Scan may serve in knifeless autopsy

November 28, 2007|By Frank D. Roylance | Frank D. Roylance,Sun reporter

More than 4,100 times each year, people who die in accidents, homicides, suicides and unexplained medical events in Maryland are dissected and probed until state medical examiners can match the death to its cause.

In each case, the grim but important work can take hours. And no matter how skilled and caring the practitioner, the autopsies may disfigure the remains and offend the beliefs or sensibilities of families.

Now Maryland researchers say they've demonstrated that computed tomography (CT) scans are nearly as accurate as traditional autopsies in revealing the cause of death.

They're also quicker - just 30 minutes to scan and interpret the results - and could replace the knife entirely in 10 percent to 30 percent of the deaths that require autopsies each year, researchers say.

The pilot study, conducted by the state medical examiner's office and the University of Maryland School of Medicine, was reported yesterday at the annual meeting of Radiological Society of North America in Chicago.

The study was small - just 20 autopsies, according to the lead author, Dr. Barry Daly, a professor of radiology at the medical school.

Even so, he said, "We certainly have some confidence that what we're seeing is ... something that will be of tremendous value, and will change the nature of the medical examiners' work."

Beyond sparing many families psychological pain, switching to CT scans would free medical examiners for other medical pursuits, the authors said. It might even make the profession more attractive.

"There is a nationwide shortage of medical examiners. It's always been one of the less-popular subspecialties within pathology," Daly said. "If it [CT scans] cuts down on the number of autopsies, it may be helpful in that respect, and add a whole new dimension to how medical examiners do their work."

Not everyone sees a new era dawning.

"I don't think there's a forensic pathologist or a medical examiner out there who would turn down a CT scanner if it was offered," said Dr. Joseph A. Prahlow, president of the National Association of Medical Examiners (NAME).

But he noted that the devices cost $1.3 million or more and require highly paid radiologists to interpret the results at a time when the offices of the nation's medical examiners and coroners are "grossly underfunded and understaffed."

"Given the opportunity to spend a chunk of money for a CT scanner or to build a new morgue, they'd go for the new morgue," he said.

Autopsies are required in all 50 states for homicides and other sudden and unexplained deaths. In Maryland, they're all performed in Baltimore by the Office of the Chief Medical Examiner, or OCME. The results are reported on death certificates, to families, insurance companies and to the justice system.

When families raise religious or ethical objections, medical examiners can modify or waive the procedure, except in homicides.

CT scanners use X-rays to probe the human body in a series of thin slices. Each slice is then digitized, allowing a computer to display any portion of the body's hard and soft tissues, in three dimensions, with remarkable detail, from any angle. "It is completely and utterly noninvasive," said Dr. David Fowler, Maryland's chief medical examiner.

Until recently, however, CT scans were rarely used for autopsies. "The technology didn't give you - and still doesn't give - the detail and resolution you can get from [a traditional] autopsy," Fowler explained.

But it has improved. In the 1980s, it could not resolve any feature smaller than a half-inch across. The limit is now just a few hundredths of an inch.

A 2003 Swiss study found modern CT scans to be useful in autopsies, and sufficient in some cases to supplant a traditional autopsy altogether. Medical examiners in several European countries use them routinely.

In the U.S., that's true only at the Charles C. Carson Center for Mortuary Affairs, at Dover Air Force Base, which performs autopsies on all of the nation's war dead.

Daly, Fowler and their team at the University of Maryland and the state OCME, launched their own comparison to determine the value of CT scans in a civilian setting.

Selecting 20 victims of accidents and homicides, they scanned each body at the medical school. Then state forensic medical examiners conducted autopsies. After two UM radiologists reviewed and interpreted the scans, researchers compared their conclusions with the autopsy results.

In all 14 cases of fatal blunt trauma, and five of six deaths from knife or bullet wounds, the radiologists accurately identified the cause. Both teams agreed the CT findings were comparable to autopsies in all but one of the blunt trauma cases, and a "helpful adjunct" in all the knife and gun cases.

The CT scans also located all 26 major bullet fragments recovered from victims during autopsies.

"Where we hope to make a big difference is in accident cases, where there is a tremendous potential to actually replace autopsy," Daly said.

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