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Special Ar ticles Original Research

Laurent et al.
CT After Fatal Diving Accidents

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Special Articles
Original Research

Postmortem CT Appearance
of Gas Collections in Fatal
Diving Accidents
Pierre-Eloi Laurent 1, 2
Mathieu Coulange 3,4
Julien Mancini 5
Christophe Bartoli 6
Jacques Desfeux 6
Marie-Dominique Piercecchi-Marti 6
Guillaume Gorincour 1,2
Laurent PE, Coulange M, Mancini J, et al.

Keywords: decompression illness, embolism, fatal diving


accident, gas, postmortem CT, virtopsy
DOI:10.2214/AJR.13.12063
Received October 7, 2013; accepted after revision
January 17, 2014.
Presented at the 2013 Congress of the International
Society of Forensic Radiology and Imaging, Zurich,
Switzerland.
1
Laboratoire dImagerie Interventionnelle E xprimentale,
Aix-Marseille Universit, 27 Blvd Jean Moulin,
13385 Marseille cedex 5, France. Address correspondence to P. E. Laurent (pierre-eloi.laurent@ap-hm.fr).
2
Ple Imagerie Mdicale, Assistance Publique des
Hpitaux de Marseille, Marseille, France.
3
Service de Mdecine Hyperbare, Ple RUSH,
Hpital Ste. Marguerite, Marseille, France.
4
UMR MD2, Dysoxie Tissulaire, Aix-Marseille Universit,
Marseille, France.
5
LERTIM, EA 3283, Aix-Marseille Universit,
Marseille, France.
6
Service de Mdecine Lgale et Droit la Sant,
Assistance Publique des Hpitaux de Marseille,
Marseille, France.

AJR 2014; 203:468475


0361803X/14/2033468
American Roentgen Ray Society

468

OBJECTIVE. The purpose of our study was to define the postmortem CT semiology of
gas collections linked to putrefaction, postmortem off-gassing, and decompression illness
after fatal diving accidents and to establish postmortem CT diagnostic criteria to distinguish
the different causes of death in diving.
SUBJECTS AND METHODS. A 4-year prospective study was conducted including
cases of death during diving. A hyperbaric physician analyzed the circumstances of death
and the dive profile, and an autopsy was performed. Subjects were divided into three groups
according to the analysis from their dive profile: decompression illness, death after decompression dive without decompression illness, and death after nondecompression dive without
decompression illness. Full-body postmortem CT was performed before autopsy.
RESULTS. The presence of intraarterial gas associated with death by decompression illness had a negative predictive value (NPV) of 100%, but the positive predictive value (PPV)
was only 54% because of postmortem off-gassing. The PPV reached 70% when considering
pneumatization of the supraaortic trunks. Pneumothorax, subcutaneous emphysema, and intraarterial gas, all of which are classic criteria for decompression illness diagnosis, are not
specific for decompression illness.
CONCLUSION. This study is the first to show that pneumothorax, subcutaneous emphysema, and intraarterial gas, all of which are classic criteria for decompression illness diagnosis, are not specific for decompression illness. Complete pneumatization of supraaortic
trunks is the best postmortem CT criteria to detect a fatal decompression illness when CT is
performed within 24 hours after death.

ross-sectional imaging has experienced an increasingly important role in legal medicine over
the past 10 years [1, 2]. In the
case of diving accidents, postmortem CT [3]
has facilitated the visualization of intravascular gas collections, which are difficult to
detect in autopsies [4]. The most frequent
cause of death in diving accidents is cardiovascular disease. Cold water leads to a redistribution of blood volume, with an increase
in cardiac work and sometimes cardiac decompensation [5, 6]. Drowning is also a frequent cause of diving fatalities but is often
secondary to technical incidents [7] or diving accidents. The third cause is decompression illness. Decompression illness includes
decompression sickness and arterial gas embolism secondary to pulmonary barotrauma
[8]. Decompression sickness is caused by
bubble formation (off-gassing) from dissolved inert gas. The solubility of the inert

gas in the blood decreases during ascent [9


11]. When recommended decompression
procedures are not performed, off-gassing
can be violent and can cause bubbles to circulate in the body [913].
Gas embolisms can also affect the arterial
circulation (paradoxical embolism) [1416]
by means of a patent foramen ovale [8, 17,
18], by a right-to-left intrapulmonary shunt
[14, 19], or by breaking through the pulmonary capillary filter [20, 21]. Pulmonary
barotrauma is linked to an increase in gas
volume during ascent (Boyle law). Pulmonary barotrauma can lead to a pneumothorax, pneumomediastinum, subcutaneous emphysema, or cerebral arterial gas embolism
(CAGE) [13, 22, 23].
Autopsies and imaging strive to detect the
presence of intravascular gas in victims of
diving accidents [2327]. These postmortem
gas collections, whether intra- or extravascular, are characterized by their topography,

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CT After Fatal Diving Accidents


abundance, and delayed postmortem appearance. Studies have shown that these characteristics are different according to their
cause [2831]. The visualization of gas collections during an autopsy is difficult. Intracardiac gas embolism has to be suspected at
autopsy to prove it because it requires dissection of the pericardial sac under water [32,
33]. However, this technique does not show
the extent of the gas embolism, unlike postmortem CT, and tends to underestimate the
quantity of gas collections [4].
The CAGE diagnosis has been systematically made when intraarterial gas is found,
but recent studies [28, 29, 31] have questioned a number of CAGE diagnoses. CAGE
is thought to be overdiagnosed, and the gas
seen can result from putrefaction [3336],
cardiopulmonary resuscitation (CPR) [33
35, 3740], and postmortem off-gassing
[2931]. An early analysis of the intravascular gas composition would enable identification of the gas from putrefaction (high levels
of hydrogen) but would not enable differentiation between postmortem off-gassing and
a decompression illness [41]. Extravascular
gas collections include pneumothorax and
subcutaneous emphysema. These two elements are classically regarded as criteria for
a barotrauma diagnosis [35].
The purpose of this study was to define
the postmortem CT semiology of different
postmortem gas collections linked to putrefaction, postmortem off-gassing, and gas
embolism from decompression illness after
fatal diving accidents. Our aim was to establish postmortem CT diagnostic criteria related to different causes of death in diving.
Subjects and Methods
A study protocol was developed in September
2008 for fatal diving accidents that took place in the
Bouches-du-Rhne area in southern France. The
ethics committee of the university and the responsible justice department approved the study. All fatal
diving accidents from September 2008 to September 2012 were included in the study. The following data were collected for each subject: early postmortem CT, diving profile analysis by a hyperbaric
physician, and autopsy. A hyperbaric physician coordinated the different teams in this study (rescue
crews, forensic pathologists, and radiologists).

Subjects
Inclusion and exclusion criteriaAll diving accidents in scuba diving and apnea free-diving (also
called breath-hold diving) from September 2008 to
September 2012 in the Bouches-du-Rhne area (the

southeast of France) were included. To avoid known


intravascular gas artifacts linked to putrefaction,
bodies that were collected more than 72 hours after
the estimated time of death were excluded from the
study because after 72 hours all vascular spaces become filled with putrefaction gasses [36].
Case informationThe forensic pathologists
conducting the autopsy and the hyperbaric physician collaborated to determine the medical history
of the subjects. At each inclusion, the hyperbaric
physician and the forensic pathologists were in direct contact with the rescue crew to obtain information relevant to the accident [42]. Information
was collected from rescue crews, witnesses, and
diving partners when possible. The medical history was obtained by contacting the family and family doctor. The criteria for questioning concerned
the victim (medical history, diving level), timing
of events (loss of consciousness on the surface or
while diving, clinical signs), and ascent conditions (panicked ascent, respect of decompression
stops). All of the elements were correlated with
the dive profile analysis and autopsy results to determine the cause of death.

Dive Profile and Technical Equipment Analysis


All involved dive computers and technical equipment were analyzed by the hyperbaric physician.
The following parameters were recorded: start time
diving, water temperature, depth, dive log, dive duration, speed of ascent, and length of time spent in
decompression stops. A dive is considered to be a
decompression dive when the depth and dive duration require one or multiple decompression stops according to French National Marine criteria (Marine
Nationale MN90 table). A dive is considered to be a
noncompression dive when no decompression stops
are required. The ascent speed is considered too fast
when it exceeds 15 meters per minute.

Postmortem CT
Before the autopsy, full-body CT was performed
on each subject with a 64-MDCT bi-tube scanner
(Definition, Siemens Healthcare). Postmortem CT
was performed in two sets: the first included the
head and neck; the second included the arms, thorax, abdomen, and legs. No contrast media was injected. The image acquisition was performed in the
dorsal decubitus position with the arms along the
body. The CT parameters for head and neck imaging were 140 kV; 320 mAs with dose modulation;
FOV, 240 mm; pitch, 0.4; and slice collimation,
1 mm. The CT parameters for full-body imaging (encephalon excluded) were 140 kV; 400 mAs
with dose modulation; FOV, 500 mm; pitch, 0.6;
and slice collimation, 1 mm. The reconstructions
and interpretations were performed with the Syngo
workstation (Siemens Healthcare).

Radiologic Interpretation
Two board-certified radiologists with experience in forensic radiology jointly analyzed the
radiologic data. The radiologists were blinded to
the circumstances of the accident and autopsy
findings. Each item in the analysis was recorded
as present or absent. The topography of the gas
collections was divided into the following categories: arterial examining the entire arterial system
including cerebral vascularization, left cardiac
cavities, and pulmonary veins; venous including
the entire venous system including cerebral vascularization, right cardiac cavities, and pulmonary arteries; and pleura including the presence
of pneumothorax.
To research postmortem CT diagnostic criteria that would lead to a CAGE diagnosis, two
supplementary criteria were defined [35]: complete pneumatization of the supraaortic trunks involving the left ventricle, aortic cross, and entire
supraaortic trunk up to and including the Willis
polygon completely filled with gas, without a visible blood-air level and pneumatization of the right
ventricle with the entire right ventricle completely
filled with gas. To document the effects of CPR,
the postmortem CT analysis also looked for subcutaneous emphysema limited to the thoracic area
and fractured ribs.

Autopsy and Further Postmortem Analyses


The autopsies were performed by two boardcertified pathologists. They noted the data from
the external examination of the body (foaming at
the mouth, color of the skin, and so on). Autopsies were conducted using conventional protocols
without the use of immersion [43]. Samples were
collected for pathologic and toxicologic analyses.
The autopsy criteria for drowning were autopsy findings including white foam at the
mouth, indentations of ribs in lungs, and pleural effusion [44]; pathologic findings including
acute emphysema of the lung with edema and
alveolar histiocytosis; and difference of blood
strontium concentrations between the left and
right ventricles [44]. At autopsy, we also looked
for a cardiac event that would lead to death or
to a rapid or ascent and that was secondary to
decompression illness. The autopsy criteria for
decompression illness will be included later in
this article.

Study Groups
Study groups were formed according to the
data from the dive profile analysis, medical history, and autopsy. A consensus was obtained
from the forensic pathologists and the hyperbaric physician. Subjects were classified in one
of three groups on the basis of the circumstanc-

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Laurent et al.
es in which the accident took place and the information from existing literature, notably from
animal studies [30, 31], to study the gases respectively due to gas embolisms, postmortem
off-gassing, and putrefaction.
Decompression illness group (CAGE) The
decompression illness group consisted of subjects whose death was directly linked to CAGE.
We purposely chose not to distinguish between
deaths linked to severe decompression sickness
and barotrauma. Because the circumstances of
death are similar, there are few criteria to differentiate between them in the autopsy and dive profile analysis. The following criteria were chosen
for inclusion as decompression illness: dive profile analysis including decompression scuba dive
and fast ascent or diver did not follow advised
decompression stops; loss of consciousness during ascent or a few seconds after having come to
the surface; autopsy findings of cyanosis, bloody
foam at the mouth, hemotympanum, or presence
of a patent foramen ovale (predisposing factor);
and pathologic findings of alveolar hemorrhage or
rupture of interalveolar walls.
Decompression diving groupSubjects in the
decompression diving group did not experience a

decompression illness but experienced a decompression dive. The divers were respectful of the
recommended decompression stops during the ascent or the death occurred on the sea floor. The
following are the criteria for the classification of
the decompression diving group: lack of evidence
for a decompression illness, the accident occurred
during a scuba dive, and the dive necessitated decompression stops.
Nondecompression groupThe subjects in the
nondecompression dive group did not perform a
decompression dive and did not experience a decompression illness. Only putrefaction gas was
observed. The following are the criteria for the
classification of the nondecompression diving
group: lack of evidence for a decompression illness, no decompression dive, and the accident occurred while free diving (apnea).

between binary variables was evaluated with the


kappa concordance coefficient. The association
between the different postmortem CT criteria and
the presence of a decompression illness was tested
with the Fisher exact test then expressed as sensitivity, specificity, and predictive values. For all the
bilateral tests, a p value less than 0.05 was considered statistically significant. All analyses were
conducted with help of SPSS 17.0 software.

Results
Subjects
We examined 20 fatalities from September 2008 to June 2012. Two divers
were excluded from the study because the
postmortem CT studies were performed
more than 72 hours after death (91 and
183 hours). In both cases, the delay in performing CT was due to difficulty in recovering the bodies. Eighteen subjects were
eventually studied, including four women and 14 men. All accidents occurred in
seawater. The results are presented in Tables 1 and 2. The median age was 47 years
(age range, 2374 years). The median dive
depth was 36 meters (range, 360 meters),

Statistics
Quantitative variables are presented in the form
of a median (minimummaximum). Categoric
variables were presented as counts (%). The three
study groups were compared with a Kruskal-Wallis analysis for quantitative variables and Fisher
exact test for categoric variables. The agreement

TABLE 1: Subject Characteristics


Subject

Maximum Duration of Death on Sea


Delay Before Delay Before
Depth (m) Dive (min)
Floor
CPRa
CT (h)
Autopsy (h)

Age (y)

Sex

BMI

49

27

52

17

Cause of Death

Decompression illness group


No

4.0

53

CAGE

66

29

36

38

No

4.0

23

CAGE

42

52

25

16

No

4.5

68

CAGE

45

25

42

56

No

4.5

27

CAGE

74

25

38

18

No

6.0

24

CAGE

39

29

50

25

No

7.0

24

CAGE

59

32

33

51

No

55.0

75

CAGE

61

25

31

23

No

3.5

52

Cardiac failure
Cardiac failure

Decompression dive group


8
9

53

23

53

29

No

43.0

47

10

48

23

60

33

Yes

14.0

53

Drowning

11

42

29

60

33

Yes

14.0

51

Drowning

12

51

23

35

19

No

8.0

27

Cardiac failure

13

23

23

NR

NR

No

7.0

24

Drowning

14

28

25

20

No

8.0

21

Drowning

No decompression dive group

15

60

25

No

15.0

25

Drowning

16

37

30

No

28.0

43

Cardiac failure

17

37

23

NR

NR

No

48.0

50

Drowning

18

24

23

NR

NR

No

20.0

24

Drowning

NoteSubjects 13, 17, and 18 were free divers. BMI = body mass index, CPR = cardiopulmonary resuscitation, CAGE = cerebral arterial gas embolism, NR = not recorded.
a1 = CPR performed, 0 = CPR not performed.

470

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CT After Fatal Diving Accidents


and the median dive duration was 25 minutes (range, 356 minutes). Four subjects
did not undergo CPR maneuvers, including
two subjects who died on the sea floor and
two deaths without witnesses. The median
time before postmortem CT, calculated on
the interval of the estimated time of death,
was 8 hours (range, 3.555.0 hours). The
autopsy was performed at 35 hours (range,
2175 hours) after death.
Study Groups
On the basis of the medical history, dive
profile analysis, and autopsy, seven deaths
were categorized in group 1 as decompression illness (Fig. 1), five divers were categorized in group 2 as decompression diving,
and six divers were categorized in group
3 as nondecompression diving, including
three free divers. The details of the subjects, diving parameters, time to postmortem CT, and autopsies are presented in Table 1. It was not possible to measure the
maximal depths reached and the duration of
the immersion for the free divers and therefore the data were not integrated into the average calculations. There was no significant
difference between body mass index (BMI)
(p = 0.084), time to postmortem CT (p =
0.112), and autopsy (p = 0.176) among these
three groups. However, there was a significant difference concerning age. The subjects in group 3 were significantly younger
(33 vs 50 years, p = 0.041).
In the decompression dive group, the cause
of death was a cardiac incident for three subjects and asphyxia complicated by drowning for two subjects. For the nondecompression dive group, autopsy revealed the cause of
death as drowning for five subjects and cardiac related for one subject. No patent foramen
ovale was found during the autopsies.
The gas collections were not systematically identified by the forensic pathologists.
Arterial gas collections were found in eight
subjects in the autopsies and in 13 subjects
using postmortem CT; pneumothorax was
found in no subject in the autopsies and in
three subjects using postmortem CT; and
subcutaneous emphysema limited to the
thoracic area was found in two subjects in
the autopsies and four patients using postmortem CT. The autopsies were conducted
with knowledge of the postmortem CT results; therefore, no unbiased statistical calculation could be made to compare autopsy
and CT. The postmortem CT results for each
included subject are collected in Table 3.

TABLE 2: Statistical Analysis of Subjects


Characteristic
Age (y)
BMI

Group 1

Group 2

Group 3

49 (3974)

51 (4261)

33 (2360)

29.2 (24.651.9) 23.5 (23.129.4) 24.1 (22.629.8)

Total

47 (2374)

0.041

25 (22.651.9)

0.084

Maximum depth

38 (2552)

53 (3160)

3 (36)

36 (360)

NR

Duration of dive

26 (1756)

29 (1933)

3 (320)

25 (356)

NR

Delay before CT

4.5 (455)

14 (3.543)

17.5 (748)

8 (3.555)

0.112

Delay before autopsy

27 (2375)

51 (2753)

27 (2150)

35 (2175)

0.176

NoteData are median with minimummaximum in parentheses. Significant difference was considered p <
0.05. Group 1 = decompression illness, group 2 = death after decompression dive without decompression
illness, and group 3 = death after nondecompression dive without decompression illness. BMI = body mass
index, NR = not recorded.

TABLE 3: CT Results
Containing Only Gas

Subject

Subcutaneous
Arterial Venous Supraaortic
Right Emphysema Limited PneumoGas
Gas
Trunks
Ventricle to Thoracic Area
thorax

Decompression illness
group
1

10

11

12

13

14

15

16

17

18

Decompression dive group

No decompression dive
group

NotePresence indicated by + and absence by .

Tested Criteria
Diagnostic criteria for decompression illnessTable 4 examines the presence or absence of postmortem CT criteria according to whether a decompression illness took
place. There was no statistically significant
link between the presence of arterial gas and
death by decompression illness (p = 0.054).

We also did not find a statistically significant


link between the presence of pneumothorax and death by decompression illness (p =
0.245). However, the complete pneumatization of the supraaortic trunks and the pneumatization of the right ventricle statistically
significantly favored a diagnosis of death by
CAGE (p = 0.004 and 0.013, respectively).

AJR:203, September 2014 471

TABLE 4: Comparison of Different Criteria for Diagnosis of Decompression Illness


Laurent et al.
No CAGE
(%)

CAGE
(%)

Sensitivity
(%)

Specificity
(%)

PPV
(%)

NPV
(%)

Intraarterial gas

54.5

100

0.054

100

45.5

53.8

100

Pneumothorax

27.3

0.245

72.7

53.3

Supraaortic trunks and left ventriclea

27.3

100

0.004

100

72.7

70

100

Subcutaneous emphysema limited to thoracic area

9.1

57.1

0.047

57.1

90.9

80

76.9

Right ventriclea

36.4

100

0.013

100

63.6

63.6

100

NoteCAGE = cerebral arterial gas embolism, PPV = positive predictive value (PPV), NPV = negative predictive value. Significant difference was considered p < 0.05.
aContaining only gas.

Discussion
Limitations
The main study limitation is the small
number of subjects in each group. This can
be explained by the prospective design of the
study as well as the relative rarity of diving
accidents. However, to our knowledge, this
is the largest study with as many subjects
and containing thorough data including a detailed description of the circumstances of the
accident, dive profile analysis, postmortem
CT, and autopsy.
The ages of the subjects included were
different within each group. The subjects in
group 3 were younger than the subjects in
the other groups. This can be explained by
the presence of three free divers in the nondecompression diving group. This sport is
mostly practiced by younger people. We also
think that the age difference between the
groups in the study did not modify our postmortem CT diagnostic criteria, specifically
the presence of intravascular gas collections.
CPR maneuvers were performed on 14
divers. CPR can generate artifact gas collections, which was shown in our animal
experiments [30] and in other studies [33,
40]. Even though the CPR performed never
successfully resuscitated the victims in this
study, it was necessary to perform CPR for
medicolegal and ethical reasons. Our study
described the real situations that confront
teams after a death while diving.

36

32

10
Depth (m)

15
20

24
20
16

30

12

35

40

472

10

Time (min)

15

20

Sensitivity of Postmortem CT for Gas Collections


The aim of this study was not to compare
the sensitivity of autopsy and postmortem CT
for the detection of gas collections. However, gas collections found on postmortem CT
were not visible or highly underestimated in
the autopsy. This confirms the superiority of
postmortem CT for the detection of gas collections, which has been reported previously
[4]. The autopsy sensitivity can be increased
by complex techniques, such as underwater
dissection [32, 33, 47], but postmortem CT is
faster, easier, and reproducible.
Postmortem CT Criteria for Decompression Illness
Our study found that the diagnostic criteria that are classically used for decompression illness are of poor statistical value. We
did not find a statistically significant link between death by decompression illness and the

28

25

Three cases of free divers were included


in our study. This study concerned examination of gas collections and, to our knowledge, no physiopathologic elements exist
that can modify the gas collections between
a death caused by nondecompression scuba
diving and a death caused by free diving,
excluding cases of barotrauma. Our study
was purposely focused on gas collections;
every radiologist reading a postmortem CT
has to bear in mind the classic criteria for
drowning [45, 46].

25

Temperature (C)

Three criteria were systematically present after a death by CAGE (negative predictive value [NPV] = 100%): presence of intraarterial gas, complete pneumatization of
the supraaortic trunks and left ventricle and
pneumatization of the right ventricle (Fig. 2).
The complete pneumatization of the supraaortic trunks and the right ventricle had a
strong concordance ( = 0.886) because only
one discordance was observed.
Postmortem off-gassingWhen comparing the decompression and nondecompression dive groups, we observed a significant
difference concerning the presence of intraarterial gas. Nondecompression dives were
characterized by the absence of intraarterial
gas (p = 0.015).
CPR maneuversThe presence of subcutaneous emphysema limited to the thoracic
area (Fig. 3) was not statistically linked to
the practice of CPR maneuvers (p = 0.234).
The positive predictive value (PPV) was
100% for the practice of CPR maneuvers,
but the NPV was weak (30.8%). However,
rib fractures and subcutaneous emphysema
limited to the thoracic area were always associated ( = 1).
Death on sea floorTwo of the included subjects died on the sea floor at great
depths (60 meters). We observed a complete pneumatization of supraaortic trunks,
left heart ventricle, and right ventricle in
both subjects.

32 m/min

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Tested Criteria

Fig. 1Dive log from fatal dive of 74-year-old man


shows overly rapid ascent (32 m/min) (arrow), which
indicates decompression illness. Black line indicates
depth of diver. Gray line indicates water temperature.

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CT After Fatal Diving Accidents


Fig. 249-year-old man with decompression illness.
AD, Minimum-intensity-projection reconstruction
images show air-filled cardiac cavities (A), air-filled
arterial system (B), venous air-filled vascular system
(C), and intraarterial gas in supraaortic trunks (D),
including common carotid arteries (arrows) and
internal carotid arteries (arrowheads, D). A = aorta,
PA= pulmonary artery, LPA = left pulmonary artery,
SVC= superior vena cava, IVC = inferior vena cava,
LA = left atrium, LV = left ventricle, RA = right atrium,
RV = right ventricle.

presence of intraarterial gas. As we expected,


the presence of intraarterial gas was not specific to CAGE but had an NPV of 100%. This
result is consistent with results from experimental studies [30, 31]. The absence of intraarterial gas therefore enables us to reject this
diagnosis. False-positive findings are most
often due to off-gassing, which occurs very
quickly starting 4 hours after death and starts
occupying the arterial topography.
Pneumothorax is classically cited as a major criterion for decompression illness [29, 35],
but we did not find a statistical link between
the two. On the contrary, the three subjects in
our study with a pneumothorax did not experience barotrauma according to the dive profile
analysis. One of the divers suffered iatrogenic
pneumothorax during resuscitation.
Subcutaneous emphysema limited to the
thoracic area also appears to be a poor diagnostic criterion for decompression illness.
Even though in our study it appeared to be
relatively specific, we think that this emphysema was actually correlated with thoracic compressions performed during CPR and

not with decompression illness. We previously showed this in an animal model [30].
We propose two postmortem CT diagnostic
criteria for a death by decompression illness.
First, complete pneumatization of the supraaortic trunks and left heart ventricle and decompression illness were statistically significantly linked (p = 0.004). The NPV was 100%,
and its presence is necessary to make this diagnosis. This sign also had a good PPV of 70%.
This criterion is therefore more relevant than
the presence of intraarterial gas, in which the
PPV was lower. In our study, the false-positive findings for complete pneumatization of
the supraaortic trunks were due to a long delay
before conducting postmortem CT or a death
on the sea floor in decompression diving. After a death on the sea floor, there is no pulmonary filtration of dissolved gas and much larger quantities of gas are released postmortem,
which explains the complete pneumatization of
vessels. In the late postmortem CT (case nine,
43 hours after death), the intravascular gas
quantities seen in the postmortem CT result in
an increase over time, as shown by the animal

model [30]. Because these circumstances were


known during the analysis of the circumstances of death, a complete pneumatization of the
supraaortic trunks seemed to be the best criteria in favor of decompression illness.
Second, the pneumatization of the right
ventricle is also a good criterion for the diagnosis of a death by decompression illness.
This criterion had an NPV of 100% and a
PPV of 63.6%. It was strongly correlated with
the pneumatization of the supraaortic trunks
( = 0.886). A strong discordance between
the large amount of arterial gas and the small
quantity of venous gas could have been proposed as a criterion for barotrauma if we take
into account the physiopathology. This hypothesis is probably not valid and we systematically observed gas in the right cavities after
decompression illness, which has been reported previously [35].
Origin of Arterial Gas
We found arterial gas in all the subjects in
the decompression illness group and the decompression diving group and in five sub-

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Laurent et al.
jects in the nondecompression diving group.
Intraarterial gas can therefore have three origins, which supports our hypotheses. The first
is decompression illness by barotrauma with
a rupture of the alveolar-capillary membrane
and arterial gas embolism, by severe desaturation accident with nitrogen bubbles breaking
through the pulmonary capillary filter with the
opening of intrapulmonary shunts [20, 21], or
by permeabilization of a patent foramen ovale
or any other right-to-left shunt [8, 17].
The second is postmortem off-gassing,
which is confirmed by the results of our animal study [30]. After exposing animals to hyperbaric conditions in a chamber and simulating the recommended decompression stops,
we observed arterial gas linked to postmortem off-gassing. To differentiate between
postmortem off-gassing and decompression
illness, we proposed to use the length of time
to CT appearance. We observed that in animal models, postmortem off-gassing occurred
3 hours postmortem [30]. We proposed a cutoff time of 3 hours before which arterial gas
that is observed can only correspond to decompression illness. However, in practice it
is difficult to perform postmortem CT within this delay, considering the time required
for rescue teams to recover, attempt to resuscitate, and transport the body. This adds to
off-gassing that occurs quickly when the dive
is deep and long. Therefore, it is difficult to
use the delay before gas appearance as a criterion. Nevertheless, to avoid the presence of
postmortem off-gassing and improve the relevance of a decompression illness diagnosis,
CT must be performed as early as possible.
The third is putrefaction gas, which does
not usually occupy the arterial topography if
CT is conducted within 24 hours postmortem. Subject 16 did show the presence of intraarterial gas because CT was performed 28
hours after death. Intraarterial gas was only
detected in subject 17, the subject with the
longest delay before CT (48 hours postmortem). These results also confirm the results
from our animal study in which no arterial
putrefaction gas was present on repeated CT
performed up to 24 hours after death [30].
Among the three possible causes, the analysis of intraarterial gas can affirm the presence of putrefaction gas [41] but does not
differentiate between decompression illness
and postmortem off-gassing.
Origin of Venous Gas
Our results, as expected, show an exclusive venous topography of putrefaction gases

474

when postmortem CT was performed within


24 hours. These results are disputed by recent
studies that describe early intraarterial putrefaction gas [48]. However, these studies did
not include repetitive postmortem CT to monitor gas collections, and the postmortem intervals between death and postmortem CT were
not controlled. The only experimental study
conducted with iterative postmortem CT in a
porcine model did not find any intraarterial
putrefaction gas in the 24 hours after death.
This hypothesis is confirmed by another animal experimental study [31] and confirms
our practice of performing postmortem CT as
soon as possible to limit such artifacts.
Subcutaneous Emphysema
Subcutaneous emphysema limited to the
thoracic area presents a PPV of 100% for CPR
maneuvers. It was observed in four subjects, all
of whom received CPR and all of whom presented rib fractures ( = 1). This concordance
confirms our hypothesis that chest lesions can
be caused by CPR, which is confirmed by data
from animal experiments [30] in which the
same types of lesions were observed.
Conclusion
Postmortem CT is a powerful tool to analyze intra- and extravascular gas collections.
We confirm the results of experiments conducted on animals that showed the nonspecificity of arterial gas for diagnosis of decompression illness, possible arterial topography
of gas caused by off-gassing, and absence of
arterial gas from putrefaction when CT was
performed within 24 hours after death. Thus,
we advise always performing postmortem
CT as early as possible to limit the possible causes of intravascular gas and to facilitate the interpretation. We suggest that the
diagnostic criteria for barotrauma should be
modified in the following ways: The presence of a pneumothorax is not a valid criterion; subcutaneous emphysema is linked to
chest compressions and should not be considered a diagnostic criterion; the presence
of intraarterial gas is necessary to make the
diagnosis of decompression illness (NPV =
100%) but the PPV is weak; and the best criterion for decompression illness is complete
pneumatization of the supraaortic trunks and
left ventricle in death that did not occur on
the sea floor. These results confirm the utility of postmortem CT after diving accidents,
which will enable forensic pathologists and
hyperbaric physicians to accurately determine the causes of diving fatalities.

Fig. 3CT image in 59-year-old man shows


subcutaneous emphysema limited to thoracic area
(arrows) and intraarterial gas in supraaortic trunks.

Acknowledgments
The authors thank Pierre Champsaur,
Pierre Perich, Evelyne Basso, and all the CT
technologists.
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