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Pitfalls in post-mortem CT-angiography – intravascular contrast induces post-mortem pericardial effusion
Legal Medicine 15 (2013) 315–317
Contents lists available at SciVerse ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
Pitfalls in post-mortem CT-angiography – intravascular contrast induces post-mortem pericardial effusion Nicole Berger a,b,⇑, Rosita Martinez a, Sebastian Winklhofer a,b, Patricia M. Flach a,b, Steffen Ross a, Garyfalia Ampanozi a, Dominic Gascho a, Michael J. Thali a, Thomas D. Ruder a,c a b c
Department of Forensic Medicine and Radiology, Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, CH-8057 Zurich, Switzerland Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Freiburgstrasse, CH 3010 Bern, Switzerland
a r t i c l e
i n f o
Article history: Received 5 April 2013 Received in revised form 24 May 2013 Accepted 1 July 2013 Available online 3 August 2013 Keywords: Forensic radiology Post-mortem computed tomography angiography Artifact Vascular injury Virtopsy
a b s t r a c t We present a case where multi-phase post-mortem computed tomography angiography (PMCTA) induced a hemorrhagic pericardial effusion during the venous phase of angiography. Post-mortem non-contrast CT (PMCT) suggested the presence of a ruptured aortic dissection. This diagnosis was confirmed by PMCTA after pressure controlled arterial injection of contrast. During the second phase of multi-phase PMCTA the presence of contrast leakage from the inferior cava vein into the pericardial sac was noted. Autopsy confirmed the post-mortem nature of this vascular tear. This case teaches us an important lesson: it underlines the necessity to critically analyze PMCT and PMCTA images in order to distinguish between artifacts, true pathologies and iatrogenic findings. In cases with ambiguous findings such as the case reported here, correlation of imaging findings with autopsy is elementary. Ó 2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Post-mortem computed tomography (PMCT) is widely used in forensic death investigations [1]. Aortic dissection (AD) may occasionally be detected on non-contrast computed tomography (CT). The presence of inwardly displaced intimal calcifications or intimal flaps is a strong indicator of the presence of (AD) [2]. The Stanford classification divides AD into two types, depending on the origin of the dissection. Type A dissections originate in the ascending aorta and are often associated with the presence of pericardial tamponade [3]. Type B dissections affect the descending aorta only and are often associated with malperfusion of the abdominal organs [4]. In living patients, diagnostic imaging is performed by CT angiography (CTA) [5]. In the post-mortem setting, non-contrast PMCT may be complemented with PMCT-angiography (PMCTA) to visualize vascular pathology [6]. Currently, there are several different methods in use to achieve post-mortem angiography [7–11]. The approach proposed by the Technical Working Group Postmortem Angiography Methods (TWGPAM) is one of the most widely used [10].
⇑ Corresponding author at: Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland. Tel.: +41 44 255 1111; fax: +41 44 255 4443. E-mail address: [email protected] (N. Berger). 1344-6223/$ - see front matter Ó 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.legalmed.2013.07.001
One key question regarding PMCTA is if the post-mortem injection of intravascular contrast may affect forensically relevant findings (such as dislodge a fresh thrombus or induce iatrogenic vascular injury). Here we present a case where multi-phase PMCTA induced a hemorrhagic pericardial effusion during the venous phase of CT-angiography. 2. Case history A 45 year old female (160 cm, 54 kg, BMI 21.1 kg/m2) collapsed after having complained from recurring back pain over two days. Cardiopulmonary resuscitation (CPR) was immediately initiated by her boyfriend who was later relieved by paramedics but the patient died on the scene. The medical history revealed that the woman had been a smoker and that her mother had died from sudden cardiac death at a young age. 2.1. Imaging and autopsy PMCT and PMCTA were performed using a dual-source CT scanner (Flash Definition, Siemens, Forchheim, Germany). Scan parameters were as follows: tube voltage 120 kVp; automatic dose modulation software (CARE dose 4D, Siemens, Forchheim, Germany); slice thickness 1.0 mm; increments 0.5 mm. PMCTA was adapted from techniques described by Ross et al. [7] and
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N. Berger et al. / Legal Medicine 15 (2013) 315–317
Grabherr et al. [10] by cannulation of the femoral vessels. A solution of 3 L of polyethylene glycol (PEG 200; Schaerer and Schlaepfer, Rothrist Switzerland) and Iopentol (Imagopaque 300; Amersham Health, Wädenswil, Switzerland), mixed at a ratio of 15:1 was injected using a pressure-controlled pump (VirtangioÒ, Fumedica AG, Muri, Switzerland) and filled with a maximal injection pressure of 60 mmHg. First the arterial phase was scanned with the contrast media filling the femoral artery to the aorta into
the left ventricle. The following venous phase started as well from the femoral vessels to the inferior cava vein, the right atrium to the right ventricle and the right and left pulmonary artery. PMCT and PMCTA were read and reported by two radiologists (with 1 and 6 years of experience in post-mortem imaging). Autopsy was performed by two forensic pathologists (with 4 and 17 years of experience). The time interval between death and autopsy was approximately 24 h.
2.2. Findings External inspection of the decedent revealed several findings related to extensive CPR attempts, including a number of small hematomas on the chest wall and puncture marks on the forearms and wrists. There was very little external lividity on the skin. Non-contrast PMCT revealed bilateral large collections of nonserous pleural fluid collections, consistent with bilateral hematothorax; a crescent shaped, collapsed ascending aorta (see Fig. 1a). In addition, there were several findings related to CPR, including a sternal fracture, bilateral serial rib fractures and a small left sided pneumothorax. PMCTA after arterial contrast injection revealed a dissection of the descending aorta from the left subclavian artery to the left exterior iliac artery and the right common iliac artery. There was extravasation of contrast media into the right pleural cavity (see Fig. 1b). Upon venous contrast injection, PMCTA revealed a previously non-existent, significant leakage of contrast medium from the inferior cava vein into the pericardium (see Fig. 1c). At autopsy, the aortic dissection, the pericardial effusion, the rupture of the inferior cava vein as well as the sternal and rib fractures were confirmed. A close inspection of the cava vein revealed that there were no signs to suggest an intra-vital injury at the site of the vascular rupture (see Fig. 2).
Fig. 1. (a) Non-contrast post-mortem computed tomography (PMCT) of the chest with collapsed and crescent shaped ascending aorta (arrow) and bilateral haematothoraces (asterisk); (b) arterial phase PMCT-angiography reveals a dissection membrane of the descending aorta (arrow) and extravasation of the contrast media in the right pleural cavity (asterisk); (c) venous phase PMCT-angiography reveals a post-mortem rupture of the inferior vena cava with extensive leakage of contrast media into the pericardial sac (arrow).
Fig. 2. Macroscopic autopsy specimen: laceration of the inferior vena cava at the point where it leads into the right atrium (arrow).
N. Berger et al. / Legal Medicine 15 (2013) 315–317
3. Discussion We report a case of aortic Type B dissection where multiphase PMCTA induced a rupture of the inferior cava vein with leakage of contrast medium into the pericardial sac. In this case the presence of aortic dissection was confirmed after arterial injection of contrast medium on PMCTA. Upon venous injection of contrast medium we noted a significant leakage of contrast medium from the inferior cava vein into the pericardial sac. This vascular rupture was confirmed at autopsy and both macroscopic and microscopic findings indicated that the vascular injury had occurred post-mortem due to absent intraparenchymal hemorrhage at the site of the laceration. This is an important finding, as the effect of intravascular contrast injection for PMCTA on forensically relevant findings is one of the key questions regarding the scope of applications of PMCTA. In this case we used a pressure controlled pump to inject the contrast medium and worked with a protocol adapted from Grabherr et al. [10] and Ross et al. [7]. The intention of pressure controlled injection with a maximum of 60 mmHg is to limit the intravascular pressure to avoid iatrogenic vascular rupture. In our experience of approximately 150 cases we have never observed a similar case. This subjective experience is supported by a recently published study on PMCTA related artifacts [12]. A thorough literature search yielded no other reports of venous rupture from postmortem instillation of contrast media. Frequent artifacts include incomplete vascular filling or layering of contrast medium and blood as well as intraluminal leakage of contrast into the gastrointestinal tract [12]. According to a scientific lecture on complications of PMCTA (presented at the second congress of the International Society of Forensic Radiology and Imaging), complications occur in up to 39% of post-mortem angiographies. However, vascular rupture from excessive pressure was present in only 2% of all cases, and was limited to arterial vessels [13].Nevertheless; it may be worth reevaluating the injection pressures used for venous injections to avoid iatrogenic vascular injury in the future. Previous reports on CPR-related changes on PMCT describe the frequent presence of intravascular or intraventricular gas [14]. The occurrence of myocardial injury as a result of CPR is only rarely observed [15]. However, significant pressure on the sternum may compress and cause the heart to burst [16]. In view of the case history, the findings on post-mortem imaging and autopsy and the current literature we assume that fierce CPR attempts induced a peri-/postmortem injury of the inferior cava vein at the level of the right atrium. The injection of contrast medium into the venous side of the vascular system caused a
317
complete tear at this level and resulted in an iatrogenic pericardial effusion. This underlines the necessity to critically analyze PMCT and PMCTA images in order to distinguish between artifacts, true pathologies and iatrogenic findings. In cases with ambiguous findings such as the case reported here, correlation of imaging findings with autopsy is elementary. References [1] Baglivo M, Winklhofer S, Hatch GM, Ampanozi G, Thali MJ, Ruder TD. The rise of forensic and post-mrtem radiology - analysis of the literature between the years 2000 and 2011. Forensic Radiol Imaging 2013;1:3–9. [2] Castaner E, Andreu M, Gallardo X, Mata JM, Cabezuelo MA, Pallardo Y. CT in nontraumatic acute thoracic aortic disease: typical and atypical features and complications. Radiographics. Oct 2003;23 Spec No:S93–110. [3] Lin PH, Huynh TT, Kougias P, Huh J, LeMaire SA, Coselli JS. Descending thoracic aortic dissection: evaluation and management in the era of endovascular technology. Vasc Endovasc Surg 2009;43(1):5–24. [4] Tran TP, Khoynezhad A. Current management of type B aortic dissection. Vasc Health Risk Manag 2009;5(1):53–63. [5] Vedantham S GJ. Case review vascular and interventional imaging. 2004 (1st ed. Philadelphia Mosby). [6] Ross SG, Thali MJ, Bolliger S, Germerott T, Ruder TD, Flach PM. Sudden death after chest pain: feasibility of virtual autopsy with postmortem CT angiography and biopsy. Radiology 2012;264(1):250–9. [7] Ross S, Spendlove D, Bolliger S, et al. Postmortem whole-body CT angiography: evaluation of two contrast media solutions. AJR Am J Roentgenol 2008;190(5):1380–9. [8] Jolibert M, Cohen F, Bartoli C, et al. Postmortem CT-angiography: feasibility of US-guided vascular access. J Radiol 2011;92(5):446–9. [9] Saunders SL, Morgan B, Raj V, Robinson CE, Rutty GN. Targeted post-mortem computed tomography cardiac angiography: proof of concept. Int J Legal Med 2011;125(4):609–16. [10] Grabherr S, Doenz F, Steger B, et al. Multi-phase post-mortem CT angiography: development of a standardized protocol. Int J Legal Med 2011;125(6):791–802. [11] Okuda T, Shiotani S, Sakamoto N, Kobayashi T. Background and current status of postmortem imaging in Japan: short history of ‘‘Autopsy imaging (Ai)’’. Forensic Sci Int 2013;225(1–3):3–8. [12] Bruguier C, Mosimann PJ, Vaucher N. Multi-phase postmortem angiography recognizing technique-related artefacts and pitfalls. Int J Legal Med 2013. [13] O’Donnell C. When it goes wrong: complications of post-mortem CT angiography (PMCTA) as performed at VIFM. J Forensic Radiol Imaging 2013;2:84–5. [14] Okuda T, Shiotani S, Kobayashi T, et al. Immediate non-traumatic postmortem computed tomographic demonstration of myocardial intravascular gas of the left ventricle: effects from cardiopulmonary resuscitation. SpringerPlus 2013;2(1):86. [15] Reardon MJ, Gross DM, Vallone AM, Weiland AP, Walker WE. Atrial rupture in a child from cardiac massage by his parent. Ann Thorac Surg 1987;43(5):557–8. [16] Ebert LC, Schon CA, Ruder TD, Thali MJ, Hatch GM. Fatal left ventricular rupture and pericardial tamponade following a horse kick to the chest. Am J Forensic Med Pathol 2012;33(2):167–9.
Contents lists available at SciVerse ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
Pitfalls in post-mortem CT-angiography – intravascular contrast induces post-mortem pericardial effusion Nicole Berger a,b,⇑, Rosita Martinez a, Sebastian Winklhofer a,b, Patricia M. Flach a,b, Steffen Ross a, Garyfalia Ampanozi a, Dominic Gascho a, Michael J. Thali a, Thomas D. Ruder a,c a b c
Department of Forensic Medicine and Radiology, Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, CH-8057 Zurich, Switzerland Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Freiburgstrasse, CH 3010 Bern, Switzerland
a r t i c l e
i n f o
Article history: Received 5 April 2013 Received in revised form 24 May 2013 Accepted 1 July 2013 Available online 3 August 2013 Keywords: Forensic radiology Post-mortem computed tomography angiography Artifact Vascular injury Virtopsy
a b s t r a c t We present a case where multi-phase post-mortem computed tomography angiography (PMCTA) induced a hemorrhagic pericardial effusion during the venous phase of angiography. Post-mortem non-contrast CT (PMCT) suggested the presence of a ruptured aortic dissection. This diagnosis was confirmed by PMCTA after pressure controlled arterial injection of contrast. During the second phase of multi-phase PMCTA the presence of contrast leakage from the inferior cava vein into the pericardial sac was noted. Autopsy confirmed the post-mortem nature of this vascular tear. This case teaches us an important lesson: it underlines the necessity to critically analyze PMCT and PMCTA images in order to distinguish between artifacts, true pathologies and iatrogenic findings. In cases with ambiguous findings such as the case reported here, correlation of imaging findings with autopsy is elementary. Ó 2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Post-mortem computed tomography (PMCT) is widely used in forensic death investigations [1]. Aortic dissection (AD) may occasionally be detected on non-contrast computed tomography (CT). The presence of inwardly displaced intimal calcifications or intimal flaps is a strong indicator of the presence of (AD) [2]. The Stanford classification divides AD into two types, depending on the origin of the dissection. Type A dissections originate in the ascending aorta and are often associated with the presence of pericardial tamponade [3]. Type B dissections affect the descending aorta only and are often associated with malperfusion of the abdominal organs [4]. In living patients, diagnostic imaging is performed by CT angiography (CTA) [5]. In the post-mortem setting, non-contrast PMCT may be complemented with PMCT-angiography (PMCTA) to visualize vascular pathology [6]. Currently, there are several different methods in use to achieve post-mortem angiography [7–11]. The approach proposed by the Technical Working Group Postmortem Angiography Methods (TWGPAM) is one of the most widely used [10].
⇑ Corresponding author at: Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland. Tel.: +41 44 255 1111; fax: +41 44 255 4443. E-mail address: [email protected] (N. Berger). 1344-6223/$ - see front matter Ó 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.legalmed.2013.07.001
One key question regarding PMCTA is if the post-mortem injection of intravascular contrast may affect forensically relevant findings (such as dislodge a fresh thrombus or induce iatrogenic vascular injury). Here we present a case where multi-phase PMCTA induced a hemorrhagic pericardial effusion during the venous phase of CT-angiography. 2. Case history A 45 year old female (160 cm, 54 kg, BMI 21.1 kg/m2) collapsed after having complained from recurring back pain over two days. Cardiopulmonary resuscitation (CPR) was immediately initiated by her boyfriend who was later relieved by paramedics but the patient died on the scene. The medical history revealed that the woman had been a smoker and that her mother had died from sudden cardiac death at a young age. 2.1. Imaging and autopsy PMCT and PMCTA were performed using a dual-source CT scanner (Flash Definition, Siemens, Forchheim, Germany). Scan parameters were as follows: tube voltage 120 kVp; automatic dose modulation software (CARE dose 4D, Siemens, Forchheim, Germany); slice thickness 1.0 mm; increments 0.5 mm. PMCTA was adapted from techniques described by Ross et al. [7] and
316
N. Berger et al. / Legal Medicine 15 (2013) 315–317
Grabherr et al. [10] by cannulation of the femoral vessels. A solution of 3 L of polyethylene glycol (PEG 200; Schaerer and Schlaepfer, Rothrist Switzerland) and Iopentol (Imagopaque 300; Amersham Health, Wädenswil, Switzerland), mixed at a ratio of 15:1 was injected using a pressure-controlled pump (VirtangioÒ, Fumedica AG, Muri, Switzerland) and filled with a maximal injection pressure of 60 mmHg. First the arterial phase was scanned with the contrast media filling the femoral artery to the aorta into
the left ventricle. The following venous phase started as well from the femoral vessels to the inferior cava vein, the right atrium to the right ventricle and the right and left pulmonary artery. PMCT and PMCTA were read and reported by two radiologists (with 1 and 6 years of experience in post-mortem imaging). Autopsy was performed by two forensic pathologists (with 4 and 17 years of experience). The time interval between death and autopsy was approximately 24 h.
2.2. Findings External inspection of the decedent revealed several findings related to extensive CPR attempts, including a number of small hematomas on the chest wall and puncture marks on the forearms and wrists. There was very little external lividity on the skin. Non-contrast PMCT revealed bilateral large collections of nonserous pleural fluid collections, consistent with bilateral hematothorax; a crescent shaped, collapsed ascending aorta (see Fig. 1a). In addition, there were several findings related to CPR, including a sternal fracture, bilateral serial rib fractures and a small left sided pneumothorax. PMCTA after arterial contrast injection revealed a dissection of the descending aorta from the left subclavian artery to the left exterior iliac artery and the right common iliac artery. There was extravasation of contrast media into the right pleural cavity (see Fig. 1b). Upon venous contrast injection, PMCTA revealed a previously non-existent, significant leakage of contrast medium from the inferior cava vein into the pericardium (see Fig. 1c). At autopsy, the aortic dissection, the pericardial effusion, the rupture of the inferior cava vein as well as the sternal and rib fractures were confirmed. A close inspection of the cava vein revealed that there were no signs to suggest an intra-vital injury at the site of the vascular rupture (see Fig. 2).
Fig. 1. (a) Non-contrast post-mortem computed tomography (PMCT) of the chest with collapsed and crescent shaped ascending aorta (arrow) and bilateral haematothoraces (asterisk); (b) arterial phase PMCT-angiography reveals a dissection membrane of the descending aorta (arrow) and extravasation of the contrast media in the right pleural cavity (asterisk); (c) venous phase PMCT-angiography reveals a post-mortem rupture of the inferior vena cava with extensive leakage of contrast media into the pericardial sac (arrow).
Fig. 2. Macroscopic autopsy specimen: laceration of the inferior vena cava at the point where it leads into the right atrium (arrow).
N. Berger et al. / Legal Medicine 15 (2013) 315–317
3. Discussion We report a case of aortic Type B dissection where multiphase PMCTA induced a rupture of the inferior cava vein with leakage of contrast medium into the pericardial sac. In this case the presence of aortic dissection was confirmed after arterial injection of contrast medium on PMCTA. Upon venous injection of contrast medium we noted a significant leakage of contrast medium from the inferior cava vein into the pericardial sac. This vascular rupture was confirmed at autopsy and both macroscopic and microscopic findings indicated that the vascular injury had occurred post-mortem due to absent intraparenchymal hemorrhage at the site of the laceration. This is an important finding, as the effect of intravascular contrast injection for PMCTA on forensically relevant findings is one of the key questions regarding the scope of applications of PMCTA. In this case we used a pressure controlled pump to inject the contrast medium and worked with a protocol adapted from Grabherr et al. [10] and Ross et al. [7]. The intention of pressure controlled injection with a maximum of 60 mmHg is to limit the intravascular pressure to avoid iatrogenic vascular rupture. In our experience of approximately 150 cases we have never observed a similar case. This subjective experience is supported by a recently published study on PMCTA related artifacts [12]. A thorough literature search yielded no other reports of venous rupture from postmortem instillation of contrast media. Frequent artifacts include incomplete vascular filling or layering of contrast medium and blood as well as intraluminal leakage of contrast into the gastrointestinal tract [12]. According to a scientific lecture on complications of PMCTA (presented at the second congress of the International Society of Forensic Radiology and Imaging), complications occur in up to 39% of post-mortem angiographies. However, vascular rupture from excessive pressure was present in only 2% of all cases, and was limited to arterial vessels [13].Nevertheless; it may be worth reevaluating the injection pressures used for venous injections to avoid iatrogenic vascular injury in the future. Previous reports on CPR-related changes on PMCT describe the frequent presence of intravascular or intraventricular gas [14]. The occurrence of myocardial injury as a result of CPR is only rarely observed [15]. However, significant pressure on the sternum may compress and cause the heart to burst [16]. In view of the case history, the findings on post-mortem imaging and autopsy and the current literature we assume that fierce CPR attempts induced a peri-/postmortem injury of the inferior cava vein at the level of the right atrium. The injection of contrast medium into the venous side of the vascular system caused a
317
complete tear at this level and resulted in an iatrogenic pericardial effusion. This underlines the necessity to critically analyze PMCT and PMCTA images in order to distinguish between artifacts, true pathologies and iatrogenic findings. In cases with ambiguous findings such as the case reported here, correlation of imaging findings with autopsy is elementary. References [1] Baglivo M, Winklhofer S, Hatch GM, Ampanozi G, Thali MJ, Ruder TD. The rise of forensic and post-mrtem radiology - analysis of the literature between the years 2000 and 2011. Forensic Radiol Imaging 2013;1:3–9. [2] Castaner E, Andreu M, Gallardo X, Mata JM, Cabezuelo MA, Pallardo Y. CT in nontraumatic acute thoracic aortic disease: typical and atypical features and complications. Radiographics. Oct 2003;23 Spec No:S93–110. [3] Lin PH, Huynh TT, Kougias P, Huh J, LeMaire SA, Coselli JS. Descending thoracic aortic dissection: evaluation and management in the era of endovascular technology. Vasc Endovasc Surg 2009;43(1):5–24. [4] Tran TP, Khoynezhad A. Current management of type B aortic dissection. Vasc Health Risk Manag 2009;5(1):53–63. [5] Vedantham S GJ. Case review vascular and interventional imaging. 2004 (1st ed. Philadelphia Mosby). [6] Ross SG, Thali MJ, Bolliger S, Germerott T, Ruder TD, Flach PM. Sudden death after chest pain: feasibility of virtual autopsy with postmortem CT angiography and biopsy. Radiology 2012;264(1):250–9. [7] Ross S, Spendlove D, Bolliger S, et al. Postmortem whole-body CT angiography: evaluation of two contrast media solutions. AJR Am J Roentgenol 2008;190(5):1380–9. [8] Jolibert M, Cohen F, Bartoli C, et al. Postmortem CT-angiography: feasibility of US-guided vascular access. J Radiol 2011;92(5):446–9. [9] Saunders SL, Morgan B, Raj V, Robinson CE, Rutty GN. Targeted post-mortem computed tomography cardiac angiography: proof of concept. Int J Legal Med 2011;125(4):609–16. [10] Grabherr S, Doenz F, Steger B, et al. Multi-phase post-mortem CT angiography: development of a standardized protocol. Int J Legal Med 2011;125(6):791–802. [11] Okuda T, Shiotani S, Sakamoto N, Kobayashi T. Background and current status of postmortem imaging in Japan: short history of ‘‘Autopsy imaging (Ai)’’. Forensic Sci Int 2013;225(1–3):3–8. [12] Bruguier C, Mosimann PJ, Vaucher N. Multi-phase postmortem angiography recognizing technique-related artefacts and pitfalls. Int J Legal Med 2013. [13] O’Donnell C. When it goes wrong: complications of post-mortem CT angiography (PMCTA) as performed at VIFM. J Forensic Radiol Imaging 2013;2:84–5. [14] Okuda T, Shiotani S, Kobayashi T, et al. Immediate non-traumatic postmortem computed tomographic demonstration of myocardial intravascular gas of the left ventricle: effects from cardiopulmonary resuscitation. SpringerPlus 2013;2(1):86. [15] Reardon MJ, Gross DM, Vallone AM, Weiland AP, Walker WE. Atrial rupture in a child from cardiac massage by his parent. Ann Thorac Surg 1987;43(5):557–8. [16] Ebert LC, Schon CA, Ruder TD, Thali MJ, Hatch GM. Fatal left ventricular rupture and pericardial tamponade following a horse kick to the chest. Am J Forensic Med Pathol 2012;33(2):167–9.