Assessment of maxillary sinus fluid volume for postmortem diagnosis of drowning

INTRODUCTION

Drowning is a comprehensive and exclusive diagnosis at autopsy. Autopsy findings such as pleural effusion and waterlogged lungs contribute to the diagnosis. Herein, we aim to reveal the practical usefulness and postmortem changes of the maxillary sinus fluid volume to diagnose drowning.

METHODS

We evaluated 52 drowning and 59 nondrowning cases. The maxillary sinus fluid volume was measured using a computed tomography (CT) scan, and pleural effusion volume and lung weight were manually measured at autopsy. The utility of these three indices for diagnosing drowning and its postmortem changes was evaluated.

RESULTS

The maxillary sinus fluid volume was significantly higher in drowning cases than in other external causes and cardiovascular death cases. Receiver operating characteristic curve analysis revealed that a total maxillary sinus fluid volume >1.04 mL more usefully indicated drowning (odds ratio, 8.19) than a total pleural effusion volume >175 mL (odds ratio, 7.23) and a total lung weight >829 g (odds ratio, 2.29). The combination of maxillary sinus fluid volume and pleural effusion volume more effectively predicted drowning than one index alone. Moreover, the maxillary sinus fluid volume was less influenced by the postmortem interval than the other two indices up to a week after death.

CONCLUSION

Maxillary sinus fluid volume can be more useful than pleural effusion volume and lung weight with higher sensitivity and odds ratio for diagnosing drowning.

IMPLICATIONS FOR PRACTICE

Fluid accumulation in both the maxillary sinuses strongly predicts drowning in the postmortem imaging.

The significance of evaluating sphenoid sinus fluid by postmortem computed tomography in cases of drowning

PURPOSE

In cases of drowning, the presence of sphenoid sinus fluid is a non-specific autopsy finding. However, studies have reported that fluid accumulation in the paranasal sinuses is more commonly observed in drowning victims. Furthermore, some laboratory tests, such as diatom and electrolyte analysis, can serve as supplementary diagnostic tools for diagnosing drowning. Therefore, accurate sphenoid sinus fluid sampling is an important aspect of an autopsy in suspected drowning cases. The aim of this study was to identify the significance of evaluating sphenoid sinus fluid by PMCT images in cases of drowning.

METHODS

We retrospectively reviewed 54 drowning victims who underwent PMCT and forensic autopsy. Fluid volume in the sphenoid sinus was measured using a graduated syringe during autopsy and a three-dimensional (3D) workstation based on PMCT images was used for the purpose of comparison. The Mann-Whitney U test and Spearman's rank correlation coefficient was used to evaluate statistically significant differences and correlations. Additionally, a Bland-Altman plot was employed to assess the agreement between PMCT and autopsy.

RESULTS

The median volume was 1.65 (range 0.00-12.4) ml and 1.55 (range 0.00-7.00) ml in the PMCT and autopsy, respectively, showing a statistically insignificant difference (p = 0.294) and a significant correlation (Rs = 0.896). In 35 cases, the PMCT overestimated the fluid volume more than the autopsy, whereas in 14 cases, the PMCT underestimated the fluid volume. No fluid was identified in seven cases during the autopsy, whereas in five patients, no fluid was found in both PMCT and autopsy. By analyzing the Bland-Altman plot, a bias of 0.73 ± 1.4 ml and limits of agreement ranging from -2.04 to 3.51 ml were observed for sphenoid sinus fluid volume measurements.

CONCLUSIONS

Based on the limitations of traditional fluid volume measurement in the sphenoid sinus during autopsy, we propose the utilization of PMCT volumetric analysis prior to autopsy as a means to enhance the detection of sphenoid sinus fluid in cases of drowning.

A 2.5D Deep Learning-Based Method for Drowning Diagnosis Using Post-Mortem Computed Tomography

It is challenging to diagnose drowning in autopsy even with the help of post-mortem multi-slice computed tomography (MSCT) due to the complex pathophysiology and the shortage of forensic specialists equipped with radiology knowledge. Therefore, a computer-aided diagnosis (CAD) system was developed to help with diagnosis. Most deep learning-based CAD systems only utilize 2D information, which is proper for 2D data such as chest X-ray images. However, 3D information should also be considered for 3D data like CT. Conventional 3D methods require a huge amount of data and computational cost when using 3D methods. In this article, we proposed a 2.5D method that converts 3D data into 2D images to train 2D deep learning models for drowning diagnosis. The key point of this 2.5D method is that it uses a subset to represent the whole case, covering this case as much as possible while avoiding other repetitive information. To evaluate the effectiveness of the proposed method, conventional 2D, previous 2.5D, and 3D deep learning-based methods were tested using an MSCT dataset obtained from Tohoku university. Then, to provide explainable diagnosis results, a visualization method called Gradient-weighted Class Activation Mapping was employed to visualize features relevant to drowning in CT images. Results on drowning diagnosis showed that our proposed method achieved the best performance compared to other 2D, 2.5D, and 3D methods. The visual assessment also demonstrated that our method could find the saliency regions corresponding to drowning.

Virtual Autopsy Morphological Features of Drowning

OBJECTIVES

To explore the application value of virtual autopsy to obtain key evidence information on drowned corpses and its application value of virtual autopsy in the diagnosis of drowning.

METHODS

In this study, 7 corpses were selected as the research objects. The image data of corpses were collected by computed tomography (CT) before conventional autopsy. The characteristics of corpses were observed through image reading, combined with virtual measurement indexes, and compared with 15 non-drowned corpses.

RESULTS

The postmortem CT of drowning showed the more fluid in respiratory tract than the non-drowning, and ground-glass opacities in the lung. The statistical volume of fluid in the sinus (maxillary sinus and sphenoid sinus) was (10.24±4.70) mL in drowning cases and (2.02±2.45) mL in non-drowning cases. The average CT value of fluid in the sinus, left atrial blood and gastric contents in drowning cases were (15.91±17.20), (52.57±9.24) and (10.33±12.81) HU, respectively, which were lower than those in non-drowning cases (P<0.05).

CONCLUSIONS

The comprehensive consideration of multiple characteristic image manifestations and the virtual measurement indexes are helpful to the forensic pathological diagnosis of drowning. Virtual autopsy can be used as an auxiliary method in the forensic diagnosis of drowning.

Radiographic changes in endodontically treated teeth submitted to drowning and burial simulations: is it a useful tool in forensic investigation?

Dental radiographs, endodontic treatment and materials are a source of useful forensic data. The response of dental materials to death-related events are widely studied and provide forensic evidence for experts. This study aimed to analyze the radiographic images of endodontically treated teeth submitted to burial and drowning simulation, verifying its forensic feasibility, applicability and usefulness.

MATERIAL AND METHOD

n=20 bovine incisor teeth were endodontically treated then divided into two groups: burial and drowning scenarios. Teeth were radiographed two times (before and after scenario) with an aluminium stepwedge, and optical density (OD) was assessed in each root third, in both radiographs, and then compared (ANOVA and Tukey test) for each scenario.

RESULTS

Burial scenario did not significantly alter radiopacity. As for the drowning scenario, there was no difference in radiopacity between the root thirds before the test. After drowning, the apical third demonstrated lower OD (p<.05) than the other two thirds. Comparing the OD before and after drowning, medium third presented lower and cervical third demonstrated higher means (p<.05) after drowning.

CONCLUSION

We concluded that drowning conditions could alter the radiopacity of endodontically treated teeth, more specifically in the medium and cervical thirds. There is no evidence that this also occurs in burial situations. This has the potential to be useful in forensic casework as an initial sign of the type of ambient in which the body was supposedly exposed or set.

Diagnosis of drowning using postmortem computed tomography combined with endoscopic autopsy: A case report

RATIONALE

Postmortem forensic imaging technologies provide a noninvasive/minimally invasive approach for imaging of internal organ structures of the human body to detect injuries, diseases, and other morphologic changes. Currently, postmortem forensic imaging methods have been widely used in determination of the cause of death. However, these methods do not allow histologic examinations. Endoscopic autopsy emerged in the 1990s. Thoracoscopy and laparoscopy are mainly used to examine organs and tissues in the thoracic and abdominal cavity. Target tissues are also sampled for histologic examination. By combining postmortem forensic imaging with endoscopic autopsy, comprehensive examination of the corpse, organs, and sampling for histologic examination can be carried out.

PATIENT CONCERNS

A 34-year-old woman was witnessed jumping into the river, sinking after struggling in the water. The body was found 24 hours later and confirmed with no vital signs. No preexisting medical conditions were known.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

Postmortem computed tomography, target coronary postmortem computed tomography angiography, and endoscopic autopsy were performed before conventional autopsy. Laparoscopic examination was used to examine the abdominal organs. The diaphragm and pericardium were cut open from the abdominal cavity to allow access to the examination of lungs and heart. Tissue samples were collected from various organs for histologic examination, and a diatom test was carried out on lung samples. Postmortem computed tomography revealed fluid in the paranasal sinuses, airways, stomach, and duodenum; emphysema aquosum; and mosaic pattern of the lung parenchyma. Endoscopic examination additionally detected Paltauf spots. The results were consistent with those of conventional autopsy. Histologic examination revealed pulmonary congestion, pulmonary edema, pulmonary emphysema, pulmonary hemorrhage, and congestion in multiple organs such as the liver, spleen, and kidneys. Diatoms were detected in lung tissues, which were identical in morphology to diatoms in water samples collected from the scene. The cause of death was determined as drowning.

CONCLUSION

Combining forensic imaging and endoscopic autopsy for postmortem examination yields a more comprehensive and scientific finding, and the combination is minimally invasive and more acceptable to the family members. This method can be used as an alternative for conventional autopsy under specific circumstances.

White Matter Tract Pathology in Pediatric Anoxic Brain Injury from Drowning

BACKGROUND AND PURPOSE

Although drowning is a leading cause of mortality and morbidity in young children, the neuropathologic consequences have not been fully determined. The purpose of this article was to quantitatively characterize white matter microstructural abnormalities in pediatric anoxic brain injury from nonfatal drowning and investigate the correlation with motor function.

MATERIALS AND METHODS

Whole-brain T1-weighted and diffusion-weighted MR imaging datasets were acquired in 11 children with chronic anoxic brain injury and 11 age- and sex-matched neurotypical controls (4-12 years of age). A systematic evaluation form and scoring system were created to assess motor function. Tract-Based Spatial Statistics was used to quantify between-group alterations in the diffusion tensor imaging indices of fractional anisotropy and mean diffusivity and to correlate with per-subject functional motor scores.

RESULTS

Group-wise Tract-Based Spatial Statistics analyses demonstrated reduced fractional anisotropy in the bilateral posterior limbs of the internal capsule and the splenium of the corpus callosum (P < .001). Mean diffusivity was more diffusely increased, affecting the bilateral superior corona radiata, anterior and posterior limbs of the internal capsule, and external capsules (P < .001). Individual-subject fractional anisotropy and mean diffusivity values derived from the ROIs of the bilateral posterior limbs of the internal capsule strongly correlated with motor scores and demonstrated more potent between-group effects than with ROIs of the entire corticospinal tract.

CONCLUSIONS

These data particularly implicate the deep white matter, predominantly the posterior limbs of the internal capsule, as targets of damage in pediatric anoxic brain injury with drowning. The substantial involvement of motor-system tracts with relative sparing elsewhere is notable. These results localize white matter pathology and inform future diagnostic and prognostic markers.

[Cardiac dysfunction secondary to an adrenergic storm or cardiomyopathy of stress among child victims of traumatism]

OBJECTIVE

To provide information specific to a catecholaminergic storm during a violent stress in children.

PATIENTS AND METHODS

Two clinical observations in children who suffered violent trauma.

FIRST CASE

a boy aged 12 years victim of a drowning in Stage 3 admitted to the pediatric intensive care 02.08.2015. He was intubated, ventilated, sedated with benzodiazepines and morphine. Cardiac exploration revealed a global hypokinesis with septal dyskinesia, a 45% FES offset a slight excess of ST, a troponin I to 31.46pg/mL NT-proBNB to 1291pg/mL. Dobutamine was set initially at 7 then 10 gamma/kg/min. The outcome was favorable on the heart level with improved SEF in 1 week.

SECOND CASE

13-year-old girl, victim of complete hanging, admitted on 06/08/2015 for a post-anoxic encephalopathy. Intubated, ventilated and sedated with morphine and benzodiazepines. Cardiac exploration showed septal hypokinesia with a 35% FES, a lengthening of the QT interval on the ECG, a troponin I in ultra 1.27μg/L, NT-proBNB to 215pg/mL. The child was put up 15 gamma dobutamine/kg/min. The evolution was marked by improved heart function without disturbance wall motion after 7 days.

CONCLUSION

Our 2 clinical cases following accidental trauma violating represent observations of a picture simulating a syndrome of Tako-Tsubo without anginal pain objectified as our 2 patients were sedated and ultrasound abnormalities returned to normal in less than a week.

Freshwater drowning in a child: A case study demonstrating the role of post-mortem computed tomography

In recent years, modern imaging techniques have gained ground in forensics. A crucial question is whether virtual autopsy is capable of replacing traditional autopsy. Forensic diagnosis of freshwater drowning (FWD) is based on the evidence of findings from external inspection (e.g. frothy fluid exuding from the mouth and nostrils), internal examination (e.g. pulmonary congestion, enlargement of heart chambers) and biochemical analysis (haemodilution), findings which are non-specific. The detection of diatoms in organs of the systemic circulation may be of some assistance, but this analysis is rarely performed and is of debatable validity. An 18-month-old child was found dead at home in a swimming pool. Considering the family's wishes to avoid autopsy, the district attorney authorised a whole-body post-mortem computed tomography scan (PMCT). The main imaging findings were frothy fluid in the upper airways, fluid in the trachea and main bronchi, many pulmonary nodular ground glass opacities (GGO) in non-dependent regions and haemodilution. CT imaging did not show any other forensically relevant abnormality.A high concordance was found between the CT findings reported in the literature in cases of FWD and the imaging results. Thus, after the exclusion of other causes of death, advised by the forensic pathologist, the district attorney closed the case and the death was attributed to FWD. This case report demonstrates that PMCT imaging in cases of suspected FWD can provide some important findings for the diagnosis of FWD as the cause of death.

Diving fatality investigations: recent changes

Modifications to the investigation procedures in diving fatalities have been incorporated into the data acquisition by diving accident investigators. The most germane proposal for investigators assessing diving fatalities is to delay the drawing of conclusions until all relevant diving information is known. This includes: the accumulation and integration of the pathological data; the access to dive computer information; re-enactments of diving incidents; post-mortem CT scans and the interpretation of intravascular and tissue gas detected. These are all discussed, with reference to the established literature and recent publications.

[Postmortem CT examination in a case of alleged drowning--a case report]

The authors present an analysis of postmortem CT examination in a case of drowning in fresh water of a young male. Both the results of conventional forensic autopsy and radiologic examination have been compared. The analysis is illustrated by two-dimensional and three-dimensional reconstructions based on the DICOM files obtained during postmortem CT examination.

Virtual Autopsy: Two- and Three-dimensional Multidetector CT Findings in Drowning with Autopsy Comparison1

PURPOSE

To retrospectively determine the multidetector computed tomographic (CT) virtual autopsy findings of death by drowning in comparison with autopsy findings.

MATERIALS AND METHODS

The institutional review board of the Armed Forces Institute of Pathology approved this HIPAA-compliant study and did not require informed consent by the next of kin. Total-body multidetector CT was performed, immediately prior to routine autopsy, in 28 consecutive male subjects (mean age, 24.2 years) who died of drowning and a control group of 12 consecutive male subjects (mean age, 50.8 years) who died of sudden death from atherosclerotic coronary artery disease. Images were evaluated for the presence of fluid and sediment in the paranasal sinuses and airways, mastoid air cell fluid, frothy fluid in the airways, pulmonary opacity (ground-glass opacity or airspace consolidation), interlobular septal thickening, and gastric distention and contents (fluid or sediment). Image findings were compared with findings from autopsy reports and photographs.

RESULTS

All drowning subjects had fluid in the paranasal sinuses and mastoid air cells and had ground-glass opacity within the lungs. Twenty-six subjects (93%) had fluid in the subglottic trachea and main bronchi. Fourteen subjects (50%) had high-attenuation sediment in the subglottic airways. Frothy fluid in the airways was present in six subjects (21%). Twenty-five (89%) of the drowning subjects had pulmonary ground-glass opacity with septal lines, which was mild with apical and perihilar distribution in 12 subjects, severe and diffuse in nine, posterior and basilar in three, and limited to the apices in one (not assessed in three of 28 subjects because of decomposition). Control subjects showed mastoid cell fluid (25%), sinus fluid (83%), subglottic airway fluid (92%), and pulmonary ground-glass opacity (100%) but did not have evidence of frothy airway fluid or high-attenuation sediment in the airways.

CONCLUSION

The multidetector CT finding of frothy airway fluid or high-attenuation airway sediment is highly suggestive of drowning; multidetector CT findings of pan sinus fluid, mastoid cell fluid, subglottic tracheal and bronchial fluid, and ground-glass opacity within the lung at multidetector CT are supportive of drowning in the appropriate scenario.

[The thorax of patients in diving accidents. Radiologic study]

On the basis of a series including 185 files on diving accidents gathered between 1981 and 1988, the authors carry out a radiological study of the thoracic signs observed after drowning and lung overpressure. The typical radiological form and the various clinical forms of drowning and lung overpressure are described in this article. Emergency plain thoracic radiography in bed in the method of choice. However, the existence of many false-negative findings leads to proposing a study with computed tomography (CT) after initial treatment in order to better assess the lesions and to characterize the accident. The utility of radiology is also demonstrated for the follow-up of evolution. Lastly, the authors lay stress on the necessity to prevent such accidents, to which radiologists can contribute by detecting thoracic lesions (dystrophy and other evolutive lesions) for which diving is contraindicated.

Local cerebral blood flow as assessed by xenon stable computed tomography in child drowning

A comatose patient who nearly drowned was studied with xenon stable computed tomography (CT) to assess regional cerebral blood flow (rCBF) after a basic CT studied revealed bilateral lucencies in the basal ganglia. Xenon stable CT revealed increased rCBF in the lucent areas of the basal ganglia and previously unsuspected absence of flow in the posterior circulation. Xenon stable CT may be a more sensitive indicator of ischemic cerebral damage than basic CT.

Use of postmortem radiographs for the investigation of underwater and hyperbaric deaths

The use of postmortem radiographs as a useful adjunct in the investigation of hyperbaric and immersion deaths is discussed. This technique enables accurate identification of gas within cavities that otherwise could not be detected at routine autopsy, which may also be artifact. In addition it is possible to define bone lesions that need a histologic diagnosis.

Chest radiographs of near-drowned children

From 1972 through 1983 there were 10 near-drowned children (7 boys and 3 girls) aged 1 to 4 years, treated as inpatients at the Children's Hospital of the Medical Academy Dresden. Three of them showed a severe aspiration pneumonia which in one case was complicated by bilateral pneumothoraces. In a further five children there were radiological signs of pulmonary oedema. Only in two children were the X-ray pictures of the chest normal.

Cerebral computed tomography in drowning victims

Computed tomography in two patients who had drowned revealed bilateral basal ganglia and medial temporal lobe low densities. Postmortem examination in one case showed these areas to be necrotic, probably secondary to the hypoxia and hypotension associated with drowning.

An unusual cycling injury

Images

Sand aspiration in drowning and near drowning

Aspiration of sand and other foreign material is often discovered at autopsy in victims of drowning, but is not commonly seen radiographically. Two such cases are described, one of drowning and one of near drowning. In each case, the sand was radiopaque because of its calcium carbonate content and created a "sand bronchogram", i.e., sand in the tracheobronchial tree. With early recognition, successful bronchoscopic removal of the aspirated sand is possible.