Accepted Manuscript

Traumatic brain injury: Comparison between autopsy and ante-mortem CT

Stephanie Panzer, Lidia Covaliov, Peter Augat, Oliver Peschel

PII: S1752-928X(17)30121-X
DOI: 10.1016/j.jflm.2017.08.007
Reference: YJFLM 1542

To appear in: Journal of Forensic and Legal Medicine

Received Date: 9 September 2016

Revised Date: 27 May 2017
Accepted Date: 23 August 2017

Please cite this article as: Panzer S, Covaliov L, Augat P, Peschel O, Traumatic brain injury:
Comparison between autopsy and ante-mortem CT, Journal of Forensic and Legal Medicine
(2017), doi: 10.1016/j.jflm.2017.08.007.

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 ACCEPTED MANUSCRIPT
Title Page

Traumatic brain injury: comparison between autopsy and ante-mortem CT

1,2 3 2 3
Stephanie Panzer , Lidia Covaliov , Peter Augat , Oliver Peschel

1 Department of Radiology
Trauma Center Murnau
Prof.-Küntscher-Straße 8 D-
82418 Murnau, Germany
2Institute of Biomechanics
Trauma Center Murnau and Paracelsus Medical University Salzburg
Prof.-Küntscher-Straße 8
D-82418 Murnau, Germany
3Institute of Legal Medicine
Ludwig-Maximilians University, Munich
Nussbaumstraße 26
D-80336 Munich, Germany

Corresponding author:

Stephanie Panzer
Department of Radiology
Trauma Center Murnau
Prof.-Küntscher-Straße 8
D-82418 Murnau, Germany
phone: +49 8841 484265
fax: +49 8841 482728
e-mail: stephanie.panzer@bgu-murnau.de
 ACCEPTED MANUSCRIPT
Abstract

Purpose
The aim of this study was to compare pathological findings after traumatic brain injury
between autopsy and ante-mortem computed tomography (CT). A second aim was to identify
changes in these findings between the primary posttraumatic CT and the last follow-up CT
before death.

Methods
Through the collaboration between clinical radiology and forensic medicine, 45 patients with
traumatic brain injury were investigated. These patients had undergone ante-mortem CT as
well as autopsy. During autopsy, the brain was cut in fronto-parallel slices directly after
removal without additional fixation or subsequent histology. Typical findings of traumatic
brain injury were compared between autopsy and radiology. Additionally, these findings were
compared between the primary CT and the last follow-up CT before death.

Results
The comparison between autopsy and radiology revealed a high specificity (≥ 80%) in most
of the findings. Sensitivity and positive predictive value were high (≥ 80%) in almost half of
the findings. Sixteen patients had undergone craniotomy with subsequent follow-up CT.
Thirteen conservatively treated patients had undergone a follow-up CT. Comparison between
the primary CT and the last ante-mortem CT revealed marked changes in the presence and
absence of findings, especially in patients with severe traumatic brain injury requiring
decompression craniotomy.

Conclusion
The main pathological findings of traumatic brain injury were comparable between clinical
ante-mortem CT examinations and autopsy. Comparison between the primary CT after trauma
and the last ante-mortem CT revealed marked changes in the findings, especially in patients
with severe traumatic brain injury. Hence, clinically routine ante-mortem CT should be
included in the process of autopsy interpretation.

Key words

Autopsy, virtual autopsy, computed tomography, ante-mortem computed tomography,

traumatic brain injury

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1. Introduction

Forensic radiology is defined as radiological applications for the forensic sciences [1]. Virtual
autopsy, sometimes called “virtopsy”, combines post -mortem radiological imaging, such as
computed tomography (CT) and magnetic resonance imaging, with autopsy [2, 3]. There has
been more than a ten-fold increase in publications related to forensic and post-mortem
radiology since 2003 as it d eveloped from an obscure topic to a relevant field in the forensic
sciences [4].
CT is extensively used to investigate traumatic injury [4]. The main strength of CT is the
cross-sectional technique, with its high spatial resolution, and the possibility of creating
various kinds of reconstructions in all desired planes [2, 3]. Furthermore, digital data can be
easily stored, and cases can be re-examined decades later, even after burial of the body and
liberation of the crime scene [5]. Post-mortem CT has been determined to be superior to
autopsy in the detection of gas accumulation and metallic foreign bodies, and it provides
valuable information for the establishment of trauma patterns and accident reconstruction [2,
6-9].
However, clinical radiology and post-mortem imaging are not the same, and radiologists are
at risk of misinterpreting findings if they rigorously apply the rules of clinical radiological
analysis to post-mortem analysis [9, 10]. Post-mortem imaging is usually restricted to
forensic institutions that collaborate with adjacent radiological departments [2, 7].
Ante-mortem CT is also considered in forensic radiology. It can provide additional
information regarding the clinical situation. Furthermore, it is applied in combination with
post-mortem CT to compare findings and to improve the understanding of post-mortem
features [7, 11-13]. The number of CT examinations continues to increase in clinical settings.
For example, in severely injured patients, whole-body CT is increasingly becoming the
standard diagnostic technique [14-16]. In addition to the above-mentioned strengths of CT,
ante-mortem CT is widely used in the clinical setting and radiologists are familiar with the
analysis. Therefore, these CT examinations may provide additional or complementary
information for forensic cases without creating new costs.
The first aim of this study was to compare the assessment of pathological findings occurring
in traumatic brain imaging between autopsy and ante-mortem CT in the clinical setting. The
second aim was to identify changes in these findings between the first posttraumatic CT and
the last follow-up CT before death. An ulterior motive was to increase the collaboration
between radiology and forensic medicine, not only in scientific studies but also in the clinical
routine. Thereby, ante-mortem CT could provide additional information for the interpretation
of autopsy findings in the clinical situation.

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2. Material and Methods

2.1. Material

Between June 2005 and November 2014, a total of 475 patients died in the Trauma Center
Murnau, Germany, and underwent autopsy at the Institute of Legal Medicine of the Ludwig-
Maximilians-University, Munich, Germany. Out of these patients, a collective was chosen,
including patients with traumatic brain injury (see 2.2.1. for pathological findings indicating
traumatic brain injury). The included patients were required to have undergone a recent (day
of the trauma or within the following two days) primary unenhanced CT examination prior
to any operational treatment in terms of a combined CT of the head and cervical spine as part
of a multiple trauma CT or a CT of the head. Additionally, patients treated neurosurgically
after the primary CT examinations were required to have undergone a postoperative CT
examination of the head.

CT examinations were performed on one of the following devices: 64-detector multislice CT

(LightSpeed VCT, General Electrics, Milwaukee, Wisconsin, USA) or 128-detector
multislice CT (SOMATOM Definition AS+, Siemens, Erlangen, Germany). Follow-up CTs of
the head were performed on these scanners or on a 4-detector multislice CT (LightSpeed
Plus, General Electrics, Milwaukee, Wisconsin, USA). Cranial CTs as part of a multiple
trauma or a combined head and neck examination were performed in helical mode with
slice thickness of 0.625 mm or 0.75 mm, and 120 kilovolts. Isolated cranial CTs were
performed in helical or single-slice mode, with slice thickness ranging from 2.5 to 5 mm
and 120 kilovolt.

During the autopsy procedure, the brain was cut in approximately 1-cm-thick fronto-parallel
slices directly after removal without additional fixation. In cases of necrotic and softened
brain parenchyma, the slice thickness was larger, depending on the brain consistency.
Autopsy reports were written by at least two independent senior forensic pathologists without
further sub-specialisation.

2.2. Methods

2.2.1. Data classification and collection

The presence of traumatic brain injury was based on pathologies assessed during routine autopsy
and daily radiological evaluation [17, 18]. Thus, at least one of these findings had to be present
in autopsy and/or radiology. The following pathological findings were considered:
- epidural hematoma,
- subdural hematoma,
- subarachnoid hemorrhage,
- intraventricular hemorrhage,
- diffuse axonal injury,
- cortical contusions,
- intracerebral hematoma,
- brain edema,
- midline shift,
- infarction/ necrosis,
- intracranial
- zAAZl gas,
- rupture of bridging vein.

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If findings were present at more than one site, they were assessed multifocally and termed by
additional Arabic numerals.

For collection of autopsy data, the autopsy reports were reviewed for the presence or absence
of the above-mentioned findings. For radiological data collection, CT examinations were re-
evaluated by the first author (who is a senior radiologist with 18 years of experience,
including trauma imaging) for the presence or absence of the findings. In patients with
follow-up CT examinations, the primary CT and the last follow-up CT examination before
death were evaluated.

2.2.2. Comparison between autopsy and radiology

For comparison between autopsy and radiology, data from the autopsy reports were compared
with the findings of the last ante-mortem CT examination. The number of positive and
negative findings was counted for each case. Sensitivity (number of positive findings in the
autopsy that were detected on CT images), specificity (number of the negative findings in the
autopsy that are also negative on CT images), and the positive predictive value (number of the
radiologically detected findings that are also positive in the autopsy) were calculated,
whereupon the autopsy was determined as the gold standard.

2.2.3. Changes in radiological findings on follow-up CTs

The presence and absence of findings was compared between the primary CT and the last
ante-mortem CT. This was done separately for the group of patients that underwent
neurosurgical treatment by craniotomy and evacuation of hematomas and the group of
patients that were treated conservatively.
Additionally, measurements were collected for the main hematomas that were surgically
evacuated as well as for the degree and side of midline shift.

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3. Results

3.1. Demographics and time intervals

The final population consisted of 45 patients, 31 males and 14 females. The mean age at death
was 66 years, ranging from 12 to 91 years. In autopsy reports, the cause of death was reported
as a cerebral cause in 34 cases, a cardiac cause in 3 cases, pneumonia in 3 cases, a thoracic
cause in 2 cases, and shock and multi-organ failure in 1 case. In 1 case, the cause of death was
unclear.
The initial CT examination was a multiple trauma CT in 22 cases, a combined CT examination of
the head and cervical spine in 18 cases and an isolated CT examination of the head in 5 cases. The
primary CT was performed at the day of trauma in 34 cases, on the following day (day 1) in 9
cases, and on day 2 in 2 cases, the mean was calculated as 0.3 days. The time interval from the
trauma to the last CT had a mean of 2.5 days, ranging from 0 to 24 days. The time interval from
the last CT to death had a mean of 5.3 days, ranging from 0 to
52. Autopsy was performed between days 0 and 5 after death, with a mean of 2.2 days.
Sixteen patients underwent craniotomy with subsequent follow-up CTs. Trepanation was
performed on the same day of the trauma in 12 patients, and on day 3, days 2 to 4, day 7 and
day 12 in one case, respectively. In 13 conservatively treated patients, a follow-up CT was
available. The time interval between the primary CT and the last follow-up CT before death
had a mean of 4.2 days, ranging from 0 to 24 days.

3.2. Comparison between autopsy and radiology

The comparison between findings in autopsy protocols and the last ante-mortem CT
examinations in the 45 studied cases revealed a high specificity (≥ 80%) in most of the
findings. Sensitivity and positive predictive value were high (≥ 80%) in almost half of the
assessed pathological findings (Table 1). In general, the presence of the particular findings
was low. The most frequent findings in both methods were brain edema and subarachnoid
hemorrhage, followed by subdural hematoma, intraventricular hemorrhage and cortical
contusions (Fig. 1).

Epidural hematomas all occurred unifocally and had a high agreement. Subdural hematomas
were predominantly found to be unifocal in up to 34 cases. In a few cases, they were detected
in up to three locations. Altogether, these had a high agreement. Subarachnoid hemorrhage
was recorded to be predominantly located in one region in up to 38 cases, multifocal
appearance was found in about half of these cases. CT images clearly revealed more cases
with subarachnoid hemorrhage than autopsy. Intraventricular hemorrhage was found more
frequently on CT images, with presence in 27 cases. Cortical contusions were predominantly
found unifocally in up to 26 cases and in two different regions in up to 7 cases. They were
recorded more frequently in autopsy. Intracerebral hematoma was detected in 15 cases in one
region, and in a few cases, they were detected in up to four different parts of the brain, with an
overall high agreement between autopsy and radiology. Brain edema was recorded slightly
more frequently in autopsies, with presence in 39 cases. Midline shift was predominantly
recorded from CT images, with presence in 23 cases. Infarction/ necrosis were found
predominantly unifocally in up to 14 cases, and in two different regions in 2 cases, with high
agreement between both methods. Diffuse axonal injury was diagnosed exclusively on CT
images in 3 cases. Intracranial gas was detected exclusively on CT images in 18 cases.
Rupture of a bridging vein was reported in 1 autopsy.

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3.3. Changes in radiological findings on follow-up CTs

In the group of 16 patients with neurosurgical treatment by craniotomy, discrepancies were

found for most of the assessed pathological entities between the primary CT and the last
postoperative CT before death (Fig. 2a). Findings that were present in the primary CT and
were no longer detectable in the last postoperative CT (“lost findings”) consisted especially
of epidural hematomas, subarachnoid hematomas and midline shift. Findings that developed
between the primary CT and the last postoperative CT before death (“new findings”)
consisted of 8 cases with intracranial gas accumulation due to the craniotomy as well as of 9
cases with infarction/necrosis. New midline shift arose in 6 cases, and different kinds of
haematomas developed in up to 3 cases (Figs. 3-6).

The group of 13 conservatively treated patients who underwent follow-up CT examinations

revealed less discrepancies in the assessed pathological findings between the primary CT and
the last follow-up CT before death (Fig. 2b). Findings that were present in the primary CT
and were no longer detectable in the last follow-up CT (“lost findings”) consisted of
subarachnoid and intraventricular hemorrhage in 2 cases, respectively, and of midline shift
and intracranial gas accumulation in 1 case, respectively. Findings that developed between the
primary CT and the last follow-up CT before death (“new findings”) were most frequently
brain edema, followed by infarction/necrosis, intraventricular hemorrhage and midline shift.

The rating into the presence and absence of findings in this study did not express their
extension. To give an idea of sizes and extensions, some measurements performed
predominantly on primary CT examinations are given as follows: Evacuated epidural
hematomas had a maximum extension of 58 mm. Evacuated subdural hematomas had a
maximum width of 24 mm. Cortical contusions had a maximum diameter of 73 mm. The
maximum change in midline shift within the ante-mortem course was 27 mm.

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4. Discussion

In this study, the typical features of traumatic brain injury were compared between autopsy
and ante-mortem CT examinations as well as between CT examinations in the temporal
course.

Despite the different approaches between autopsy, which aims to clarify the cause of death,
and radiology, which aims to make a diagnosis as a basis for therapeutic decisions, the main
pathological findings of traumatic brain injury were found to be comparable between both
methods. Discrepancies might be partially explained as follows.
In this study, autopsy was determined as the gold standard for the statistical evaluation. The
autopsy protocols were performed for the whole body without special focus on the brain.
Assessment of the findings for this study by using only the present written autopsy report was
not always possible. Furthermore, clearly detectable findings on CT images that were
supposed to be present in autopsy could not be found in some cases. They might have been
undetectable on thicker slices in necrotic brains, or they were possibly not documented in the
autopsy report. In contrast, CT examinations were re-evaluated to check the desired findings,
with a focus on the traumatic brain injury.
Assessment of extra-axial hematomas and hemorrhages could be performed relatively clearly
for both modalities. However, on CT examinations, the assessment of cortical contusions and
intracerebral hematomas was difficult, especially in cases with severe traumatic brain injuries,
as they were present in several locations and sometimes with a confluent characteristic. The
correspondent autopsies also revealed partially unclear descriptions. Difficulties in the
diagnosis of brain contusions on CT examinations are known from the literature, with marked
variation between even the most experienced readers [19]. In our study, cortical contusions
and intracerebral hematomas were assessed not as single lesions but rather as entities at
several locations in many cases. The assessment of diffuse axonal injury turned out to be
limited to CT examinations, because in autopsy, it is practicable exclusively in histological
examinations. Diffuse axonal injury indicates extensive injury to the white matter and occurs
in about half of all severe head trauma cases. However, only a minority of diffuse axonal
injury lesions are associated with hemorrhage and identifiable on CT images [17, 20, 21].
Intraventricular hemorrhage on initial CT has been reported as a marker of diffuse axonal
injury after traumatic brain injury [20]. In this study, intraventricular hemorrhage was
assessed frequently, especially on CT examinations indicating diffuse axonal imaging on
more than the 3 directly diagnosed cases. Brain edema, as the most frequent finding in this
study, had a high agreement between modalities. The diagnosis is based on the combination
of several features in the autopsy and on CT images, which are known to have variations.
Additionally, different populations, and especially different age groups, lead to different brain
morphology [22, 23]. However, in this study, the high agreement is supposed to result from
the distinct occurrence of the brain edema in the ante-mortem course, which can be clearly
diagnosed in both modalities. Assessment of the midline shift appeared to have more
significance in CT evaluation. Intracranial gas was assessed only on CT examinations.
Assessment of pathological gas collections on ante- and post-mortem CT examinations is
known to be superior to autopsy [6, 7, 9, 10, 24]. The rupture of a bridging vein was included
in this study as a finding, although it was reported exclusively in 1 autopsy. Ruptures of
bridging veins are the major cause of the development of subdural hematomas [17]. On non-
enhanced CT examinations, they are not detectable.
In addition to the preceding discussion, ante-mortem, peri-mortem and post-mortem changes
between the last ante-mortem CT and the autopsy must be considered as a possible cause for
differences.

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Comparison between the primary CT after trauma and the last ante-mortem CT revealed
marked changes in the presence and absence of findings, especially in patients with severe
traumatic brain injury requiring decompression craniotomy. This indicates that the diagnoses
of the primary CT are often not the same as those in the last ante-mortem CT or the following
autopsy. In these cases, the primary CT can be used to assist in the forensic reconstruction of
the peritraumatic events, whereas the last ante-mortem CT can be used to assist in the analysis
of the cause of death.
Loss of findings was predominantly due to neurosurgical evacuation of epi- and subdural
hematomas and cortical contusions, which were among the main reasons for craniotomy in
these cases. Subarachnoid and intraventricular hemorrhage got lost in few cases, probably
by dilution by liquor or by resorption.
Development of new findings or new detection of findings occurred predominantly in cases in
which the primary injuries were due to progressive hemorrhage, which is a known
phenomenon in the clinical literature [25-29]. Early after moderate or severe head injury, the
initial CT does not reveal the full extent of hemorrhagic injury in approximately 45% of
patients [27]. Decompressive craniectomy is reported to be one of the risk factors for
progressive hemorrhage [25]. Additionally, redistribution especially of subdural hematomas
[23, 30-32], might have led to a new finding at another location in our study.
Finally, acute secondary injury developed in terms of brain edema and infarction [17],
especially in patients with severe traumatic brain injury and craniotomy.

There are several limitations of the study that should be considered. The population consisted
of only 45 cases. The time intervals between CT examinations and death were heterogeneous.
The study was based on macroscopic autopsy and CT images. The standard autopsy
procedure consisted of brain dissection without prior fixation. Histology of the brain was
available only in a few cases and, therefore, could not be used for this study. Additional
radiological methods, such as magnetic resonance tomography, were not used as these
methods were available only in a few cases.

The definition of findings as “present” or “absent” did not acknowledge the degree of
occurrence. However, this method was chosen in preference to a rating scale because the
latter was deemed too multifactorious for our aims

Conclusions

In this study, the assessed pathological findings of traumatic brain injury were basically
comparable between clinical ante-mortem CT examinations and macroscopic autopsy in the
clinical situation. Comparison between the primary CT after trauma and the last ante-mortem
CT revealed marked changes in the presence and absence of pathological findings, especially
in patients with severe traumatic brain injury and subsequent craniotomy. In these cases, the
primary CT can be used to assist in the forensic reconstruction of the peritraumatic events,
whereas the last ante-mortem CT can be used to assist in the analysis of the cause of death.
Altogether, ante-mortem CT revealed to be useful in documenting an evolving brain injury.
Therefore, ante-mortem CT should be increasingly included in the interpretation of autopsy
findings in clinical settings.

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Figure Legends

Fig. 1. Illustration of the frequencies of findings in autopsy and radiology in the 45 studied
cases.
EDH epidural hematoma, SDH subdural hematoma, SAH subarachnoid hemorrhage, IVH
intraventricular hemorrhage, DAI diffuse axonal injury, CC cortical contusion, ICH
intracerebral hematoma, BE brain edema, MLS midline shift, I/N infraction/necrosis,
GAS intracranial gas, RBV rupture of bridging vein.

Fig. 2.a Illustration of lost and new findings between the primary CT and the last follow-up
CT before death in the 16 patients with craniotomy. b Illustration of lost and new findings
between the primary CT and the last follow-up CT before death in the 13 patients without
craniotomy.
EDH epidural hematoma, SDH subdural hematoma, SAH subarachnoid hemorrhage, IVH
intraventricular hemorrhage, DAI diffuse axonal injury, CC cortical contusion, ICH
intracerebral hematoma, BE brain edema, MLS midline shift, I/N infraction/necrosis,
GAS intracranial gas, RBV rupture of bridging vein.

Fig. 3. 73-year-old female patient with severe traumatic brain injury. a Primary CT
examination (multiplanar paraaxial reconstruction) illustrating a large epidural hematoma on
the left side. The hypodense structures within the hematoma represent the “whirlpool sign”,
indicating active bleeding. Note moderate to severe brain edema. b Follow-up CT
examination (paraaxial single slice) 6.5 hours after decompression craniotomy on the left side
and evacuation of the epidural hematoma. Massive brain edema with herniation of the brain
through the osseous defect is shown. Note the development of subdural hematoma
surrounding the right hemisphere and extension along the interhemispheric fissure.

Fig. 4. 66-year-old male patient with severe traumatic brain injury. a Primary CT examination
(multiplanar paraaxial reconstruction) illustrating a large subdural hematoma on the left side
with “whirlpool sign”. Marked mass effect with midl ine shift to the right side is recognisable.
Note the fracture of the cranial vault on the right side with hematoma of the galea and gas
inclusion. b Follow-up CT examination (multiplanar paraaxial reconstruction) 4 hours after
decompression craniotomy on the left side, evacuation of the hematoma and insertion of two
drainages. Slight remains of the subdural hematoma, moderate brain edema and relocation of
the midline are visible. Note the development of intracerebral hematoma bilaterally in the
frontal lobes as well as around the third ventricle, with surrounding edema, and slight
traumatic subarachnoid hemorrhage frontally.

Fig. 5. 42-year-old patient with severe traumatic brain injury. a Primary CT examination
(paraaxial single slice) illustrating a large cerebral contusion in the right frontal lobe with distinct
mass effect, a thin subdural hematoma on the right side and a thin epidural hematoma with gas
inclusion on the left side parietally. b Follow-up CT examination (paraaxial single slice) 24 hours
after decompression craniotomy on the right side and evacuation of the hematoma. Slight
remains of the cortical contusion are visible, and the midline shift had decreased. Intraventricular
hemorrhage is detectable as well as a thin subdural hematoma on the left side frontally. The
epidural hematoma on the left side slightly increased.

Fig. 6 55-year-old patient with traumatic brain injury. a Primary CT examination (multiplanar
paraaxial reconstruction) illustrating a large cortical contusion in the right frontal lobe, slight
intraventricular hemorrhage and a hematoma of the galea on the left side. b Follow-up CT
examination (paraaxial single slice) 4 days after decompression craniotomy on the right side

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and evacuation of the hematoma. Remains of the cortical contusions are visible, the
intraventricular hemorrhage had increased and moderate brain edema is present. Note the
development of hypodense areals in the posterior aspect of the brain, indicating infarction,
and around the cortical contusion extending into the corpus callosum indicating edema
and resumable infarction.

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Table 1 Comparison of presence and absence of pathological findings between autopsy and
radiology in the 45 studied cases. Values ≥ 80% are highlighted. Diffuse axonal injury and
intracranial gas was not listed as these findings were assessable only on CT. Rupture of
bridging vein was not listed as this finding was only assessable in autopsy.

Findings Sensitivity (%) Specificity (%) Positive predictive

value (%)
Epidural hematoma 100 97 86
Subdural hematoma 1 83 60 88
Subdural hematoma 2 64 84 64
Subdural hematoma 3 75 93 50
Subarachnoid hemorrhage 1 94 36 76
Subarachnoid hemorrhage 2 85 81 65
Intraventricular hemorrhage 89 58 61
Cortical contusion 1 77 89 91
Cortical contusion 2 43 95 60
Intracerebral hematoma 1 80 90 80
Intracerebral hematoma 2 75 98 75
Intracerebral hematoma 3 0 100 -
Intracerebral hematoma 4 - 98 0
Brain edema 82 67 94
Midline shift 100 55 22
Infarction/necrosis 1 75 85 64
Infarction/necrosis 2 100 100 100

“-“ indicates that the finding was not present in a ny of the autopsies or CT examinations.
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Highlights

The comparison revealed a high specificity in most of the findings.

In severe traumatic brain injury findings clearly changed in the ante-mortem course.

As first imaging modality following trauma ante-mortem CT has a high value.

Ante-mortem CT is supposed to provide complementary information to autopsy.