MJA 2002;176:91. 30. Levy AD, Abbott RM, Mallak CT, Getz JM,
Harcke HT, Champion HR, Pearse LA. Virtual
23. Thali MJ, Yen K, Vock P, Ozdoba C, Kneubuehl autopsy: preliminary experience in highvelocity
BP, Sonnenschein M & Dirnhofer R. Image-guided gunshot wound victims. Radiology 2006; 240: 522.
virtual autopsy findings of gunshot victims
performed with multi-slice computed tomography 31. Bisset R A, Thomas N B , Turnbull & Lee S.
and magnetic resonance imaging and subsequent Postmortem examinations using magnetic
correlation between radiology and autopsy findings, resonance imaging: Four year review of a working
Forensic Sci Int. 2003 Dec 17;138(1-3):8-16. service. BMJ,2002;324:1423-1424.

24. Thali MJ, Braun M, Buck U, Aghayev E, 32. Thali MJ, Barun M & Dirnhofer R. Optical 3D
Jackowski C, Vock P, Sonnenschein M & Dirnhofer surface digitizing in Forensic Medicine: 3D
R. VIRTOPSY-scientific documentation, reconstion Documentation of skin and bone injuries, Forensic
and animation in forensic: individual and real 3D Sci Innt, 2003,Nov26:137(2-3):203-8.
data based geometric approach including optical
body/object surface and radiological CT/MRI 33. Hayakawa M, Yamamoto S, Motani H, Yajima
scanning, J Forensic Sci. 2005 Mar;50(2):428-42. D, Sato Y, Iwase H. Does imaging technology
overcome problems of conventional postmortem
25. Dirnhofer R, Jackowski C, Vock P, Potter K & examination? A trial of computed tomography
Thali MJ. VIRTOPSY: minimally invasive, imaging for postmortem examination. Int J Legal
imaging-guided virtual autopsy. Radiographics, Med 2006;120:24-26.
2006 Sep-Oct;26 (5):1305-33.
34. Thali MJ, Braun M, Buck U, Aghayev E,
26. Buck U, Naether S, Braun M, Bolliger S, Jackowski C, Vock P, Sonnenschein M, Dirnhofer
Friederich H, Jackowski C, Aghayev E,Christe A, R. Virtopsy - scientific documentation,
Vock P, Dirnhofer R & Thali MJ.Application of 3D reconstruction and animation in forensic: individual
documentation andgeometric reconstruction and real 3Dmdata based geo-metric approach
methods in traffic accident analysis: with high including optical body/object surface and
resolution surface scanning, radiological MSCT / radiological CT/MRI scanning. J Forensic Sci
MRI scanning and real data based animation. 2005;50:428-42.
Forensic Sci Int, 2007 Jul 20;170 (1):20-8.

JAFMC Bangladesh. Vol 9, No 2 (December) 2013 105

 35. Levy AD, Harcke HT, Getz JM, Mallak CT, 45. Bassed RB, Hill AJ. The use of computed
Caruso JL, Pearse L, Frazier AA, Galvin JR. tomography (CT) to estimate age in the 2009
Virtual autopsy: Two- and three-dimensional Victorian Bushfire Victims: a case report. Forensic
multidetector CT findings in drowning with autopsy SciInt 2011;205:48-51.
comparison. Radiology 2007;243:862-8.
46. . Odonell C, Lino M, Mansharan K, Leditscke
J, Woodford N. Contribution of post mortem
36. Paperno S, Riepert T, Grug B, Rotschild MA,
multidetector CT scanning to the identification of
Schultes A, Staak M, Lackner L. Value of the deceased in a mass disaster: experience
postmortem computed tomography in comparison gained from the 2009 Victorian bushfires. Forensic
to autopsy. Rofo 2005;177:130-6. Sci Int 2011;205:15-28.

37. Thali MJ, Yen K, Plattner T, Schweitzer W, 47. Cordner SM, Woodford N, Bassed R. Forensic
Vock P, Ozdoba C, Dirnhofer R. Charred body: aspects of the 2009 Victorian Bushfires Disaster.
virtual autopsy with multi-slice computed Forensic Sci Int 2011;205:2-7.
tomography and magnetic resonance imaging. J
Forensic Sci 2002;47:1326-1331. 48. Jackowski C, Thali MJ, Buck U, Aghayev E,
Sonnenschein M, Yen K, Dirnhofer R, Vock P.
Noninvasive estimation of organ weights by
38. Wullenweber R, Schenider V, Grumme T. A
postmortem magnetic resonance imaging and
computertomographical examination of cranial
multislice computed tomography. Invest Radiol
bullet wounds. Z Rechtsmed 1977;80:227-46. 2006;41:572-8.

39. Dirnhofer R, Jackowski C, Vock P, Potter K, 49. Aghayev E, Yen K, Sonnenschein M, Ozdoba
Thali MJ. Virtopsy minimally invasive, imaging C, Thali M, Jackowski C, Dirnhofer R. Virtopsy
guided virtual autopsy. Radio Graphics post-mortem multi-slice computed tomography
2006;26:1305-33. (MSCT) and magnetic resonance imaging (MRI)
demonstrating descending tonsillar herniation:
40. Oesterhelweg L, Bolliger SA, Thali MJ, Ross comparison to clinical studies. Neuroradiology
S. Postmortem imaging of laryngeal foreign 2004;46:55964.
bodies. Arch Pathol Lab Med 2010;133:806-10.
50. Aghayev E, Thali MJ, Jackowski C,
Sonnenschein M, Dirnhofer R, Yen K. MRI detects
41. Levy AD, Abbott RM, Mallak CT, Getz JM,
hemorrhages in the muscles of the back in
Harcke HT, Champion HR, Pearse LA. hypothermia. Forensic Sci Int 2008;176:183-6.
Virtualautopsy Preliminary experience in
high-velocity gunshot wound victims. Radiology 51. Oyake Y, Aoki T, Shiotani S, Kohno M, Ohashi
2006;240:522-8. N, Akutsu H, Yamazaki K. Postmortem computed
tomography for detecting causes of sudden death
42. Birngruber CG, Obert M, Ramsthaler F, Kreutz in infants and children: retrospective review of
K, Verhoff MA. Comparative dental radiographic cases. Radiat Med 2006;24:493-502.
identification using flat panel CT. Forensic Sci Int
2011;209:31-4. 52. Levy G, Goldstein L, Blachar A, Apter S,
Barenboim E, Bar-Dayan Y, Shamis A, Atar E.
Postmortem computed tomography in victims of
43. 43. Dedouit F, Telmon N, Costaglioga R, Otal
military air mishaps: radiological-pathological
P, Joffre F, Roug D. Virtual anthropology and
correlation of CT findings. Isr Med Assoc J
forensic identification: Report of one case. 2007;9:699-702.
Forensic Sci Int 2007;173:182-7.
53. Polacco M, , Pasquale DA, Francesco, Bruno
44. Dedouit F, Telmon N, Guilbeau-Frugier C, Z, et al. Virtual Autopsy in Hanging. American
Gainza D, Otal P, Joffre F, Roug D. Virtual Journal of Forensic Medicine & Pathology: June
autopsy and forensic identification practical 2013 :34 ( 2 ). 1079.
application: are port of one case. J Forensic Sci
2007;52:960-4.

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