Virtopsy

Virtopsy is a virtual alternative to a traditional autopsy, conducted with scanning and imaging technology. The name is a portmanteau of 'virtual' and 'autopsy' and is a trademark registered to Prof. Richard Dirnhofer (de), the former head of the Institute of Forensic Medicine of the University of Bern, Switzerland.^[1][2]

The term “virtual” in this context apparently is meant in both the modern and original senses. Virtual's Latin root word “virtus” (virtue) implies the qualities of capability, efficiency, effectiveness and objectivity. However, some proponents propose to replace traditional autopsy with this approach.^[3] "Virtual" also has the sense of "digital".

Drihnhofer claimed that Virtopsy fully satisfies the requirement that medical forensic findings provide “a complete and true picture of the object examined”.^[4] Furthermore, Virtopsy also achieves the objective “that the pathologist’s report should ‘photograph’ with words so that the reader is able to follow his thoughts visually”.^[5]

Concept

Forensic pathology is a field within which physicians are mainly preoccupied with examining what initially are victims of possible, suspected or obvious violence that ultimately die. Clinical forensic medicine essentially does the same but with living victims; traffic medicine and age determination are applications that are not, strictly speaking, restricted to clinical forensic medicine in that general practitioners, pediatricians and other specialists also provide services for such requests.

As examinations typically are performed under the legal and task restraints of investigative authorities such as courts, prosecutors, district attorneys or police, there are constraints as to cost, time, objectivity and task specification depending on local law.

The most relevant step is adequately documenting findings. Virtopsy employs imaging methods that are also used in clinical medicine such as computed tomography (CT), magnetic resonance imaging (MRI).^[6] Also, 3D surface scanning typically used in automotive industry is being employed to integrate body surface documentation with 3D scene or tool scans. The choice of methods is further supplemented with 3D imaging guided biopsy systems^[7] and post mortem angiography.^[8]

CT is well suited to show foreign objects, bone and air or gas distribution throughout the body, whereas MRI sequences are strong in detailing organ and soft tissue findings. A comprehensive analysis of both surface and deep tissue findings may require fusion of CT, MRI and 3D surface data.^[9]

Resulting data can be archived and reproduced without loss,^[10] analysed elsewhere, or distributed to specialists for technically demanding analysis.

Autopsy still produces both different and ancillary findings compared to Virtopsy results so that currently, Virtopsy is not a generally accepted method to entirely replace autopsies.^[11] In fact, the first scientific study detailing the results of comparing postmortem CT scanning with conventional autopsies was conducted by a team from Israel and was published 1994.^[12] Their conclusion already had been that single methods were not as useful to maximize on yielding as many findings as possible as the combination of scanning and autopsy were.

Terms

The term “Virtobot” is a trademark also registered to Prof. R. Dirnhofer. It describes a multi-functional robotic system.^[7]

The Virtangio machine is a device that is trademarked to Prof. R. Dirnhofer ^[13] and manufactured by FUMEDICA .^[14]

Usage of Greek words in the context of examining deaths may not withstand the test of falsification that spearheaded the Virtopsy idea to begin with, but, in fact, usage of existing and creation of new neologisms may have to be reconsidered.^[15]

Operative aspects

The Virtopsy project started as a research project that was initiated at the end of the twentieth century by Prof. Richard Dirnhofer, and now covers both applied methods and research.Virtopsy contains applied research into various methods of high-tech imaging with the goal to introduce them into the practice of forensic pathology.^[6]

With Prof. Michael Thali as operative head of the group, the Virtopsy research team operates out of the Institute of Forensic Medicine at the University of Zurich, Switzerland since early 2011.^[16]

Examination of death

The idea to conduct virtual autopsy is not new. In 2003, the British Museum contacted the University of Bern's Institute of Forensic Medicine in Switzerland for their Virtopsy to do autopsy on a 3000-year-old mummy named Nesperennub without compromising the body.^[17] While manner of death,^[6] cause of death,^[6] time of death,^[18][19] identification of deceased and a range of practical and reconstructive applications are obviously related to medicolegal investigation of death, Virtopsy methods were ground breaking in that they have established a new high-tech toolbox into both research and practice morphological investigation aspects of modern forensic pathology.

Since virtopsy is non-invasive, it is less traumatic for surviving family members and may not violate religious taboos against violating bodily integrity.^[20]

Examination of the living

Non-invasive imaging is also conducted in living or surviving subjects, but as that has been the main clinical application of CT and MR imaging to begin with, their use in medicolegal investigation of the living is not as ground breaking as using them for investigation of death. Nevertheless, a number of applications that may be regarded as specific for medicolegal imaging applications in the living have found attraction for Virtopsy-derived methods:

• Matching weapon or injury-causing agent and injury. The application of 3D surface documentation of injuries for the benefit of medicolegal reconstruction must be accredited to Brueschweiler et al. (2003).^[21]
• Strangulation and estimation of risk of death. The first paper documenting systematic application of MRI to survivors of strangulation for the benefit of forensic medicine was published by Yen et al. in 2005.^[22]
• Body packing. According to a paper of the Virtopsy group, CT scanning may be more suitable to body packer identification than conventional or plain abdominal X-rays.^[23]

Technology

The technology currently used for conducting a “virtual autopsy” comprises:

• Robot-guided surface scanning for three-dimensional documentation of the surface of the body, to scale and in color.^[7] This supplements the external postmortem examination of the body" that is done in a conventional autopsy;
• Multislice spiral CT and MRI for visualising the body in 3D. This supplements the internal postmortem examination of the body in an autopsy;^[6]
• Post mortem angiography, which visualises the cardiovascular system of the deceased with the aid of a peristaltic pump and contrast medium;^[8]
• Image- and robot-guided, contamination-free sampling for a wide range of supplementary forensic analyses, such as histology, bacteriology, virology, toxicology and diatomology.^[7] This procedure replaces the usual collection and storage of sample material from the body.

Virtopsy objectives

The Virtopsy idea was generated to yield results along a comprehensive number of performance indicators:

• The practical objective of both research and application of Virtopsy methods are to improve the objectivity of findings made in forensic autopsies.
• The academic objective of Virtopsy research is to publish original and validation type research.
• Last but not the least, financial gains are also a relevant aspect of new technology particularly in the private industry sector whereas saving cost is an aspect for public institutes or offices.

Success

Virtopsy methods have helped to solve a range of cases that would have been difficult or impossible to solve otherwise.^[24] While academically, case-reports tend to be looked down on by medical faculty, they can expand the existing experience by significant contributions.

Advantages

This method offers the following advantages:

• Preservation of the body in a virtual form.
• Observer-independent documentation of the evidence – "delegation of seeing to the machine".
• Complete, non-destructive gathering of findings from head to toe
• Data acquisition in parts of the body that otherwise would not be examined out of respect for the deceased (e.g. the face).
• Data acquisition in regions that are difficult to dissect and access (e.g. atlanto-occipital joints), and in cases of advanced decomposition.
• Visualization of the cardiovascular system.
• Replacement of manual dexterity by the "virtual knife" of the automatic sectional imaging technique.
• Standardized data acquisition procedure.
• High-precision, contamination-free sampling (poisons, infections, tissue, etc.) accurate to the millimeter.
• True-to-scale 3D documentation for precise forensic reconstructions.
• Clean, bloodless visualization of the documentation.
• Improvement in the quality of forensic reports – simultaneous examination by different experts via tele-forensics.
• Simplification of the assessment of evidence by improved comprehensibility of the visual 3D findings.
• Acceptance by relatives and religious communities over conventional autopsies.
• The complete saved data-set can be re-examined at any time if a second expert opinion is required, even after burial or cremation of the body.
• Rapid and complete data acquisition as part of analyses following disasters (terrorist attacks, plane crashes, etc.).

Disadvantages

• High equipment costs
• The limitations for radiology apply:
  • Metal foreign objects
  • One cannot determine the color of internal organs and color changes
  • One cannot determine all the pathological conditions (e.g. inflammation)
  • One cannot determine the infection status of tissue
  • It is difficult to differentiate antemortem from postmortem wounds and postmortem artifacts
  • Small tissue injuries may be overlooked
• The limitations for surface scanning apply:
  • Recording concave features, out of view
  • Turning the body over for total body recording can alter the body shape due to gravity (e.g. stomach) which may disturb the merging of recorded surfaces
  • Recording reflective or transparent surfaces (e.g. the eye)
• Merging data from multiple techniques will always result in some loss of precision
• A reliance on imagery alone may lead to omissions (e.g. bruising under the scalp not visible with surface scanning)
• Validity
  • No proper validation of the method has been made using closely prepared prospective studies
  • No error rate available
  • No juridical validity (yet)
  • As applicable to all simulated evidence presented in the court room, there are concerns of suggestiveness
• Objectivity
  • It has not been investigated whether experts are consistent in their judgment
  • Context effects (e.g. post-hoc target shifting in cases in which injury patterns are compared to possible injury-causing objects)

Best Practice

It is for this reason that the National Research Council in the USA, as part of its proposals for reforms in the forensic sciences, has proposed Virtopsy as “Best Practice” for the gathering of forensic evidence [www.ncjrs.gov/pdffiles1/nij/grants/228091.pdf].

In addition, the International Society of Forensic Radiology and Imaging was founded in 2012 with the aim of enabling a continuous exchange of research results among its members and developing quality standards for the techniques employed .

A TWGFIM (Technical Working Group Forensic Imaging Methods) was founded in 2005 by Michael Thali and Richard Dirnhofer. It aims to promote an increasingly internationally standardised approach.

Furthermore, a TWGPAM (Technical Working Group Postmortem Angiography Methods) was founded in 2012 to promote best practice. Under the direction of the University Hospital of Lausanne (CHUV) in Lausanne (Dr. Silke Grabherr), the TWGPAM (made up of nine European institutes of forensic medicine) is developing reliable, standardized methods and guidelines for conducting and assessing postmortem angiographic examinations [www.postmortem-angio.ch].

Virtopsy project leading house

• Universität Zürich Institut für Rechtsmedizin
• The virtopsy website at the Institute of Forensic Medicine at the University of Zurich

Institutes contributing to the Virtopsy project

• Institut für Rechtsmedizin der Universität Basel
• Charité Berlin, Institut für Rechtsmedizin
• University of Bern, Institut für Rechtsmedizin
• Centre universitaire romand de médecine légale, Lausanne - Genève (CURML)

Institutes, districts or countries conducting post mortem scanning

• Japan - Autopsy Imaging ^[25]
• Australia - Melbourne - VIFM ^[11]
• Europe - Denmark - Odense - Institute of Forensic Medicine, University of Southern Denmark ^[26]
• United States - State of Maryland Medical Examiner ^[27]

External links

• Strengthening Forensic science in the USA
• National Research Council
• An article on virtopsies by Popular Science
• An article on virtopsies by the New York Times

Films

• The Virtopsy Process
• The Virtopsy Table
• Virtual Autopsy Table

Books and Journals

• Brogdons's Forensic Radiology, 2nd Edition Michael J. Thali, Mark D. Viner, Byron Gil Brogdon, 2011 CRC Press
• The Virtopsy Approach: 3D Optical and Radiological Scanning and Reconstruction in Forensic Medicine Michael J. Thali, Richard Dirnhofer, Peter Vock, 2009 CRC Press
• Entwicklung des Systems, Interview mit Thali
• Virtopsy – Obduktion neu in Bildern; Dirnhofer/Schick/Ranner, Schriftenreihe Recht der Medizin, 2010 Manz
• Revolution in der Gerichtsmedizin erschienen in „Öffentliche Sicherheit 9-10/09
• Die Virtopsie wird die Autopsie ablösen Erschienen in KRIMINALPOLIZEI Oktober/November 2009

Virtopsies in popular culture

• In the CSI: Miami episode "Deep Freeze", Dr. Woods performs a virtopsy on a recently murdered athlete to prevent damaging it so that he could be cryogenically frozen.
• In the CSI: NY episode "Veritas", Sid does a virtual autopsy on Derek, showing Stella that the bullet that killed him entered through his cheek.

References

1. "VIRTOPSY - wirtschaft.ch - trademarks - Universität Bern Institut für Rechtsmedizin (IRM) Prof. Dr. R. Dirnhofer, Direktor Bern - Trademark no. P-491277 - Application no. 04728/2001". wirtschaft.ch. Retrieved 2013-08-28.
3. Richard Dirnhofer, Peter J. Schick, Gerhard Ranner (2010). Virtopsy - Obduktion neu in Bildern. Wien, Austria: Manzsche Verlags- und Universitaetsbuchhandlung. ISBN 978-3-214-10191-6.
4. E. von Hofmann
5. Schwarzacher
6. Thali MJ, Yen K, Schweitzer W, Vock P, Boesch C, Ozdoba C, Schroth G, Ith M, Sonnenschein M, Doernhoefer T, Scheurer E, Plattner T, Dirnhofer R (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 (2): 386–403. PMID 12665000.
7. Ebert LC, Ptacek W, Naether S, Fürst M, Ross S, Buck U, Weber S, Thali M. (2010). "Virtobot--a multi-functional robotic system for 3D surface scanning and automatic post mortem biopsy.". Int J Med Robot 6 (1): 18–27. doi:10.1002/rcs.285. PMID 19806611.
8. Grabherr S, Djonov V, Friess A, Thali MJ, Ranner G, Vock P, Dirnhofer R. (2006). "Postmortem angiography after vascular perfusion with diesel oil and a lipophilic contrast agent.". AJR Am J Roentgenol. 187 (5): W515–23. doi:10.2214/AJR.05.1394. PMID 17056884.
9. Thali MJ, Braun M, Buck U, Aghayev E, Jackowski C, Vock P, Sonnenschein M, Dirnhofer R. (2005). "VIRTOPSY--scientific documentation, reconstruction and animation in forensic: individual and real 3D data based geo-metric approach including optical body/object surface and radiological CT/MRI scanning.". J Forensic Sci. 50 (2): 428–42. PMID 15813556.
10. Aghayev E, Staub L, Dirnhofer R, Ambrose T, Jackowski C, Yen K, Bolliger S, Christe A, Roeder C, Aebi M, Thali MJ. (2010). "Virtopsy - the concept of a centralized database in forensic medicine for analysis and comparison of radiological and autopsy data.". J Forensic Leg Med. 15 (3): 135–40. doi:10.1016/j.crad.2008.05.008. PMID 18929036.
11. O'Donnell C, Woodford N. (2008). "Post-mortem radiology--a new sub-speciality?". Clin Radiol 63 (11): 1189–94. doi:10.1016/j.jflm.2007.07.005. PMID 18313007.
12. Donchin Y, Rivkind AI, Bar-Ziv J, Hiss J, Almog J, Drescher M. (1994). "Utility of postmortem computed tomography in trauma victims.". J Trauma 37 (4): 552–5. doi:10.1097/00005373-199410000-00006. PMID 7932884.
13. "VIRTANGIO - wirtschaft.ch - trademarks - Forim-X AG c/o Prof. Dr. Richard Dirnhofer Bern - Trademark no. 602006 - Application no. 51685/2010". wirtschaft.ch. Retrieved 2013-08-28.
14. "Folders - postmortem-angio". Postmortem-angio.ch. Retrieved 2013-08-28.
15. Ampanozi G, Ruder TD, Thali MJ (2012). "Autopsy, necropsy, and necrotomy: if used, why not correctly?". Am J Forensic Med Pathol 33 (2): e6. doi:10.1097/PAF.0b013e3182092bf9. PMID 21224734.
16. – 28. August 2013, 20:52 –. "Gestochen scharfe Diagnosen: Der neue Direktor des Instituts für Rechtsmedizin setzt auf digitale Technik als Ergänzung zum Skalpell - Übersicht Nachrichten". NZZ.ch. Retrieved 2013-08-28.
17. "Bringing ideas to life: Making virtual autopsy a reality - The Edge Malaysia". Infovalley.net.my. 2010-06-07. Retrieved 2013-08-28.
18. Ith, Michael and Bigler, Peter and Scheurer, Eva and Kreis, Roland and Hofmann, Lucie and Dirnhofer, Richard and Boesch, Chris (2002). "Observation and identification of metabolites emerging during postmortem decomposition of brain tissue by means of in situ 1H-magnetic resonance spectroscopy.". Magnetic Resonance in Medicine 48 (5): 915–920. doi:10.1002/mrm.10294. PMID 12418008.
19. Scheurer E, Ith M, Dietrich D, Kreis R, Hüsler J, Dirnhofer R, Boesch C. (2005). "Statistical evaluation of time-dependent metabolite concentrations: estimation of post-mortem intervals based on in situ1H-MRS of the brain". Journal of Magnetic Resonance Imaging 18 (3): 163–172. doi:10.1002/nbm.934. PMID 15578674.
20. "Digital autopsy: Replacing scalpels with scanners". Gizmag.com. Retrieved 2013-08-28.
21. W. Brueschweiler and M. Braun and R. Dirnhofer and M.J. Thali (2003). "Analysis of patterned injuries and injury-causing instruments with forensic 3D/CAD supported photogrammetry (FPHG): an instruction manual for the documentation process". Forensic Science International 132 (2): 130–138. doi:10.1016/s0379-0738(03)00006-9. PMID 12711193.
22. Yen, Kathrin Thali, Michael J and Aghayev, Emin and Jackowski, Christian and Schweitzer, Wolf and Boesch, Chris and Vock, Peter and Dirnhofer, Richard and Sonnenschein, Martin (2012). "Strangulation signs: Initial correlation of MRI, MSCT, and forensic neck findings". Journal of Magnetic Resonance Imaging 81 (10): 2518–2526. doi:10.1002/jmri.20396. PMID 16142698.
23. Flach PM, Ross SG, Ampanozi G, Ebert L, Germerott T, Hatch GM, Thali MJ, Patak MA. (2005). ""Drug mules" as a radiological challenge: sensitivity and specificity in identifying internal cocaine in body packers, body pushers and body stuffers by computed tomography, plain radiography and Lodox". Eur J Radiol 81 (4): 501–510. doi:10.1016/j.ejrad.2011.11.025. PMID 22178312.
24. Ruder TD, Germerott T, Thali MJ, Hatch GM. (2011). "Differentiation of ante-mortem and post-mortem fractures with MRI: a case report.". Br J Radiol. 84 (1000): e75–8. doi:10.1259/bjr/10214495. PMC 3473468. PMID 21415297.
25. N. Ohashi (1989). "Diagnosis of the causes on CPAOA cases: usefulness and problems of postmortem CT". KANTO J. Jpn. Assoc. Acute Med. (in Japanese) 10: 24–25.
26. "Institute of Forensic Medicine". Sdu.dk. 2012-09-24. Retrieved 2013-08-28.
27. "Visible Proofs: Forensic Views of the Body: Galleries: Media: Medical examiners at work". Nlm.nih.gov. 2010-12-14. Retrieved 2013-08-28.