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University of Leicester findings could represent breakthrough in how autopsy practice is conducted in UK and worldwide

Research suggests non-invasive post-mortem should become future standard first-line test in natural death

“We expect our results to have a major influence on the future of autopsy practice in the UK, and across the world” – Professors Guy Rutty and Bruno Morgan

Though most people have never witnessed a real autopsy, the basics of the procedure are well-known from innumerable films and TV series. For someone who has just lost a loved one unexpectedly, the thought that the person’s body will be sliced open and their organs removed can be extremely distressing and can also have cultural or religious implications. But is it necessary? Where the cause of death is unclear, a Coroner will order an autopsy – but an alternative does exist.

Post mortem computed tomography (PMCT) uses a CT scanner, a device found in many hospitals, which enables doctors to build up a 3D image of a patient by taking successive X-ray slices through their body. Employing computed tomography on the deceased presents a non-invasive alternative to autopsy – the potential to accurately determine cause of death without disturbing the body. PMCT has been used since 1983 as an additional tool to support an autopsy, and has been proposed since 1994 by some people as a full alternative.

But how reliable is PMCT against the ‘gold standard’ of cutting someone open and performing a full autopsy? Previous studies in this area have been inconclusive; some used very small numbers of cadavers and others did not adhere to the guidelines of the English/Welsh Coroner system. This study, led by Professor Guy Rutty and Professor Bruno Morgan and published in The Lancet (May 2017), is the first to provide statistically significant data on the effectiveness of PMCT as an alternative to autopsy within the English/Welsh system.

How the study was conducted

In total, 241 cases were recruited to the study between January 2010 and September 2012, each of which had been referred for an invasive autopsy by a Coroner. The cases were chosen randomly by picking the first suitable case on each study day (when staff were available to conduct a PMCT scan). Of these 241 cases, 24 were excluded from the data analysis because the cause of death was an obvious injury, such as a shooting or car crash, and so the cause of death was known prior to both PMCT and the invasive autopsy. Another seven were excluded for other reasons, leaving a sample size of 210 bodies. Two thirds were male, all were adults, and none were morbidly obese (there is a practical limit to the size of person who can pass through the doughnut-shaped CT scanner). In every case, consent to use the body in this study was given by relatives of the deceased.

The first step was a thorough external examination, followed by a PMCT scan. However, although PMCT can diagnose many conditions, it cannot detect coronary artery disease. In other words, it cannot spot if someone died from a heart attack – and heart attacks are the commonest cause of sudden adult death. In hospital practice for the living, this type of investigation is performed using an injection of a contrast agent into a vein, normally in the arm, using the circulation of blood to deliver the contrast agent to the heart. The contrast agent is a type of “dye” that shows up on x-rays. To solve this problem in the post mortem setting, we therefore do a second scan incorporating direct angiography (termed PMCTA).

Angiography is performed by inserting a flexible catheter into an artery and progressing its tip to exactly where the contrast agent needs to be delivered. For living patients, the catheter is often inserted into the femoral artery at the top of the leg, which seems a long way from the heart but provides a conveniently direct route. For PMCTA we pass the catheter through the left common carotid artery, which requires a small cut on the neck. For this reason, the PMCTA process can be described as ‘minimally invasive’ rather than non-invasive. In a few cases, the angiography was not successful for various technical reasons. These were recorded in the study results. We used standard x-ray contrast agents used in daily hospital practice and we used air, which cannot be used in the living to study heart vessels.

Video Demonstrating PMCTA in Action

What the study showed

Once the PMCTA scans were complete, an autopsy followed within 24 hours. The doctors conducting the autopsy were unaware of the PMCTA results (unless there was something they needed to know for safety reasons like an infectious disease). Separate reports were prepared from the PMCTA scans and from the autopsy so that the study was effectively “blinded” and neither process could influence the other. Then the reports were compared.

There were, naturally, a few discrepancies. PMCTA is better than autopsy at spotting trauma and haemorrhage, while autopsy is better than PMCTA when it comes to identifying pulmonary thromboembolism. This implies that the best accuracy (the gold standard) is achieved by combining both procedures. However, for most cases the gold standard is not required, because in 193 of the 210 cases studied (92%), PMCTA was able to establish the cause of death with an accuracy similar to autopsy.

England and Wales have one of the highest autopsy rates in the world, with about 90,000 cases each year where a Coroner requests an autopsy to determine cause of death. This important study suggests that in nine out of ten cases of natural disease an invasive autopsy is not necessary, with all the necessary information being available through PMCTA. Only in about 10% of cases would there be a need to follow the PMCTA with an autopsy, with all the ethical, cultural and legal baggage that the procedure carries. These findings could completely alter the way that the cause of sudden adult death is determined, initially within England and Wales and potentially across the globe. Press Release 

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