Differentiation of Antemortem Pulmonary Thromboembolism and Postmortem Clot with Unenhanced MRI: a Case Report

Overview

Journal Forensic Sci Med Pathol

Specialties Forensic Sciences
Pathology

Date 2018 Jan 5

PMID 29299826

Authors

Ingo von Both

Silvio Giancarlo Bruni

Jayantha C Herath

Affiliations

Soon will be listed here.

Abstract

We report a case of a 39-year-old woman who died of fulminant pulmonary thromboembolism (PE). Autopsy showed classical findings of fulminant PE with occlusion of the bilateral main stem pulmonary arteries. Ancillary testing revealed inherited thrombophilia (Prothrombin 20,210 G > A and MTHFR 677 C > T mutation). Pre-autopsy postmortem computed tomography was used to test whether virtual imaging studies alone (virtual autopsy) would be sufficient to detect PE. Our studies show that computed tomography (CT) can differentiate antemortem clots from a postmortem clot in certain cases, particularly when combined with magnetic resonance imaging (MRI), which is superior in the assessment of soft tissue. We show that postmortem CT and MRI can aid in the diagnosis of pulmonary embolism by virtual autopsy, especially when used in conjunction.

References

Ohno Y, Koyama H, Matsumoto K, Onishi Y, Nogami M, Takenaka D . Dynamic MR perfusion imaging: capability for quantitative assessment of disease extent and prediction of outcome for patients with acute pulmonary thromboembolism. J Magn Reson Imaging. 2010; 31(5):1081-90. DOI: 10.1002/jmri.22146. View

Jackowski C, Hofmann K, Schwendener N, Schweitzer W, Keller-Sutter M . Coronary thrombus and peracute myocardial infarction visualized by unenhanced postmortem MRI prior to autopsy. Forensic Sci Int. 2011; 214(1-3):e16-9. DOI: 10.1016/j.forsciint.2011.07.010. View

Westerbeek R, van Rooden C, Tan M, Van Gils A, Kok S, De Bats M . Magnetic resonance direct thrombus imaging of the evolution of acute deep vein thrombosis of the leg. J Thromb Haemost. 2008; 6(7):1087-92. DOI: 10.1111/j.1538-7836.2008.02986.x. View

Wolberg A, Campbell R . Thrombin generation, fibrin clot formation and hemostasis. Transfus Apher Sci. 2008; 38(1):15-23. PMC: 2408736. DOI: 10.1016/j.transci.2007.12.005. View

Varga E, Moll S . Cardiology patient pages. Prothrombin 20210 mutation (factor II mutation). Circulation. 2004; 110(3):e15-8. DOI: 10.1161/01.CIR.0000135582.53444.87. View

Moody A, Pollock J, OConnor A, Bagnall M . Lower-limb deep venous thrombosis: direct MR imaging of the thrombus. Radiology. 1998; 209(2):349-55. DOI: 10.1148/radiology.209.2.9807558. View

Varga E, Sturm A, Misita C, Moll S . Cardiology patient pages. Homocysteine and MTHFR mutations: relation to thrombosis and coronary artery disease. Circulation. 2005; 111(19):e289-93. DOI: 10.1161/01.CIR.0000165142.37711.E7. View

Jackowski C, Thali M, Aghayev E, Yen K, Sonnenschein M, Zwygart K . Postmortem imaging of blood and its characteristics using MSCT and MRI. Int J Legal Med. 2005; 120(4):233-40. DOI: 10.1007/s00414-005-0023-4. View

Tan M, Mol G, van Rooden C, Klok F, Westerbeek R, Sol A . Magnetic resonance direct thrombus imaging differentiates acute recurrent ipsilateral deep vein thrombosis from residual thrombosis. Blood. 2014; 124(4):623-7. DOI: 10.1182/blood-2014-04-566380. View

10.

Jackowski C, Bolliger S, Aghayev E, Christe A, Kilchoer T, Aebi B . Reduction of postmortem angiography-induced tissue edema by using polyethylene glycol as a contrast agent dissolver. J Forensic Sci. 2006; 51(5):1134-7. DOI: 10.1111/j.1556-4029.2006.00207.x. View

11.

Christe A, Flach P, Ross S, Spendlove D, Bolliger S, Vock P . Clinical radiology and postmortem imaging (Virtopsy) are not the same: Specific and unspecific postmortem signs. Leg Med (Tokyo). 2010; 12(5):215-22. DOI: 10.1016/j.legalmed.2010.05.005. View

12.

Hayman L, Taber K, Ford J, Saleem A, Gurgun M, Mohamed S . Effect of clot formation and retraction on spin-echo MR images of blood: an in vitro study. AJNR Am J Neuroradiol. 1989; 10(6):1155-8. PMC: 8332428. View

13.

Pichereau C, Maury E, Monnier-Cholley L, Bourcier S, Lejour G, Alves M . Post-mortem CT scan with contrast injection and chest compression to diagnose pulmonary embolism. Intensive Care Med. 2014; 41(1):167-8. DOI: 10.1007/s00134-014-3520-4. View

14.

Higgins S, Parsons S, Woodford N, Lynch M, Briggs C, ODonnell C . The effect of post-mortem computed tomography angiography (PMCTA) using water-soluble, iodine-based radiographic contrast on histological analysis of the liver, kidneys and left ventricle of the heart. Forensic Sci Med Pathol. 2017; 13(3):317-327. DOI: 10.1007/s12024-017-9871-8. View

15.

Roberts I, Benamore R, Benbow E, Lee S, Harris J, Jackson A . Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study. Lancet. 2011; 379(9811):136-42. PMC: 3262166. DOI: 10.1016/S0140-6736(11)61483-9. View

16.

Mudge C, Healey T, Atalay M, Pezzullo J . Feasibility of detecting pulmonary embolism using noncontrast MRI. ISRN Radiol. 2014; 2013:729271. PMC: 4045508. DOI: 10.5402/2013/729271. View

17.

Burke M, Bedford P, Baber Y . Can forensic pathologists diagnose pulmonary thromboembolism on postmortem computed tomography pulmonary angiography?. Am J Forensic Med Pathol. 2014; 35(2):124-31. DOI: 10.1097/PAF.0000000000000086. View

18.

Shiotani S, Kohno M, Ohashi N, Yamazaki K, Itai Y . Postmortem intravascular high-density fluid level (hypostasis): CT findings. J Comput Assist Tomogr. 2002; 26(6):892-3. DOI: 10.1097/00004728-200211000-00006. View

19.

Capuani C, Guilbeau-Frugier C, Mokrane F, Delisle M, Marcheix B, Rousseau H . Tissue microscopic changes and artifacts in multi-phase post-mortem computed tomography angiography in a hospital setting: a fatal case of systemic vasculitis. Forensic Sci Int. 2014; 242:e12-e17. DOI: 10.1016/j.forsciint.2014.06.039. View

20.

Moody A, Liddicoat A, Krarup K . Magnetic resonance pulmonary angiography and direct imaging of embolus for the detection of pulmonary emboli. Invest Radiol. 1997; 32(8):431-40. DOI: 10.1097/00004424-199708000-00001. View