Postmortem Imaging: The Next Radiology Subspecialty?

This article is part two of a two-part series about postmortem and forensic imaging. Read part one here.

While medical care is often seen as more advanced in the United States, postmortem imaging is still in its infancy.

Countries like Switzerland, Sweden, and Japan routinely use CT in the mortuary or in nearby medical clinics, and have access to this imaging more readily than in the U.S. Some countries use CT on every person who dies there. Several countries also use MRI for the deceased, said Angela Levy, MD, professor of radiology at Georgetown University in Washington, DC.

Imaging the deceased has a number of advantages over straight autopsy, as described in the first article in our series. So why isn’t more postmortem imaging done in the U.S.?

Economics of Postmortem Imaging
One can make an economic argument that CT can save money, even after the costs of buying the equipment and hiring radiologists to do the work, said Barry Daly, MD, professor of diagnostic radiology and nuclear medicine at University of Maryland School of Medicine. One way CT saves money is in not needing to hire pathologists. According to Daly, there is a shortage of trained pathologists in the U.S.

 “It hasn’t really been one of the more attractive medical subspecialties,” he said.

While high resolution imaging makes postmortem imaging more interesting and may help in recruiting, it’s also helpful in offices without enough pathology staff. Using CT helps determine who needs an autopsy, or whether it’s practical to examine only a single body part in a deceased patient. It can help streamline the work and reduce the number of autopsies. “If you don’t have to hire so many pathologists, you can help justify a CT scanner and associated costs,” Daly said.

Another way CT can save money is in court costs, using CT imaging as exhibits. Daly has seen several instances where 3D CT images are used as exhibits, prompting plea bargains before the trial even starts.

“The defense didn’t want to go to trial and have these very obvious injuries displayed,” Daly said. These are cases with bad skull fractures, spinal fractures, and sometimes 15-20 fractures throughout the body. Rather than risk the jury seeing that the injuries, the defense took a plea bargain.

“A big plus is that the prosecution is agreeable that the sentence is appropriate, so trial isn’t necessary. It saves the public a lot of money because you don’t have a trial,” Daly said. He said that plea bargains can save at least a hundred thousand dollars in trial costs. He detailed how CT scans were used as evidence in criminal courts in a paper published in June, 2015 in Academic Forensic Pathology.

What Kind of Scanner Do You Need?
Given that the patients aren’t moving or breathing, a 16-slice CT is adequate for the job. It doesn’t have to scan quickly or be state-of-the-art, Daly said. Plus, it has the same software and computing power as a 64-slice scanner, good because you’ll generate 3,000-4,000 images per study.

Daly recommends getting an especially long table to fit most bodies so the scan is completed in a single table movement. “You could get that kind of scanner new or refurbished for a couple hundred thousand dollars. It’s not as horrendously expensive as buying a dual energy scanner which will set you back several million,” he said. You’ll also need a mini-PACS system.

CT machines for postmortem radiology don’t need bells and whistles, said Craig Hughes, a radiology technologist who now sells imaging equipment through Counterpoint Healthcare Consulting. He also said a 16-slice scanner works in most cases, unless you’re doing research.

Why Isn’t Postmortem Imaging More Common in the U.S.?
The medical examiner system isn’t centralized in the United States, which experts say is one reason why CT scanning hasn’t been widely adopted.

“Everything is different from state to state,” Daly said. “Trying to organize anything on a national basis is difficult.”[[{"type":"media","view_mode":"media_crop","fid":"46640","attributes":{"alt":"postmortem imaging","class":"media-image media-image-right","id":"media_crop_8349593410196","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5426","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 155px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Scott Richardson/Shutterstock.com","typeof":"foaf:Image"}}]]

States like Maryland have a single medical examiner system where all forensic pathology services are provided by the state and centralized in one location. Virginia has three medical examiner offices, Daly said. In some states, pathology services might be divided by city or county, or cases are sent to an outside service. In these situations, the medical examiner system is fragmented, so funding a high tech system is harder. Plus, some states have coroner offices instead of medical examiner offices, making them less willing to use a CT scanner. While medical examiners are physicians, coroners aren’t. They might be former police officers, judges, or have some death investigation experience, said Georgetown’s Levy.

Maryland built a $43 million forensic medical center housing the Chief Medical Examiner office in Baltimore, about four years ago. They have a CT scanner on site and hope to have an MRI scanner at some point too, said Daly, who has been collaborating with Maryland’s Office of the Chief Medical Examiner since 2006.

“If you really want to do this well, this is the type of financial commitment you’re talking about,” Daly said.

The facility covers public forensic pathology for the entire state, with approximately 10,000 deaths a year referred for investigation. About 5,000 autopsies are done per year here, said Daly, while each of the 18 medical examiners is only supposed to do 250 cases a year.

“When you get a complicated case, it’s not just a three hour autopsy, it’s the hours of work involved with follow-up investigation, and hours or days or weeks spent by the forensic pathologist in court testifying about complicated cases,” Daly said.

In the U.S., only a handful of medical examiner offices use CT, said Daly. In addition to Maryland and the Armed Forces Medical Examiner Office in Delaware, the University of New Mexico Office of the Medical Examiner has a facility, he said, and they have research funding for technologists. Virginia has three medical examiner offices and Daly said that at least one of them has a CT scanner, with radiology support from the Medical College of Virginia. Schuylkill County’s coroner office in Pennsylvania has a CT scanner as well.

While the medical examiner system is fragmented, with different organization and funding models, other countries “moved far ahead of the U.S. because they have centrally funded medical examiner systems that cover their entire country,” said Levy.

The use of advanced imaging is being explored by various medical organizations. The College of American Pathologists is exploring CT, Levy said. The College is actively setting standards for autopsy, and is very interested in imaging and autopsy, she said.

The field is still emerging in radiology. “We’ve had some support from the major radiology organizations, but it’s really not a big focus of radiology at this time,” Daly said. “But it’s an important one we don’t want to neglect.”

Radiologists who are interested in the field can contact local medical examiner offices who have the technology, said Daly, and may be able to review scans remotely. While a small number of radiologists have expressed an interest in the field, it’s fascinating work.

“This is still a subspecialty with a diaper on,” Daly said. “It’s in its infancy.”