Elsevier

European Journal of Radiology

Volume 89, April 2017, Pages 249-269
European Journal of Radiology

Review article
Diagnostic accuracy of postmortem imaging vs autopsy—A systematic review

https://doi.org/10.1016/j.ejrad.2016.08.003Get rights and content

Highlights

  • The search generated 340 possibly relevant publications, of which 49 were assessed as having high risk of bias and 22 as moderate risk.

  • Due to considerable heterogeneity of included studies it was impossible to estimate the diagnostic accuracy of the various findings.

  • Future studies need larger materials and improved planning and methodological quality, preferentially from multi-center studies.

Abstract

Background Postmortem imaging has been used for more than a century as a complement to medico-legal autopsies. The technique has also emerged as a possible alternative to compensate for the continuous decline in the number of clinical autopsies. To evaluate the diagnostic accuracy of postmortem imaging for various types of findings, we performed this systematic literature review.

Data sources The literature search was performed in the databases PubMed, Embase and Cochrane Library through January 7, 2015. Relevant publications were assessed for risk of bias using the QUADAS tool and were classified as low, moderate or high risk of bias according to pre-defined criteria. Autopsy and/or histopathology were used as reference standard.

Findings The search generated 2600 abstracts, of which 340 were assessed as possibly relevant and read in full-text. After further evaluation 71 studies were finally included, of which 49 were assessed as having high risk of bias and 22 as moderate risk of bias. Due to considerable heterogeneity – in populations, techniques, analyses and reporting – of included studies it was impossible to combine data to get a summary estimate of the diagnostic accuracy of the various findings. Individual studies indicate, however, that imaging techniques might be useful for determining organ weights, and that the techniques seem superior to autopsy for detecting gas

Conclusions and Implications In general, based on the current scientific literature, it was not possible to determine the diagnostic accuracy of postmortem imaging and its usefulness in conjunction with, or as an alternative to autopsy. To correctly determine the usefulness of postmortem imaging, future studies need improved planning, improved methodological quality and larger materials, preferentially obtained from multi-center studies.

Introduction

Half a century ago the rate of clinical autopsies in Europe and the USA was around 60%, but since then, clinical autopsy rates have drastically declined, and is today less than 10% (e.g. [1], [2], [3]).

The autopsy has long been regarded as the “gold standard” for retrospective quality assessment of clinical diagnoses [4]. Studies comparing clinical diagnoses and autopsy findings have revealed major discrepancies in ¼ or more of deceased patients undergoing autopsy [5], [6], [7]. Low autopsy rates may conceal medical malpractice, thereby preventing an important quality assurance indicator in health care [8]. Further, low autopsy rates will decrease the reliability of the cause-of-death statistics, in turn decreasing the usefulness of this statistics for health care planning and research. In the individual death, the family may be provided with wrongful or insufficient information regarding the cause of death, the underlying disease, etc. Hence, the decrease in clinical autopsy rate has negative consequences for the family, future patients, health care, and the society as a whole.

The reasons for this decline are manifold, and include the non-reimbursement of autopsies, clinician’s fear of medico-legal problems, reluctance of the family and/or of health care personnel, more deaths occurring at long-term care facilities, shortage of clinical pathologists, judicial principles, inadequate and delayed communication of autopsy results to clinicians, the requesting of autopsies being delegated to junior medical staff, organ retention issues, and advances in laboratory diagnostic technology – wrongfully – result in the belief among clinicians that the autopsy has become redundant.

If alternatives such as postmortem imaging techniques should turn out to be reliable in a situation where the autopsy rate is (too) low, these techniques could contribute to a more reliable cause-of-death diagnostic process. Particular virtues of postmortem imaging are the following; non-invasive, more rapid diagnostic process, and higher availability of radiologists than of clinical pathologists – further increased by telemedicine techniques. Imaging techniques also enables permanent documentation and meticulous reexamination, and would also enable increased quality assurance in health care by analyses of cases which currently are not autopsied at all.

The diagnostic accuracy of the postmortem imaging techniques is, however, not yet clarified, and as yet there is no evidence they are able to adequately replace the conventional autopsy. Hence, it is of importance to evaluate the scientific basis of postmortem imaging as a substitute for clinical autopsy, and as an adjunct for additional information to an autopsy.

The main objectives of this systematic review were to determine (i) the diagnostic accuracy of post-mortem imaging for different findings in populations which otherwise would be subjected to a (clinical) autopsy or no autopsy at all, and (ii) what additional information imaging can provide to a clinical and a medico-legal autopsy in different populations.

Section snippets

Protocol and registration

This systematic review was conducted at The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) and published in April 2015 as a report in Swedish [www.sbu.se/201501]. SBU uses a peer-reviewed protocol including pre-specified objectives in accordance with standards in HTA assessments (http://www.sbu.se/upload/ebm/metodbok/SBUsHandbok.pdf). The protocol is available from SBU upon request.

Eligibility criteria

The criteria for eligibility were:

  • Population: Fetuses, children and

Study selection

The literature search generated 2600 records, and of these 340 original papers were of potential relevance and read in full text. 269 of these were excluded (178 other research question, 87 not original data, 4 duplicates), and the remaining 71 were assessed for risk of bias. No report was deemed to have low risk of bias, 22 to have moderate risk, and 49 to have a high risk (Fig. 1).

Study characteristics, risk of bias within studies

The 22 included studies with moderate risk of bias [10], [11], [12], [13], [14], [15], [16], [17], [18], [19],

Summary and evidence

With the advantage of being rapid and non-invasive [32] and documenting the exact in situ state of body organs, postmortem imaging techniques such as computed tomography (PMCT) and magnetic resonance imaging (PMMR) have become increasingly used in forensic medicine during the last decade [33], [34].

This systematic literature review reveals, however, that the current scientific literature does not allow us to determine the diagnostic accuracy of postmortem imaging, whether used in conjunction

Conflicts of interest

No author declares any conflict of interest.

Funding

The project was conducted at by the Swedish Agency for Health Technology Assessment and Assessment of Social Services.

Acknowledgements

We gratefully acknowledge the administrative and secretarial support by Ms Anna Attergren Granath, and the literature searches by documentation specialist Ms Hanna Olofsson. Valuable comments were provided by professor Niels Lynnerup and professor Jytte Banner, Copenhagen, professor emeritus Christer Sundström, Uppsala, and associate professor Carl Winskog, Adelaide.

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