#JournalReading

by kelompok 2
 Time-related change evaluation of the
cerebrospinal fluid using postmortem CT
Kohei Morikawa a, Hideki Hyodoh b,, Kotaro Matoba c, Keisuke Mizuo a,
Shunichiro Okazaki a, Satoshi Watanabe a

- Dept. Legal Medicine, Sapporo Medical University School of Medicine, Japan

- Center for Cause of Death Investigation, Hokkaido University, Graduate School of
Medicine, Japan
- Dept. Forensic Medicine, Hokkaido University, Graduate School of Medicine, Japan

2016
 Big concept
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jangan malah tidur lagi
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Our process is easy

Recall Journal Discussion

Session its self
 1.
RECALL Session
Lets start with the first set of slides
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 2.
Journal Its Self
Repetition is the Key!

Vera a. firman
 BACKGROUND

One of the recent topics

Postmortem CT images attracting interest in
the field of legal
medicine
able to provide objective represent about 10
information when 15% of these fractures the reasons
required in cases such for this attraction is its
personal identification objectivity
and injury

Thali et al. have reported

on postmortem CT images combined with 3D surface recording,
So called Virtopsy, and the postmortem image has been established as
one of the important medical documents
Vera a. firman
 BACKGROUND (Contd)

Use
Post mortem ct
Exp. examination
There are some unknown
findings
so that it is important to evaluate specific
postmortem change

normal changes related

postmortem to other causes.
changes (pathological)

some postmortem CT image

changes presented similarly to
specific pathological lesions,

Vera a. firman
Background (Contd)
Repeated studies on CT
imaging reported
the time-related
postmortem change in
brain
Especially the lateral ventricle
density in early postmortem period
But these reports covered
only the short postmortem
period
longer postmortem interval?
Necessary to evaluate
to understand the time-related
change in practical forensic
radiology investigation. Sella Rizki
 Background (Contd)

In this study,
we retrospectively evaluated the
cerebrospinal fluid (CSF) CT density at
the lateral ventricle to compare the
postmortem intervals in cadavers.

Sella Rizki
 Material & Methods
This study was approved by the ethics committees of our institutions.

Postmortem CT images obtained prior to full autopsy

from January 2012 to November 2015

pediatric (younger than 20)

small ventricle size (less than region-of-interest (ROI) size)

Exclusion Criteria Cause of death was hypothermia or intra-cranial bleeding

Containing intra-cranial gas

part of brain missing

ambiguous postmortem interval time. Sella Rizki

 approved by the ethics
committees
Process
Material & Methods
(Contd)
selection of the Cadaver

The number of cadavers enrolled in this study was

189 (male 120, female 69)

divided into 13 groups (postmortem

day 0.5, 1, 1.5, 2, 2.5, 3, 4, 5, 7, 10, 14, 21, 30)

Imaging protocol

Imaging analysis

Estimated postmortem time

Statistical analysis Oktasi Stella

 Imaging Protocol

All cadavers were examined by postmortem CT prior to the full autopsy.

The whole body scan was evaluated using a 64-slice multidetector CT
scanner (Aquilion CX, Toshiba, Japan).

The parameters from neck to head part were as follows:

120 kV, 300 mA, 1.0 s/rotation, pitch factor 0.641, configuration 0.5 32,
reconstruction 0.5 mm, MPR (multiplanar reconstruction) image
reconstruction 5 mm in axial, sagittal, and coronal sections.
Oktasi Stella
 Imaging analysis

All data sets were transferred to an image server in Digital

Imaging and Communication in Medicine (so called DICOM) format
and the 3 ROIs, at the lateral ventricle excluding the choroid plexus
or artifact,

were positioned to measure the CSF density using OsiriX

(App v.3.9.4).

The CSF density was calculated from the average of the 3 measured
ROIs and the standard deviation (SD) was also calculated
(Fig. 1).
Oktasi Stella
 Estimated postmortem time

Postmortem time was evaluated according to the results of the

full autopsy and the information on the cadavers circumstances.

When the postmortem time was estimated with time width, the
maximum period was used to estimate postmortem time.

Ratna R.
 Statistical Analysis

To evaluate the time-related CSF density change course, the full

number of cadavers was divided into groups according to the
postmortem time:

such as day 0.5, 1, 1.5, 2, 2.5, 3, 4, 5, 7, and >7

In Addition.
up to day 2.5 beyond day 7
(group A) (group C)

day 37
(group B) Ratna
 Statistical Analysis (Contd)

We used StatView (SAS Institute Inc., North Carolina, USA,

Version 5.0) software with a Bonferroni/Dunn study

DATA
Differences with p < 0.05 were
considered statistically significant

COMPARISON!!

CSF density Ratna

Spearmans rank correlation test estimated postmortem
time
 This is The Result Exclusion
The cadavers, postmortem CT less than 20 year-old hypothermia (n = 10) undefined postmortem-time
prior to full autopsy numbered 391 (n = 25) (n = 21)

202 cadavers ambiguousness of intra-cranial bleeding intra-cranial gas lost information of

were excluded lateral ventricles (n = 5) (n = 26) (n = 109) head part (n = 6)

Eventually, 189 cadavers (male 120, female 69) were enrolled in this study Byandra
 This is The Result
Cause of Death
drowning (n = 31) multi-organ failure (n = 7),

Sudden cardiac death (n = 23) carbon monoxide poisoning (n = 10)

Sepsis (n = 4) pulmonary artery embolization (n = 2)

burn (n = 4) crash syndrome (n = 2)

drug poisoning (n = 4) Electrocution (n = 2)

peritonitis (n = 1), cardiac tamponade (n = 1)
hanging (n = 1), cancer (n = 1),
brain infarction (n = 1), malnutrition (n = 1)
renal failure (n = 1), unknown (n = 69).
Byandra
 This is The Result Postmortem times
day 0.5 (n = 12)
day 1 (n = 17)
day 1.5 (n = 24) Group A
day 2 (n = 80), (mean 1.7 days)
day 3 (n = 22)
day 2.5 (n = 4)
day 4 (n = 7)
Group C day 5 (n = 2)
(mean 17.3 days) day 7 (n = 9)
day 10 (n = 4)
day 14 (n = 4),
day 21 (n = 1) Group B
day 30 (n = 3) (mean 4.2 days)

Byandra
 This is The Result
CSF CT value

The CSF density was around 20 HU up to day 2.5,

and it increased gradually after day 3.

Day 5, 10, 14, 21, and 30 were excluded from statistical

evaluation because of insufficient numbers

See Table 1. Tegar

 Tegar

This is The Result

CSF CT value
 This is The Result
CSF CT value

Using Bonferroni-Dunn test, day 3 and day 4 presented

higher CSF density than day 1, and day 1.5 (p < 0.05)
day 7 presented higher CSF
density than day 0.5, 1, 1.5, 2, 2.5, and day 3 (p < 0.05)

See Fig. 2. Enyke

Enyke
 This is The Result
CSF CT value

According to the postmortem time-width, the mean CT values of CSF

density were
20.0 3.3 in group A,
22.0 4.2 in group B, and
26.5 5.9 in group C

See Fig. 3.
Vina R
See table. 3.
CSF CT value

Vina
CSF CT value

table. 3.

Vina
 Discussion

In previous study Postmortem CT findings, showing changes, with the postmortem intervals

lung
vascular diameters pleural effusion
appearance

In this study, the CSF density at the lateral ventricles was concordant
showed an increase with postmortem time with previous reports

according to postmortem time-width,

the CSF density exhibited a statistically This is the first report of a
significant increase along with statistical increase in CSF.
postmortem time. Ganis
 Discussion (Contd)

The mechanisms of increasing CSF density.

Hasegawa et al. are still under evaluation

Reported possibility of decomposition of
CSF Protein and/or the ependymal layer,

while a swelling brain

CSF condensation Exerts pressure
to the ventricles

inflow of protein-like substances from the

periventricular brain tissues to the CSF Ganiss
Discussion (Contd)

The increasing X-ray

absorption leads to the increasing CT value

so that the CSF must

be increasing its density along with
postmortem time.

Further study will be

needed to evaluate the tissue affect increasing CT
pathological change of the density with the
ependymal layer and/or postmortem time.
periventricular brain
Ganis
 Discussion (Contd)

Koopmanschap et al. They used cadavers with

reported a linear equation formula relating confirmed time of
& postmortem time and CSF CT density death and examined within the
early postmortem time
Hasegawa et al.

From our results, there was no The postmortem times

significant linear correlation between covered too wide a time range
CSF density and estimated
the standard deviation of CSF
postmortem time
density was large

environmental factors
there was overlap between
postmortem
times
Temperature Humidity Wind Yoga Iswara
 Discussion (Contd)

small ventricle
pediatrics size hypothermic death

Exclusion Criteria

intra-cranial bleeding unknown postmortem

interval time
intra-cranial gas

Yoga Iswara
 Limitation

First,
we used the same CT equipment with the same protocol
throughout, but if different CT equipment and/or a
different protocol was used, the CSF density might result
in a different CT number
Second,
the 3 ROI measurements were taken by one operator to
minimize the operator dependency.
But if we use automatic ROI setting more objective
Naela
 Limitation (Contd)

Third,
we used the postmortem time from the evaluation
of the autopsy findings, which might contain some
error range.

Naela
 Conclusion

The CSF density was increasing, but not linearly, according to the postmortem time

3rd postmortem 7th postmortem

day was the day was the first
earliest time to to show a
show any statistically
increase significant
difference

Because much overlap of CSF density was evident, it was difficult to

estimate the postmortem time based on CSF density. Naela
 3.
Discussion Session
Lets start with the first set of slides
Danke!