Current issues in postmortem imaging of perinatal and forensic childhood deaths
Current issues in postmortem imaging of perinatal and forensic childhood deaths
Owen J. Arthurs 0 1 2
John C. Hutchinson 0 1 2
Neil J. Sebire 0 1 2
0 Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
1 Institute of Child Health, UCL , London, UK 3
2 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust , London WC1N 3JH , UK
Perinatal autopsy practice is undergoing a state of change with the introduction of evidence-based cross-sectional imaging, driven primarily by parental choice. In particular, the introduction of post mortem magnetic resonance imaging (PMMR) has helped to advance less-invasive perinatal autopsy in the United Kingdom (UK) and Europe. However, there are limitations to PMMR and other imaging techniques which need to be overcome, particularly with regard to imaging very small fetuses. Imaging is also now increasingly used to investigate particular deaths in childhood, such as suspected nonaccidental injury (NAI) and sudden unexpected death in infancy (SUDI). Here we focus on current topical developments the field, with particular emphasis on the application of imaging to perinatal autopsy, and pediatric forensic deaths. Different imaging modalities and their relative advantages and disadvantages are discussed, together with other benefits of more advanced cross-sectional imaging which currently lie in the research domain. Whilst variations in local imaging service provision and need may determine different practice patterns, and access to machines and professionals with appropriate expertise and experience to correctly interpret the findings may limit current practices, we propose that gold standard perinatal and pediatric autopsy services would include complete PMMR imaging prior to autopsy, with PMCT in suspicious childhood deaths. This approach would provide maximal diagnostic yield to the pathologist, forensic investigator and most importantly, the parents.
Autopsy; Perinatal; Imaging; Forensic; Pediatric; MRI
Perinatal autopsy practice is undergoing a state of change with
the introduction of evidence-based cross-sectional imaging,
driven primarily by parental choice. In particular, the
introduction of post mortem magnetic resonance imaging (PMMR)
has helped to advance less-invasive perinatal autopsy in the
UK. However, there are limitations to PMMR and other
imaging techniques which need to be overcome, particularly
with regard to imaging very small fetuses. Imaging is also
now used to investigate particular deaths in childhood, such
as suspected non-accidental injury (NAI) and sudden
unexpected death in infancy (SUDI). Here we focus on current
topical developments the field, with particular emphasis on
the application of imaging to perinatal autopsy, and pediatric
forensic deaths. Different imaging modalities and their
relative advantages and disadvantages will be discussed, together
with other benefits of more advanced cross-sectional imaging
which currently lie in the research domain.
The need for minimally invasive autopsy
Fetal and pediatric autopsy rates are at historically low levels,
with overall acceptance rates now around 12–15% in the USA
and UK respectively [1, 2]. This decline is largely due to
reduced parental acceptance, including reluctance based on a
range of factors including moral or religious grounds, not
understanding the benefits, fear of disfigurement, and delay in
funeral plans . In parallel, non-invasive imaging techniques
have been evaluated to establish their clinical diagnostic utility
in this field, to determine whether a less-invasive approach
might provide similar information whilst being more
acceptable to parents. Less invasive autopsy (LIA) is based on
postmortem imaging followed by targeted tissue examination
using a variety of techniques including endoscopic guidance
or image-guided biopsy . Since neither selected tissue
biopsy nor endoscopic examination and sampling allow
adequate anatomical information to be obtained, it is essential that
comprehensive imaging of the whole body is carried out
Over the last 10 years, several studies have now reported
that post mortem magnetic resonance (PMMR) imaging,
together with ancillary investigations including microbiology
and placental examination where appropriate, has very high
agreement with a conventional invasive autopsy, especially in
fetal and perinatal cases. The largest prospective trial of
PMMR versus standard traditional autopsy (Magnetic
Resonance Imaging in Autopsy: MARIAS study) reported
>90% concordance in fetuses and stillbirths, and 75%
concordance in children . Published evidence suggests that this is
an acceptable approach for the majority of clinical staff  and
parents [7, 8] alike. In some cases, parents may not agree to
any form of autopsy tissue sampling but post-mortem imaging
combined with ancillary investigations, such as placental
histological examination, can still provide useful clinical
Recent advances in post mortem imaging
Not only has the diagnostic accuracy and diagnostic
acceptability of PMMR now been demonstrated, but limitations of
the technique have also been documented. Whilst PMMR has
been validated for several other activities usually performed
during autopsy, such as organ weight or volume estimation [9,
10], there is a steep learning curve in PMMR acquisition and
reporting, as would be expected with any new imaging
development. In particular, recognizing normal PM changes which
occur such as fluid redistribution (subcutaneous edema,
pleural and pericardial effusions and ascites) can be challenging to
radiologists unfamiliar with autopsy work [11, 12] (Fig. 1). As
would be expected, PMMR is particularly good for congenital
anatomical abnormalities, such as intracranial hemorrhage,
brain malformations, renal anomalies (Fig. 2), congenital heart
disease and skeletal dysplasias [13–16]. However, several
normal changes may be misinterpreted for disease states, such as
bowel dilatation as obstruction  or normal pulmonary
changes as pneumonia [11, 14]. Conventional PMMR is
particularly poor at detecting microscopic changes such as renal
Fig. 1 Normal appearances on PMMR. Coronal T2-weighted PMMR in
a late gestation stillbirth, demonstrating normal physiological post
mortem imaging appearances. There is intracardiac gas, pleural and
pericardial effusions in the chest (black arrows), bowel dilatation and
widespread subcutaneous edema (white arrows), all of which can be
misinterpreted as pathological to radiologists unfamiliar with autopsy
dysplasias and disseminated sepsis, which often have no
imaging correlate [14, 17].
In imaging childhood deaths, PMMR can be particularly
useful to delineate traumatic injuries prior to autopsy,
including any internal hemorrhage, visceral or mesenteric injury
associated with blunt or penetrating trauma to the body. It
can give precise details about soft tissue injuries associated
with rib fractures, the severity of intracranial injury (e.g.
Fig. 3), and soft tissue limb injury. PMMR can be useful to
Fig. 2 PMMR of congenital abnormalities. PMMR is particularly good
for congenital anatomical abnormalities, such as intracranial hemorrhage,
brain malformations, renal anomalies, congenital heart disease and
skeletal dysplasias. This example shows bilateral enlarged high signal
kidneys at coronal T2-weighted PMMR in a 27 week gestation fetus,
which are classical features of autosomal recessive polycystic kidney
disease (a), confirmed at microscopy (b)
Fig. 3 PMMR to document injuries. Post mortem imaging is useful to
document the extent of intracranial injury prior to autopsy. In this case,
axial T2-weighted PMMR demonstrates a large left parietooccipital
subdural hemorrhage, which is causing mass effect on the brain. There
is a small amount of intraventricular hemorrhage in addition
show complications from inaccurate intraosseous needle
placements, including unilateral soft tissue edema or gas
tracking up the lower limbs .
Bone fractures are still probably best imaged using
conventional radiographs, as these demonstrate long bone fractures
adequately and some subtle fractures may be missed on
PMMR  (Fig. 4). The precise contribution that PMMR
makes to a forensic autopsy will be on a case-by-case basis,
but any additional information regarding the extent of
intracranial injury, extent of thoracic and abdominal injury, number
and site of fractures, can be useful to guide the forensic
pathologist in conducting their detailed examination (Fig. 3).
Fig. 4 Fracture detection on PMMR. Long bone fractures are still
probably best imaged using conventional radiographs, as these
demonstrate long bone fractures adequately and some subtle fractures
may be missed on PMMR, such as this corner metaphyseal fracture of
the left distal humerus in a 5 month old child. It was identified on
conventional radiography (a) but deemed too subtle to be identified on
PMMR (b). Reproduced with permission from 
Post mortem CT or MRI?
Post mortem computed tomography (PMCT) is becoming
widely used in the adult autopsy setting, particularly with
the addition of vascular contrast medium to create PMCT
angiography [19, 20]. The main advantages of PMCT over
PMMR are speed of acquisition, availability in most hospitals,
and the better bone detail that is achieved using unenhanced
CT. However, in children, PMCT has several disadvantages,
including reduced soft tissue contrast due to reduced
abdominal and subcutaneous fat, poor soft tissue contrast in the brain,
and without vascular contrast medium, assessment of the
thoracic and abdominal cavity is particularly challenging 
Recently, unenhanced PMCT has been shown to perform
worse than PMMR in children. Preliminary studies of PMCT
in infants showed 90% accuracy in a large proportion of
deaths which remained unexplained , but the main
problem with PMCT is that it is largely non-diagnostic in the
smaller bodies which are often referred for perinatal autopsy
. PMMR performs better than PMCT in the same
individuals, largely because of PMCT’s relatively high
nondiagnostic rates . Without the addition of intravenous
contrast (via femoral, umbilical vessels or direct intracardiac
injection) for angiography [23, 24], or ventilating the lungs to
improve lung imaging , PMCT typically performs worse
than PMMR apart from for bone imaging (e.g. rib fractures),
which is discussed later in this article in more detail.
PMCT is becoming particularly useful at detecting rib
fractures, and detailed abnormalities of other bone injuries
(Fig. 6). As both PMCT and PMMR become more widely
used in perinatal autopsy and the forensic setting, their
diagnostic utility will become established as both radiologists and
pathologists gain experience.
Sudden unexpected death in infancy (SUDI)
In 2013, there were 2686 infant deaths in England and Wales
; of these, approximately 1000 will have presented as a
sudden, unexpected death (SUDI). Due to the nature of these
cases, they usually require investigation through HM Coroner
(in England, Wales and Northern Ireland) or the Procurator
Fiscal (Scotland). SUDI presentations represent the
commonest group of infant deaths undergoing autopsy
examination  but despite a relatively high throughput of cases,
SUDI remains poorly understood, and investigation of SUDI
deaths are a challenging area for medical practitioners. The
majority of investigations within the Coronial / Fiscal system
require a cause of death to be established to a standard of proof
equating to ‘on the balance of probability’, rather than
‘beyond reasonable doubt / so as to be sure’. Even so, the
majority of SUDI deaths remain unexplained . Of the cases
Fig. 5 Example of non diagnostic PMCT. PMCT has several
disadvantages, including reduced soft tissue contrast due to reduced
abdominal and subcutaneous fat. In an 18 week fetuses, an abdominal
wall defect was clearly diagnosed on PMMR (b), with liver and small
bowel loops herniated outside of the normal abdominal cavity in
gastroschisis (white arrow), but the PMCT in the same patient was
nondiagnostic. Gastroschisis was clearly identified at autopsy (c; white
arrow). Reproduced with permission from 
where a cause of death may be identified, the potential
underlying may be subtle, thus requiring a rigorous approach to the
investigation. A keen understanding of the rapid physiological
changes that occur during the first year of life is therefore
essential when considering SUDI cases. The investigative
Fig. 6 PMCT for fractures. PMCT is becoming particularly useful at
detecting rib fractures. An example is given of a 4 month old girl with a
rib fracture on the right, difficult to identify on the frontal chest
radiograph (a), easier to see on the oblique view of the left sided ribs
(b), and very easy to identify on axial 3D reconstructed PMCT (c). PMCT
confirms that there are bilateral anterolateral fractures, in a typical
location resuscitation related injuries, and there were no other signs of
injuries in this child. Fresh anterolateral fractures are highly likely to be
related to resuscitation if there are no other associated injuries
strategy recommended by the Royal College of Pathologists
is extensive  but largely based on expert opinion, rather
than evidence. An updated guideline is expected to be
published in 2016. A recent systematic review evaluating SUDI
investigation strategies described the need for mandatory
investigation of SUDI cases, ideally through specialist centers,
that can provide strong leadership and integrate with Coronial
Some presentations of SUDI will be attributable to natural
causes (undiagnosed infections, congenital malformations),
whilst some will occur in unnatural circumstances, including
accidents, and some within the context of inflicted injury .
Of the SUDI cases that remain unexplained, some will occur
in association with well-described risk-factors, such as
cosleeping, prone sleeping, soft-bedding, parental smoking or
drug use, and socio-economic deprivation [30–33] though a
definitive cause of death may elude the investigative team. A
proportion of unexplained SUDI cases may be classified as
SIDS (Sudden Infant Death Syndrome) if the cause and
mechanism of death cannot be explained following completion of
all investigations and the death occurred during normal sleep.
SIDS remains a diagnosis of exclusion, and in practical terms
is likely to represent a heterogeneous mixture of cases with
complex, multifactorial causes that current gold standard
investigations cannot adequately detect or classify [26, 34].
It is relatively rare to detect a cause of death macroscopically
at a SUDI autopsy . The macroscopic autopsy procedure is
undertaken to exclude traumatic injuries and obtain samples for
microbiological, biochemical, toxicological and genetic analysis
that may identify a definitive cause of death. Post-mortem
imaging can therefore assist in several ways; firstly, cross-sectional
imaging can identify cases with a structural lesion present.
Secondly, imaging can then be used live within the mortuary
to facilitate a targeted procedure (e.g. localized infection
identified on PMMRI sampled for histology and microbiology under
ultrasound guided biopsy). Such approaches are increasingly
popular with Coroners, as targeted investigation permits a cause
of death to be identified in a timely manner whilst minimizing
distress associated with the autopsy. This is particularly true for
Muslim and Jewish families, for many of whom the idea of an
autopsy remains ideologically unacceptable . Thirdly,
negative findings obtained by imaging may be of importance to
families and clinicians if there is there are specific questions
surrounding the death, for example, in the context of a family
history of congenital heart disease. As “omic” approaches to
diagnosis continue to expand, tissue sampling is likely to further
increase in importance in the context of SUDI deaths, with
nextgeneration sequencing and proteomic studies showing promise
within this field [36–40]. As a result, imaging techniques,
including laparoscopically assisted biopsy and ultrasound-guided
biopsy, are likely to become essential skills for pathologists and
radiologists involved in post-mortem investigations in order to
obtain tissue for diagnostic and research purposes. Furthermore,
given the difficulties in establishing asphyxia as a cause of death
in this group, it is possible that future developments, such a MR
spectroscopy evaluation, may provide additional specific
information regarding mechanisms and timing of death . This is
of particular importance given the recognition of the increasing
relative frequency of co-sleeping associated infant deaths, and
Comprehensive skeletal radiography is a well-established part
of the routine investigation of suspicious childhood deaths,
particularly with regard to suspected non-accidental injury
(NAI). Skeletal radiography provides an overview of bone
structure and development, bone biometry and any specific
bone abnormalities . Detailed recommendations for
performing and reporting skeletal imaging in suspected NAI
are available from both Royal College of Radiologists (UK)
, and American equivalent ACR . Skeletal surveys are
used in the NAI setting in order to identify, or exclude, occult
or hidden fractures. Skeletal surveys have a high yield of
revealing abuse, particularly in children under the age of
2 years, who may otherwise have no external manifestations.
Typical occult fractures may involve corner metaphyseal
injuries or posterior rib fractures, particularly in states of healing,
which have a high specificity for non-accidental injury .
Whilst CT of the brain is widely used in suspected NAI,
evidence from post mortem CT studies suggests that PMCT
may also give a higher yield of fracture diagnosis in suspected
NAI than conventional radiographs, particularly with regard
to rib fractures. Acute, un-displaced rib fractures can be
difficult to detect on radiography, particularly in the absence of
any callus formation. Rib fractures following
cardiopulmonary resuscitation are reportedly rare on skeletal radiographs,
and when they do occur, are often multiple, anterolateral,
incomplete (greenstick) fractures [45–47]. Fresh anterolateral
fractures are highly likely to be related to resuscitation if there
are no other associated injuries (Fig. 6) [46, 47]. One
retrospective study showed that approximately twice as many
fractures are identified on PMCT than radiographs, particularly
subtle rib fractures , although rib fracture detection rates
using both techniques are dependent on observer experience
[48, 49]. PMCT may be particularly useful for fractures near
the manubrium and sternum, and near the costovertebral
junctions, which are particularly difficult to assess on radiographs.
In the post mortem setting, there is little disadvantage to
performing more detailed cross-sectional imaging such as
PMCT, and an argument could be made that any imaging
modality that could possibly increase the detection of injuries
should be employed. Routine use of PMCT in non-accidental
injury in live patients remains to be evaluated.
There are other advantages of PMCT over conventional
radiographs, above and beyond potential increased
diagnostic yield. A permanent 3D record of detailed
anatomical features can be stored in perpetuity, for teaching and
training purposes, which is not achievable by current
histopathological dissection. Detailed 3D imaging also lends
itself to 3D models, which can be printed out and held in
one’s hand (Fig. 7). Simple magnification allows larger
replication of any pathological features, making it easier
to appreciate normal and abnormal anatomy, and printed
models can also be annotated and stored long-term for
teaching purposes, improving understanding of 3D
relationships of complex congenital abnormalities .
Fig. 7 3D prototype printing. 3D model of a fracture skull and
underlying brain hemorrhage in an infant brain. The PMCT dataset (to
provide the 3D skull structure) was co-registered with the PMMR image
(to identify the bleed volume and position) to give a composite image (d).
This was printed into a skull (b), to demonstrate the fracture (black arrow
head, a) and internal hemorrhage (black arrows, c). These findings were
confirmed at autopsy. Reproduced with permission from 
Clinicians may find these models particularly useful for
explaining abnormalities to parents, as a “clean” model of
the abnormalities without any autopsy photographs to be
used. Some parents may wish to keep an artificial replica
of the baby or organ, to help with the bereavement
process. In medico-legal cases, juries and judges may benefit
from being shown rapid prototyping model of the
significant findings, rather than relying on photographs or
Current research in post mortem imaging
The more imaging that is performed, the more other
advantages of imaging become apparent aside from primary
diagnosis. For example, in abandoned babies found dead, two
primary questions are raised: was the baby born alive and
subsequently died, or born dead (stillbirth), and can we
determine the time interval since death? There is preliminary
evidence that PMMR may be able to address both of these
Conventional autopsy techniques of establishing lung
aeration include the lung flotation technique, an invasive test
requiring lung evisceration and observing whether they float
or sink when placed into water; floating lungs are traditionally
deemed to contain air, suggesting breathing before neonatal
demise , with published accuracy ranging from 37 to 95%
[52, 53]. We have recently shown in a small group of subjects
that subjective lung parenchyma aeration on PMMR is a good
indicator of spontaneous breathing, with similar accuracy to
lung flotation methods. This has the advantage of being
completely non-invasive, may be acquired along with routine
Fig. 9 PMMR of hypoxic brain changes. Axial T2-weighted PMMR
image through a fetal post mortem brain, showing an example of
typical low signal change in the basal ganglia which may be associated
with hypoxia. Conventional PMMR cannot currently distinguish
antemortem from postmortem hypoxic change
PMMR imaging, and may be useful to distinguish livebirth
from stillbirth in most cases (Fig. 8) .
Post mortem interval is more difficult to determine.
Since some aspects of PMMR may be quantifiable, there
is preliminary research to show that changes in imaging
parameters may relate to the post mortem interval (time
interval between death and imaging). For example, the
accumulation of fluid in the lungs and pleural space
Fig. 8 PMMR for lung aeration. Signal intensity differences in the lungs
on PMMR may be used to differentiate between a baby who has breathed
(dark airways and lungs on coronal T2-weighted PMMR image in a
2 week old baby; a) versus one that has not (light lungs in a 30 week
gestation fetus with no signs of life at delivery; b). Reproduced with
permission from  under Open Access agreement
Fig. 10 Limits of body PMMR imaging. 3D reconstruction from high
resolution CISS PMMR image of a 14 week gestation (b). Skeletal
radiography (a) at this gestation is often better than the highest
resolution imaging at 1.5 T PMMR (b), which at low body weights is
often non-diagnostic 
Fig. 11 Micro CT of fetal heart.
Normal fetal heart from an
unexplained intrauterine fetal
death at 23 weeks gestation (heart
weight 5.3 g) at autopsy (a) with
the corresponding micro-CT
volume rendering at
approximately 20 μm spatial
resolution, following immersion
in iodine (b). Adapted with
permission from 
following death results in signal changes on PMMR chest
imaging. The rate of pleural fluid accumulation may
correspond with post mortem interval in children , and the
rate at which lung parenchymal air is replaced with fluid
may also show correlations with post mortem interval .
Other studies have attempted to evaluate brain signal
changes (e.g. hypoxic changes in the basal ganglia) with
respect to post mortem interval (Fig. 9) . It may be that
a combination of quantifiable imaging parameters are
needed to retrospectively estimate the time of death.
 and has recently been used to show very high quality
imaging with good diagnostic accuracy for fetal hearts
(Fig. 11) [62, 63] and kidneys  although extracting and
‘fixing’ tissue for optimal contrast is necessary. Pilot studies of
whole-body imaging using microCT are also promising .
Several of these techniques may improve PM imaging at low
bodyweights where conventional PMMR is challenging 
and virtual 3D datasets allow virtual dissection and
redissection of organs, providing detailed examination and
review without need for organ retention.
Imaging in small fetuses
With the increasing introduction of routine first trimester
antenatal US screening, fetuses are being submitted for autopsy
examination at early gestational ages. These represent a
challenge, not only for traditional autopsy examination but also
post mortem imaging. Standard clinical PMMR at 1.5 T is
non-diagnostic in around a third of <24 week gestation fetuses
, and diagnostic performance drops significantly below
500 g bodyweight (Fig. 10) ; PMCT performs equally
Techniques for post mortem imaging of very small and
early gestation fetuses now includes PMMR at stronger field
strengths, and micro CT. The diagnostic feasibility of very
high field (9.4 T) PMMR has been described  although
this technology is expensive, and time consuming and not
widely available, although a case could be made for
centralizing services for precisely this provision. 3 Tesla PMMR may
become more widely available, and has been shown to have
good diagnostic yield in particular for congenital cardiac
abnormalities  but whether there is a significant diagnostic
improvement over 1.5 T PMMR remains to be established.
Micro-CT is another potential alternative diagnostic
modality for imaging small objects, using CT technology but at
improved resolution down to micrometers rather than
millimeters. Micro-CT is described in post mortem forensic work
The addition of post mortem imaging to conventional autopsy
methods allows for autopsies to be offered to those who would
ordinarily refuse, for detailed examination of the body prior to
incisions as an adjunct to pathologists, to create 3D datasets
for storage and teaching, and improved diagnostic accuracy
compared to conventional techniques in certain settings.
Whilst variations in local imaging service provision and need
may determine specific practice patterns, including access to
machines and appropriately skilled and experienced
interpreters, the gold standard perinatal and pediatric autopsy
service would include complete PMMR imaging prior to
autopsy, with PMCT in suspicious childhood deaths. This would
allow maximal diagnostic yield to the pathologist, forensic
investigators and most importantly, the parents.
1. Post mortem imaging techniques in children and fetuses
have high concordance rates with traditional autopsy and
show good levels of acceptability with parents.
2. PMCT is becoming useful for bony injuries, particularly
the assessment of rib fractures.
3. PMMR can delineate traumatic injuries prior to autopsy,
particularly precise details about soft tissue injuries
associated with rib fractures, the severity of intracranial injury
and soft tissue limb injury.
4. PMMR imaging may be useful to distinguish livebirth
from stillbirth by assessment of lung aeration.
5. A gold standard perinatal and pediatric autopsy service
would include complete PMMR imaging prior to autopsy,
with PMCT in suspicious childhood deaths.
Acknowledgements OA is funded by an NIHR Clinician Scientist
Fellowship award, and NJS is funded by a NIHR Senior Investigator
award. NJS is partially supported by the Great Ormond Street
Children’s Charity and the NIHR Great Ormond Street Hospital
Biomedical Research Centre. This article presents independent research
funded by the National Institute for Health Research (NIHR) and
supported by the Great Ormond Street Hospital Biomedical Research Centre.
The views expressed are those of the author(s) and not necessarily those
of the NHS, the NIHR or the Department of Health.
Compliance with ethical standards
Ethical approval Informed consent was obtained from all individual
participants included in the studies performed by the authors and cited in
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