Skip to main content
SpringerLink
Log in

Sensitivity and specificity of post-mortem computed tomography in skull fracture detection—a systematic review and meta-analysis

  • Review
  • Published:
International Journal of Legal Medicine Aims and scope Submit manuscript

Abstract

Post-mortem computed tomography (PMCT) has been increasingly used as routine examination in forensic pathology. No recent review of the growing number of papers on the ability of PMCT to detect skull fracture exists, and original papers report sensitivities from 0.85 to 1.00. This systematic review (PROSPERO: CRD42021233264) aims to provide a meta-analysis of sensitivity and specificity of PMCT in skull fracture detection. We searched PubMed, MEDLINE and Embase for papers published between January 2000 and August 2021 reporting raw numbers, sensitivity and specificity or Abbreviated Injury Score for PMCT compared to autopsy. Papers without both PMCT and autopsy, no separate reporting of the neuro-cranium, exclusively on children, sharp trauma, gunshot or natural death as well as case reports and reviews were excluded. Two authors independently performed inclusion, bias assessment and data extraction. QUADAS-2 was used for bias assessment and a random effects models used for meta-analysis. From 4.284 hits, 18 studies were eligible and 13 included in the meta-analysis for a total of 1538 cases. All deceased were scanned on multi-slice scanners with comparable parameters. Images were evaluated by radiologists or pathologists. Intra- and inter-observer analyses were rarely reported. In summary, sensitivity of PMCT for detection of fractures in the skull base was 0.87 [0.80; 0.92] with specificity 0.96 [0.90; 0.98], and sensitivity for the vault was 0.89 [0.80; 0.94] with specificity 0.96 [0.91; 0.98]. The mixed samples are a limitation of the review.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

source of original papers, reasons for exclusion and number of papers at each stage. n number, AIS Abbreviated Injury Score, “JOFRI” Journal of Forensic Radiology and Imaging (now Forensic Imaging)

Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Code availability

The R code is available in the supplementary material.

References

  1. Wullenweber R, Schneider V, Grumme T (1977) A computer-tomographical examination of cranial bullet wounds [German]. Z Rechtsmed 80:227–246. https://doi.org/10.1007/bf02114619

    Article  CAS  PubMed  Google Scholar 

  2. Baglivo M, Winklhofer S, Hatch GM, Ampanozi G, Thali MJ, Ruder TD (2013) The rise of forensic and post-mortem radiology—analysis of the literature between the year 2000 and 2011. J Forensic Radiol Imaging 1:3–9. https://doi.org/10.1016/j.jofri.2012.10.003

    Article  Google Scholar 

  3. Blackmun H. (1993) WILLIAM DAUBERT, et ux., etc., et al., PETITIONERS v. MERRELL DOW PHARMACEUTICALS, INC. In: Court USS, ed.

  4. Scholing M, Saltzherr TP, Fung Kon Jin PH et al (2009) The value of postmortem computed tomography as an alternative for autopsy in trauma victims: a systematic review. Eur Radiol 19:2333–2341. https://doi.org/10.1007/s00330-009-1440-4

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Jalalzadeh H, Giannakopoulos GF, Berger FH et al (2015) Post-mortem imaging compared with autopsy in trauma victims—a systematic review. Forensic Sci Int 257:29–48. https://doi.org/10.1016/j.forsciint.2015.07.026

    Article  PubMed  Google Scholar 

  6. G Ampanozi D Halbheer LC Ebert MJ Thali U Held 2019 Postmortem imaging findings and cause of death determination compared with autopsy: a systematic review of diagnostic test accuracy and meta-analysis Int J Legal Med 321–37. https://doi.org/10.1007/s00414-019-02140-y

  7. D Uthandi A Sabarudin Z Mohd MAA Rahman MKA Karim 2019 Effectiveness of post-mortem computed tomography (PMCT) in comparison with conventional autopsy: a systematic review Curr Med Imaging Rev https://doi.org/10.2174/1573405615666190821115426

  8. Le Blanc-Louvry I, Thureau S, Duval C et al (2013) Post-mortem computed tomography compared to forensic autopsy findings: a French experience. Eur Radiol 23:1829–1835. https://doi.org/10.1007/s00330-013-2779-0

    Article  PubMed  Google Scholar 

  9. Daly B, Abboud S, Ali Z, Sliker C, Fowler D (2013) Comparison of whole-body post mortem 3D CT and autopsy evaluation in accidental blunt force traumatic death using the abbreviated injury scale classification. Forensic Sci Int 225:20–26. https://doi.org/10.1016/j.forsciint.2012.08.006

    Article  PubMed  Google Scholar 

  10. Bossuyt PM, Reitsma JB, Bruns DE et al (2015) STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. BMJ 351:h5527. https://doi.org/10.1136/bmj.h5527

    Article  PubMed  PubMed Central  Google Scholar 

  11. Page MJ, Moher D, Bossuyt PM et al (2021) PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ 372:n160. https://doi.org/10.1136/bmj.n160

    Article  PubMed  PubMed Central  Google Scholar 

  12. Eriksen MB, Christensen JB, Frandsen TF (2016) Embase er et centralt værktøj til medicinsk litteratursøgning. Ugeskrift for Læger 178:2–6

    Google Scholar 

  13. McKeever L, Nguyen V, Peterson SJ, Gomez-Perez S, Braunschweig C (2015) Demystifying the search button. J Parenter Enter Nutr 39:622–635. https://doi.org/10.1177/0148607115593791

    Article  Google Scholar 

  14. Haynes RB, Wilczynski NL (2004) Optimal search strategies for retrieving scientifically strong studies of diagnosis from Medline: analytical survey. BMJ 328:1040. https://doi.org/10.1136/bmj.38068.557998.EE

    Article  PubMed  PubMed Central  Google Scholar 

  15. C Jacobsen BH Bech N Lynnerup 2009 A comparative study of cranial, blunt trauma fractures as seen at medicolegal autopsy and by computed tomography BMC Med Imaging 9 https://doi.org/10.1186/1471-2342-9-18

  16. Jacobsen C, Lynnerup N (2010) Craniocerebral trauma—congruence between post-mortem computed tomography diagnoses and autopsy results: a 2-year retrospective study. Forensic Sci Int 194:9–14. https://doi.org/10.1016/j.forsciint.2009.10.001

    Article  PubMed  Google Scholar 

  17. Blokker BM, Wagensveld IM, Weustink AC, Oosterhuis JW, Hunink MG (2016) Non-invasive or minimally invasive autopsy compared to conventional autopsy of suspected natural deaths in adults: a systematic review. Eur Radiol 26:1159–1179. https://doi.org/10.1007/s00330-015-3908-8

    Article  PubMed  Google Scholar 

  18. A Paez 2017 Grey literature: an important resource in systematic reviews J Evid Based Med https://doi.org/10.1111/jebm.12265

  19. Schwarzer G, Carpenter JR, Rücker G. (2015) Meta-analysis with R. Springer International Publishing.

  20. Viechtbauer W (2010) Conducting meta-analyses in R with the metafor Package. 2010 36: 48. https://doi.org/10.18637/jss.v036.i03

  21. Whiting PF, Rutjes AW, Westwood ME et al (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155:529–536. https://doi.org/10.7326/0003-4819-155-8-201110180-00009

    Article  PubMed  Google Scholar 

  22. Deeks JJ, Macaskill P, Irwig L (2005) The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol 58:882–893. https://doi.org/10.1016/j.jclinepi.2005.01.016

    Article  PubMed  Google Scholar 

  23. Macaskill P, Gatsonis C, Deeks JJ, Harbourd RM, Takwingi Y. (2010) Cochrane handbook for systematic reviews of diagnostic test accuracy. In: Deeks JJ, Bossuyt PM, Gatsonis C, eds. Cochrane handbook for systematic reviews of diagnostic test accuracy. The Cochrane Collaboration http://srdta.cochrane.org/.

  24. Egger M, Smith GD, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315:629. https://doi.org/10.1136/bmj.315.7109.629

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Yen K, Lövblad KO, Scheurer E et al (2007) Post-mortem forensic neuroimaging: correlation of MSCT and MRI findings with autopsy results. Forensic Sci Int 173:21–35. https://doi.org/10.1016/j.forsciint.2007.01.027

    Article  CAS  PubMed  Google Scholar 

  26. Hoey BA, Cipolla J, Grossman MD et al (2007) Postmortem computed tomography, “CATopsy”, predicts cause of death in trauma patients. J Trauma 63: 979–85; discussion 85–6. https://doi.org/10.1097/TA.0b013e318154011f

  27. Sochor MR, Trowbridge MJ, Boscak A, Maino JC, Maio RF (2008) Postmortem computed tomography as an adjunct to autopsy for analyzing fatal motor vehicle crash injuries: results of a pilot study. J Trauma 65:659–665. https://doi.org/10.1097/TA.0b013e3181238d66

    Article  PubMed  Google Scholar 

  28. Cha JG, Kim DH, Kim DH et al (2010) Utility of postmortem autopsy via whole-body imaging: initial observations comparing MDCT and 3.0 T MRI findings with autopsy findings. Korean J Radiol 11:395–406. https://doi.org/10.3348/kjr.2010.11.4.395

    Article  PubMed  PubMed Central  Google Scholar 

  29. Mishra B, Joshi M, Lalwani S et al (2018) A comparative analysis of the findings of postmortem computed tomography scan and traditional autopsy in traumatic deaths: Is technology mutually complementing or exclusive? Arch Trauma Res 7:24–29. https://doi.org/10.4103/atr.atr_55_17

    Article  CAS  Google Scholar 

  30. Steenburg SD, Spitzer T, Rhodes A (2019) Post-mortem computed tomography improves completeness of the trauma registry: a single institution experience. Emerg Radiol 26:5–13. https://doi.org/10.1007/s10140-018-1637-4

    Article  PubMed  Google Scholar 

  31. Legrand L, Delabarde T, Souillard-Scemama R et al (2019) Comparison between postmortem computed tomography and autopsy in the detection of traumatic head injuries. J Neuroradiol = J nneuroradiol 47: 5–12. https://doi.org/10.1016/j.neurad.2019.03.008

  32. Di Paolo M, Maiese A, dell’Aquila M et al (2020) Role of post mortem CT (PMCT) in high energy traumatic deaths. Clin Ter 171:490–500. https://doi.org/10.7417/ct.2020.2263

    Article  Google Scholar 

  33. Worasuwannarak W, Peonim V, Srisont S, Udnoon J, Chudoung U, Kaewlai R (2020) Comparison of postmortem CT and conventional autopsy in five trauma fatalities. Forensic Imaging 22:200389. https://doi.org/10.1016/j.fri.2020.200389

    Article  Google Scholar 

  34. Graziani G, Tal S, Adelman A, Kugel C, Bdolah-Abram T, Krispin A (2018) Usefulness of unenhanced post mortem computed tomography—findings in postmortem non-contrast computed tomography of the head, neck and spine compared to traditional medicolegal autopsy. J Forensic Leg Med 55:105–111. https://doi.org/10.1016/j.jflm.2018.02.022

    Article  PubMed  Google Scholar 

  35. Wijetunga C, O'Donnell C, So TY et al (2020) Injury detection in traumatic death: postmortem computed tomography vs. open autopsy. Forensic Imaging 20: 100349. https://doi.org/10.1016/j.jofri.2019.100349

  36. Leth PM, Struckmann H, Lauritsen J (2013) Interobserver agreement of the injury diagnoses obtained by postmortem computed tomography of traffic fatality victims and a comparison with autopsy results. Forensic Sci Int 225:15–19. https://doi.org/10.1016/j.forsciint.2012.03.028

    Article  PubMed  Google Scholar 

  37. Leth P, Thomsen J (2013) Experience with post-mortem computed tomography in Southern Denmark 2006–11. J Forensic Radiol Imaging 1:161–166. https://doi.org/10.1016/j.jofri.2013.07.006

    Article  Google Scholar 

  38. Leconte C, Peyron PA, Meusy A, Lossois M, Baccino E (2016) Confrontation of the efficiency of post-mortem computed tomography and classical autopsy in the detection of osteoarticular traumatic injuries: About 28 cases. Revue de Médecine Légale 7:51–59. https://doi.org/10.1016/j.medleg.2016.02.002

    Article  Google Scholar 

  39. Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, Botella J (2006) Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods 11:193–206. https://doi.org/10.1037/1082-989x.11.2.193

    Article  PubMed  Google Scholar 

  40. Hoaglin DC (2016) Misunderstandings about Q and ‘Cochran’s Q test’ in meta-analysis. Stat Med 35:485–495. https://doi.org/10.1002/sim.6632

    Article  PubMed  Google Scholar 

  41. Cattaneo C, Marinelli E, Di Giancamillo A et al (2006) Sensitivity of autopsy and radiological examination in detecting bone fractures in an animal model: implications for the assessment of fatal child physical abuse. Forensic Sci Int 164:131–137. https://doi.org/10.1016/j.forsciint.2005.12.016

    Article  CAS  PubMed  Google Scholar 

  42. Thali MJ, Yen K, Schweitzer W et al (2003) Virtopsy, a new imaging horizon in forensic pathology: virtual autopsy by postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)—a feasibility study. J Forensic Sci 48:386–403

    PubMed  Google Scholar 

  43. Hueck U, Muggenthaler H, Hubig M et al (2020) Forensic postmortem computed tomography in suspected unnatural adult deaths. Eur J Radiol 132:109297. https://doi.org/10.1016/j.ejrad.2020.109297

    Article  CAS  PubMed  Google Scholar 

  44. Pescarini L, Inches I (2006) Systematic approach to human error in radiology. Radiol Med (Torino) 111:252–267

    Article  CAS  Google Scholar 

  45. Gascho D, Thali MJ, Niemann T (2018) Post-mortem computed tomography: technical principles and recommended parameter settings for high-resolution imaging. Med Sci Law 58:70–82. https://doi.org/10.1177/0025802417747167

    Article  PubMed  Google Scholar 

  46. Flach PM, Gascho D, Schweitzer W et al (2014) Imaging in forensic radiology: an illustrated guide for postmortem computed tomography technique and protocols. Forensic Sci Med Pathol 10:583–606. https://doi.org/10.1007/s12024-014-9555-6

    Article  PubMed  Google Scholar 

  47. Filograna L, Tartaglione T, Filograna E, Cittadini F, Oliva A, Pascali VL (2010) Computed tomography (CT) virtual autopsy and classical autopsy discrepancies: radiologist’s error or a demonstration of post-mortem multi-detector computed tomography (MDCT) limitation? Forensic Sci Int 195:13–17. https://doi.org/10.1016/j.forsciint.2009.11.001

    Article  Google Scholar 

  48. Schulze C, Hoppe H, Schweitzer W, Schwendener N, Grabherr S, Jackowski C (2013) Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy. Forensic Sci Int 233:90–98. https://doi.org/10.1016/j.forsciint.2013.08.025

    Article  PubMed  Google Scholar 

  49. Schweitzer W, Bartsch C, Ruder TD, Thali MJ (2014) Virtopsy approach: structured reporting versus free reporting for PMCT findings. J Forensic Radiol Imaging 2:28–33. https://doi.org/10.1016/j.jofri.2013.12.002

    Article  Google Scholar 

  50. Ruder TD. (2021) PMCT from head to toe—how to approach a stack of 4000 images. 10th Annual Ongress of the International Society of Forensic Radiology and Imaging Krakow, Poland.

Download references

Author information

Authors and Affiliations

  1. Department of Forensic Medicine, Section of Forensic Pathology, University of Copenhagen, Frederik V’s vej 11, 2100, Copenhagen, Denmark

    Mikkel Jon Henningsen, Sara Tangmose Larsen, Christina Jacobsen & Chiara Villa

Authors
  1. Mikkel Jon Henningsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sara Tangmose Larsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christina Jacobsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Chiara Villa
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MJH and CV conceived the study. All authors contributed to the protocol and search strategy. MJH and STL performed the literature search and data extraction. MJH analysed the data and wrote first draft. All authors contributed to writing and approved the manuscript.

Corresponding author

Correspondence to Mikkel Jon Henningsen.

Ethics declarations

Ethics approval

No ethical approval was needed for this review.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Henningsen, M.J., Larsen, S.T., Jacobsen, C. et al. Sensitivity and specificity of post-mortem computed tomography in skull fracture detection—a systematic review and meta-analysis. Int J Legal Med 136, 1363–1377 (2022). https://doi.org/10.1007/s00414-022-02803-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00414-022-02803-3

Keywords

Search

Navigation