May 2008, VOLUME 190
NUMBER 5

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May 2008, Volume 190, Number 5

Forensic Radiology

Original Research

Postmortem Whole-Body CT Angiography: Evaluation of Two Contrast Media Solutions

+ Affiliations:
1Centre for Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Bern, Buehlstrasse 20, CH-3012 Bern, Switzerland.

2Department of Radiology, Inselspital Bern, University of Bern, Bern, Switzerland.

3Institute of Forensic Medicine, University of Lausanne, Lausanne, Switzerland.

4Clinic for Cardiovascular Surgery, Inselspital Bern, University of Bern, Bern, Switzerland.

Citation: American Journal of Roentgenology. 2008;190: 1380-1389. 10.2214/AJR.07.3082

ABSTRACT
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OBJECTIVE. The objective of our study was to establish a standardized procedure for postmortem whole-body CT-based angiography with lipophilic and hydrophilic contrast media solutions and to compare the results of these two methods.

MATERIALS AND METHODS. Minimally invasive postmortem CT angiography was performed on 10 human cadavers via access to the femoral blood vessels. Separate perfusion of the arterial and venous systems was established with a modified heart–lung machine using a mixture of an oily contrast medium and paraffin (five cases) and a mixture of a water-soluble contrast medium with polyethylene glycol (PEG) 200 in the other five cases. Imaging was executed with an MDCT scanner.

RESULTS. The minimally invasive femoral approach to the vascular system provided a good depiction of lesions of the complete vascular system down to the level of the small supplying vessels. Because of the enhancement of well-vascularized tissues, angiography with the PEG-mixed contrast medium allowed the detection of tissue lesions and the depiction of vascular abnormalities such as pulmonary embolisms or ruptures of the vessel wall.

CONCLUSION. The angiographic method with a water-soluble contrast medium and PEG as a contrast-agent dissolver showed a clearly superior quality due to the lack of extravasation through the gastrointestinal vascular bed and the enhancement of soft tissues (cerebral cortex, myocardium, and parenchymal abdominal organs). The diagnostic possibilities of these findings in cases of antemortem ischemia of these tissues are not yet fully understood.

Keywords: angiography, contrast media, noninvasive autopsy, postmortem whole-body angiography, virtopsy, virtual autopsy

Introduction
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Conventional autopsies are facing increasing objections on behalf of the families of deceased persons, thus leading to a marked decrease of clinical autopsies. This, in turn, leads to the loss of a valuable tool for clinical quality control in evidence-based medicine. Forensic autopsies, which are commissioned by the district attorney's office (or another comparable institution) and thus usually cannot be objected to, are also facing increasing difficulties. Apart from surmountable difficulties such as objections on behalf of the next of kin and religious groups, the main problem is reproducibility in court. Currently, autopsy reports are descriptive and observer dependent and rely on the integrity of the examiner. However, blind trust in the subjective opinion of medical examiners in court is dwindling, thus giving rise to calls for a more objective documentation method. Therefore, a postmortem examination should be as minimally invasive as possible to reduce the anguish of the next of kin, while still serving quality control and being reproducible at a later date.

Because cross-sectional imaging techniques, especially CT, have experienced tremendous improvements since the 1990s, several groups have started to perform these methods on cadavers with the aim of gaining additional information to augment autopsy or even to replace conventional autopsy. The promising results have led to an increased acceptance of postmortem imaging in the field of forensic pathology.

Indeed, CT has proven to be very useful in diagnosing osseous findings, foreign bodies, air embolisms, and gross abnormalities of the soft tissue. MRI, on the other hand, is better suited for the detection of smaller soft-tissue lesions and organ abnormalities [1, 2]. CT-guided biopsies for the histologic evaluation of findings (e.g., cancer research) are easily performed [3]. One of the last “blind spots” of postmortem imaging is the displaying of vascular abnormalities. The unenhanced examination using CT or MRI gives little information about damage to major vessels. Therefore, conventional, albeit time-consuming, autopsy techniques are the method of choice for the examination of the vascular bed of an organ. However, the visualization of the vascular system of an entire cadaver is technically impossible.

A form of limited postmortem angiography has often augmented the above-mentioned conventional techniques regarding the vascular bed. Indeed, this technique has a long history starting with the experiments of Leonardo da Vinci in the 16th century. Several experiments were made with the injection of casts, oily liquids, and corpuscular and hydrophilic preparations [4]. In most cases, isolated organs were perfused. There are few reports about angiographies of human fetuses [57]. Although a whole-body angiography would be useful for screening for the presence of vascular abnormalities, successful complete whole-body postmortem CT imaging in adults has not been achieved to date.

For this objective, our group studied the implementation of several contrast media, of which two proved useful: an iodinated oily contrast agent and a water-soluble iodinated contrast agent [810]. Both agents showed different advantages and disadvantages. The oily solution offered a longer intravascular phase (more than 72 hours) with the possibility of an extended interval between injection and imaging. The major drawback was the unwanted extravasation through damaged vessel walls in areas of early autolysis (gastrointestinal tract), making correct detection of traumatic vessel lesions in these areas impossible. The mixture of a water-soluble, hydrophilic contrast medium with polyethylene glycol (PEG) as a large molecular (polymerized) carrier substance showed the potential to overcome the already known rapid penetration through the undamaged vessel wall with successive edema of the surrounding tissue. We performed the present study to evaluate the practicability of whole-body angiography with these two contrast media mixtures and to assess the respective advantages and drawbacks.

Materials and Methods
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The responsible justice department and the ethics committee of the University of Bern approved of this study. Ten cadavers delivered to the Institute of Forensic Medicine for forensic autopsy were studied (Table 1). Three were women and seven were men. The mean age at time of death was 59.2 years, ranging from 25 to 96 years. The mean interval between estimated times of death and imaging was 29.3 hours, ranging from 12 to 60 hours. A conventional autopsy with sampling of histologic specimens was performed in every case for a direct comparison with the radiologic findings. Samples of peripheral blood and urine were collected before the angiographic procedures.

TABLE 1: Cause of Death and Concordance with Autopsy Findings

A compound of paraffin oil and iodized oil (Lipiodol Ultra Fluide, Guerbet) was administered in the first five bodies in a mixture ratio of 15:1 (mean radiodensity, 600 H). The remaining five bodies underwent perfusion with a solution of PEG (PEG 200, Schaerer and Schlaepfer AG) and iopentol (Imagopaque 300, GE Healthcare) in a mixture ratio of 10:1 (mean radiodensity, 600 H). The radiodensity of the contrast media was raised in comparison with clinical antemortem examinations for better contrast in the vascular peri phery and better depiction of small extravasations.

Access to the arterial and venous systems was gained through a unilateral inguinal incision and preparation of the femoral vessels, with subsequent retrograde cannulation of the femoral artery and antegrade cannulation of the femoral vein (arterial, 16-French; venous, 20-French) (Fig. 1). The fixed cannulas were con nected to a pressure-controlled modified heart–lung machine (HL20, Maquet) (Fig. 2). The arterial can nula was turned around in a second step to inject the arteries distal from the femoral access point. Perfu sion of the vascular system was performed using the following parameters. For the head, neck, and thorax including the upper extremi ties and abdomen: perfu sion volume, ∼ 2,000 mL; pressure gradient, ∼ 80 mm Hg; flow rate, ∼ 800 mL/min. For the lower extrem ities: perfusion volume, ∼ 400 mL; pressure gradient, ∼ 50 mm Hg; flow rate, ∼ 200 mL /min.

Postmortem imaging was executed on a 6-MDCT scanner (Somaton Emotion 6, Siemens Medical Solutions). All examinations included a triphasic scanning protocol (unenhanced, arterial injection, venous injection) in the supine position. Imaging of the thorax and abdomen with raised arms was performed. A change to the prone position was per formed in case of incomplete filling of the coronary arteries. The primary angiographic CT scan followed in every case directly after the complete administration of the contrast media solution (3 seconds). The second injection (arterial or venous dependent on the case) was done with a minimum interval of 15 minutes (maximum, 30 minutes). Raw data acquisition was performed with the following settings: 110 kV; 100 mAs; collimation, 6 × 1 mm whole body and 6 × 0.5 mm in selected regions. Image reconstruction was performed in slice thicknesses of 5, 1.25, and 0.625 mm, each with an increment of half the slice thickness, soft tissue, and bone-weighted recon struction kernel. Pri mary image review and 3D reconstructions were performed on a CT work station (Leonardo, Siemens Medical Solutions). For the intra- and interindividual comparison, a PACS workstation was used (IDS5, Sectra AB).

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Fig. 1 Photograph shows minimally invasive access to vascular system through right femoral incision and cannulation of femoral artery (red arrow) and vein (blue arrow). Removable ligatures ensure fixation of cannulas and ligation of vessels opened during preparation process.

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Fig. 2 Photograph shows setup of CT angiography. Pressure-controlled heart–lung machine is connected to cannulated femoral vessels. Cadaver lies in impermeable body bag.

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Fig. 3A Cadaver after osteoclastic craniotomy at right side and clipping of M1 segment of right medial cerebral artery. (case 1; iodized oil [Lipiodol, Guerbet] and paraffin oil solution) Maximum-intensity-projection (MIP) images of cerebral vasculature in axial (A) and coronal (B) reconstructions show even peripheral vessels are displayed exactly. Note asymmetric enhancement of vessels in area of craniotomy and asymmetrically contrasted lentigostriatic branches in coronal reconstruction (B). Cerebral cortex shows no enhancement. Fetal origin of left posterior artery is anatomic variant.

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Fig. 3B Cadaver after osteoclastic craniotomy at right side and clipping of M1 segment of right medial cerebral artery. (case 1; iodized oil [Lipiodol, Guerbet] and paraffin oil solution) Maximum-intensity-projection (MIP) images of cerebral vasculature in axial (A) and coronal (B) reconstructions show even peripheral vessels are displayed exactly. Note asymmetric enhancement of vessels in area of craniotomy and asymmetrically contrasted lentigostriatic branches in coronal reconstruction (B). Cerebral cortex shows no enhancement. Fetal origin of left posterior artery is anatomic variant.

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Fig. 4A Cadaver with subdural hematoma. (case 10; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Axial reconstruction image (A) shows large, right subdural hematoma (asterisks) with active extravasation of contrast media solution in anterior parts (closed arrow). Asymmetric enhancement of cortex and basal ganglia with depiction of massive midline shift to left can be seen in A and subfalcial and infratentorial herniation of brain tissue to left (open arrows) in coronal view (B). Absent cortical enhancement in supplying area of right anterior cerebral artery and posterior branches of left medial cerebral arteries suggests antemortem infarction. Note hypodensity of subdural hematoma due to adaptation of window level and width on enhancing cortex.

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Fig. 4A Cadaver with subdural hematoma. (case 10; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Axial reconstruction image (A) shows large, right subdural hematoma (asterisks) with active extravasation of contrast media solution in anterior parts (closed arrow). Asymmetric enhancement of cortex and basal ganglia with depiction of massive midline shift to left can be seen in A and subfalcial and infratentorial herniation of brain tissue to left (open arrows) in coronal view (B). Absent cortical enhancement in supplying area of right anterior cerebral artery and posterior branches of left medial cerebral arteries suggests antemortem infarction. Note hypodensity of subdural hematoma due to adaptation of window level and width on enhancing cortex.

Image interpretation was performed by one board-certified radiologist with 2 years of experience in forensic imaging and by an advanced radiologic resident with 3 years of experience in clinical radiology and 1.5 years of experience in for ensic CT. Each whole-body data set (unenhanced and arterial and venous injection) underwent a complete evaluation, similar to an examination in clinical radiology. For each case, a detailed written report of the findings was created. Image quality was evaluated by objective parameters in terms of complete filling of the vessel lumen and obvious iatrogenic extravasations (gastrointestinal tract, femoral cannulation). Through the interindividual differences of the postmortem interval and the associated tissue degradation, the parenchymal enhancement (brain, myocardium, upper abdominal organs, and peripheric soft tissue) was evaluated as a subjective criterion.

Results
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Head and Neck

Both contrast media solutions showed excellent visualization of the basal cerebral arteries. Anatomic variants of the circle of Willis and postinterventional changes with resulting perfusion deficits of the cerebral arteries (Fig. 3A, 3B) were clearly depicted with both contrast media solutions. Extravasation into intracerebral hematomas is suggestive of active bleeding at the time of death. The gray matter of the brain showed a unique enhancement after the injection of the PEG contrast solution, which improved visualization of the brain tissue distinctively. Brain structures that were affected by subfalcial or infratentorial herniations became much better visualized than in unenhanced CT (Fig. 4A, 4B). This kind of delineation of the cortex and the basal ganglia was not seen in the cases injected with the oily contrast compound. The arteriovenous vascularity of the neck was also clearly depicted by both contrast media solutions. Malignant tissues showed contrast enhancement after injection of the PEG contrast solution as well, as seen in a case with a partly necrotic laryngeal carcinoma. The enhancement of the submandibular glands after injection was a unique finding in the cases with PEG contrast solution (Fig. 5). Traumatic intramuscular and subcutaneous hematomas (Fig. 6) were seen radiographically as an extravasation of both contrast media solutions.

Thorax and Abdomen

The perfusion of the right coronary artery in a supine position was in some cases problematic, most likely due to an incomplete filling of the ventral parts of the ascending thoracic aorta. This problem was overcome by placing the cadaver in a prone position because this led to a good filling of the more ventrally positioned right coronary artery (Fig. 7). After injection of the PEG contrast solution, the myocardium of both ventricles displayed significant enhancement, a finding not observed in the cases with oily contrast media. A perforation of the right cardiac ventricle by a bullet was clearly identified by showing the holes in the myocardium and the extravasation into the pericardial space (Fig. 8A, 8B).

The antegrade perfusion of the venous system allowed excellent visualization of the pulmonary arteries via the right atrium and ventricle. We diagnosed pulmonary embolism (central and paracentral) (Fig. 9A, 9B) as a cause of death with both contrast media solutions (Table 1). Minor filling defects of the sub-segmental pulmonary arteries were found in three other cases. Histology proved these to be small postmortem clots, which were pushed from the right ventricle in the pulmonary periphery.

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Fig. 5 Axial CT image of neck shows partly necrotic laryngeal carcinoma with enhancing part on left side (dashed circle). Enhancement of musculature of neck is most likely due to reanimation attempts. Autopsy showed no evidence of metastatic disease. Note enhancement of right submandibular gland (arrow). (case 7; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol)

All cases of injections with the oily contrast solution showed extravasations in the areas with early autolysis (pancreas, gastrointestinal tract, intra-, and extraluminal) with no autoptic correlate of a lesion in the organ tissue or the adjacent vasculature. Furthermore, no significant decrease in enhancement of the vessels between the arterial and venous injections during the CT examinations was noted. The injection series with the PEG-mixed water-soluble contrast media showed no uncorrelated extravasations in any scans. However, there was intensive enhancement of the vascular bed in the parenchyma of the organs in the upper abdomen and the gastrointestinal wall, enabling the depiction of parenchymal lesions in these areas (Fig. 10A, 10B). We were able to display lesions of the abdominal aorta and the inferior vena cava after the injection with PEG contrast media (Figs. 11A, 11B, 11C and 12A, 12B), with the corresponding intra- and retroperitoneal extravasates. Even tiny lesions of branches of the superior mesenteric arteries could be displayed well (Fig. 13). With the PEG contrast solution, an intravascular contrast decrease of about 50% in 15 minutes was found and allowed an almost separate imaging of the abdominal arterial and venous systems (Fig. 14A, 14B).

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Fig. 6 Large intramuscular extravasation in left sternocleidomastoid muscle, identified at autopsy as intramuscular hematoma. (case 3; iodized oil [Lipiodol, Guerbet] and paraffin oil solution)

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Fig. 7 On volume-rendering technique image of coronaries, no relevant stenoses were diagnosed. Complete depiction of both coronary arteries was achieved by second scanning in prone position for better filling of more ventrally situated right coronary ostium. (case 8; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol)

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Fig. 8A Gunshot victim. (case 9; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol Axial CT image (A) and photograph of autopsy specimen (B) show gunshot to chest with perforation of inferior right cardiac ventricle (arrow, B) and massive hemorrhagic pericardial tamponade (asterisks, A). Note extravasation of contrast media solution in pericardial space. Scale (B) = cm.

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Fig. 8B Gunshot victim. (case 9; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol Axial CT image (A) and photograph of autopsy specimen (B) show gunshot to chest with perforation of inferior right cardiac ventricle (arrow, B) and massive hemorrhagic pericardial tamponade (asterisks, A). Note extravasation of contrast media solution in pericardial space. Scale (B) = cm.

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Fig. 9A Pulmonary embolism. (case 8; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Axial CT image (A) and photograph of autopsy specimen (B) with frontal view of opened pulmonary trunk after removal of heart show massive central and peripheral pulmonary embolism (arrows) with filling defects in pulmonary trunk and lobe arteries of both lungs. Thrombotic genesis of material was confirmed at autopsy.

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Fig. 9B Pulmonary embolism. (case 8; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Axial CT image (A) and photograph of autopsy specimen (B) with frontal view of opened pulmonary trunk after removal of heart show massive central and peripheral pulmonary embolism (arrows) with filling defects in pulmonary trunk and lobe arteries of both lungs. Thrombotic genesis of material was confirmed at autopsy.

Extremities

With both contrast media solutions, the arteries of the upper extremities showed a sufficient enhancement, even of the phalangeal arteries (Fig. 15A, 15B). The vessels of the thigh and the lower leg were also excellently depicted. This even allowed for the detection of peripheral arterial occlusive disease (Fig. 16A, 16B).

The retrograde filling of the venous bed of the extremities was occasionally unsatisfying. Depending on the sufficient functioning of the venous valves, only a proximal portion of the veins of the limbs filled with contrast media solution. Subcutaneous and intramuscular hemorrhages were consistently characterized by contrast extravasations.

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Fig. 10A Gunshot to chest. (case 9; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Sagittal multiplanar reconstruction image (A) and photograph of autopsy specimen (B) show bullet track (dashed line, A) through inferior sternum, with final position of projectile in intervertebral space L1–L2. Penetration of left lobe of liver with parenchymal extravasation of contrast media solution along intrahepatic bullet track (arrow, A) and in omental bursa can also be seen. Note retrosternal gas bubbles. Because of postmortem decreased lung volume and cadaver lying on back, heart and liver have been shifted cranially from original bullet track.

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Fig. 10B Gunshot to chest. (case 9; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Sagittal multiplanar reconstruction image (A) and photograph of autopsy specimen (B) show bullet track (dashed line, A) through inferior sternum, with final position of projectile in intervertebral space L1–L2. Penetration of left lobe of liver with parenchymal extravasation of contrast media solution along intrahepatic bullet track (arrow, A) and in omental bursa can also be seen. Note retrosternal gas bubbles. Because of postmortem decreased lung volume and cadaver lying on back, heart and liver have been shifted cranially from original bullet track.

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Fig. 11A Gunshot to chest. (case 9, iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Axial CT image after arterial perfusion (A), photograph of gross autopsy specimen (B), and histologic specimen (elastic Van Gieson stain) (C) show laceration of right lateral wall of abdominal aorta (arrows) with local aortic dissection and intraperitoneal extravasation (asterisk, A). Note enhancement of renal cortex. Scale (B) = cm. Magnification (C) = × 20.

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Fig. 11B Gunshot to chest. (case 9, iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Axial CT image after arterial perfusion (A), photograph of gross autopsy specimen (B), and histologic specimen (elastic Van Gieson stain) (C) show laceration of right lateral wall of abdominal aorta (arrows) with local aortic dissection and intraperitoneal extravasation (asterisk, A). Note enhancement of renal cortex. Scale (B) = cm. Magnification (C) = × 20.

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Fig. 11C Gunshot to chest. (case 9, iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Axial CT image after arterial perfusion (A), photograph of gross autopsy specimen (B), and histologic specimen (elastic Van Gieson stain) (C) show laceration of right lateral wall of abdominal aorta (arrows) with local aortic dissection and intraperitoneal extravasation (asterisk, A). Note enhancement of renal cortex. Scale (B) = cm. Magnification (C) = × 20.

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Fig. 12A Gunshot to chest. (case 9, iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Axial CT image (A) and photograph of autopsy specimen (B) show laceration of left lateral wall of inferior vena cava (arrows). Note local and perihepatic–perisplenic (asterisk, A) extravasation of contrast media solution.

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Fig. 12B Gunshot to chest. (case 9, iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Axial CT image (A) and photograph of autopsy specimen (B) show laceration of left lateral wall of inferior vena cava (arrows). Note local and perihepatic–perisplenic (asterisk, A) extravasation of contrast media solution.

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Fig. 13 Coronal maximum-intensity-projection reconstruction of superior mesenteric artery shows extravasation around left proximal branch of vessel. Rupture was caused by massive compression of thorax and upper abdomen. Note enhancement of pancreatic parenchyma and walls of gastrointestinal tract. (case 6; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol)

Discussion
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Both contrast media solutions allowed for postmortem whole-body angiographies. The most distinct difference of the two solutions is the enhancement of physiologically well-perfused tissues (cerebral cortex, myocardium, pancreatic and splenic tissue, renal cortex, and liver) seen with the PEG contrast solution and the unwanted extravasation through the pancreas and the intestines with the oily contrast compound. This enhancement phenomenon may be due to the molecular size of the oily compound, with a molecular size approximately equal to that of paraffin oil and Lipiodol.

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Fig. 14A Same case after contrast injection. (case 6; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Maximum-intensity-projection reconstruction images after arterial (A) and venous (B) injection of contrast media solution provide detailed depiction of thoracoabdominal vasculature. Note decreasing arterial enhancement during interval (15 minutes) between injections, allowing almost separate imaging of arteries and veins.

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Fig. 14B Same case after contrast injection. (case 6; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Maximum-intensity-projection reconstruction images after arterial (A) and venous (B) injection of contrast media solution provide detailed depiction of thoracoabdominal vasculature. Note decreasing arterial enhancement during interval (15 minutes) between injections, allowing almost separate imaging of arteries and veins.

The PEG and water-soluble contrast media solution consists, by contrast, of a large polymerized part (PEG 200) and an unpolymerized part with smaller molecular dimensions (Imagopaque). The oily compound, including the contrast agent, may seep through small vascular leaks in areas of early decomposition and may therefore give rise to unwanted extravasation. However, PEG, by virtue of its greater molecule size, will tend to remain in unharmed vessels and therefore be more decomposition-artifact resistant. The enhancement of well-vascularized tissues probably arises from a diffusion of the small molecular hydrophilic contrast media in the interstitial and intracellular spaces. This mechanism enables the separate visualization of the arterial and venous system with PEG, but it also raises the need of an instant CT examination after the injection. The oily compound of paraffin oil and Lipiodol remains in the greater vessels for a couple of hours, leaving more time between the injection and scanning. If the contrast media injection is performed in the CT room, this apparent advantage of the oily solution is negligible.

In conclusion, postmortem angiography with PEG has clear advantages in displaying abnormalities of well-vascularized tissues and avoids unwanted extravasations in the gastrointestinal tract. With this method, whole-body angiography with visualization of vascular abnormalities is possible. This may augment clinical and forensic postmortem examinations and, in combination with imaging-guided specimen sampling for histology and toxicology and whole-body CT and MRI, serve as a viable compromise to autopsy while ensuring clinical quality control and forensic assessment. Furthermore, the acquired data can be reevaluated at any time and is therefore fully reproducible for future research and counter-expertise.

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Fig. 15A Imaging of arm and hand. (case 7; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Volume-rendered technique image of right brachial arteries after arterial filling provides complete visualization of radial and ulnar arteries. Osseous structures have been removed by volume editing.

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Fig. 15B Imaging of arm and hand. (case 7; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol) Volume-rendered technique image of right hand, palmar view, provides visualization of even small phalangeal arteries.

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Fig. 16A Imaging of leg and foot. Volume-rendered technique image shows trifurcation of right popliteal artery, with signs of peripheral arterial occlusive disease of right leg, mainly seen as lumen irregularities in right peroneal artery (arrows). (case 7; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol)

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Fig. 16B Imaging of leg and foot. Volume-rendered technique image shows medial view of arteries of left foot. (case 6; iopentol [Imagopaque, GE Healthcare] and polyethylene glycol)

Address correspondence to S. Ross ().

References
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