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June 24, 2024 Feature

Postmortem Computed Tomography: A Forensic Primer

Daniel F. Gallego, Edward L. Mazuchowski, Howard T. Harcke, and Heather S. Jarrell


Due to the graphic nature of some of the autopsy and postmortem computed tomography images, including depictions of the aftermath of suicide and other trauma, we have removed all images discussed in this article and compiled them in one PDF that readers may choose to download here if desired. Some of the endnotes below direct readers to visit this web address to download the PDF of the images [Download PDF]

In 1895, X-rays were discovered by Willam Roentgen. The following year, it was used to localize a projectile in a case of a gunshot wound of a woman. Since then, radiographs (also known as plain X-rays) have been widely used in the context of forensic pathology. Radiographs are very useful for single imaging projection planes with particular interest in the skeleton. The X-ray creates an image based on the different X-radiation absorption by different structures of the body, as they have varying densities. Radiographs (now almost always generated as digital images) can help in forensic practice by detecting retained projectiles, bone fractures, and certain findings in internal organs (e.g., air and fluid in the chest or abdomen). The implementation of postmortem imaging has come to a point where Medical Examiner’s office accreditation by the National Association of Medical Examiners (NAME) requires the ability to obtain body radiographic imaging, whether in-house or otherwise. However, it does not state which type of imaging modality should be used.

Computed tomography (CT) was developed in 1974 and allows for a series of two-dimensional images to give a three-dimensional perspective. The CT scan acquires sequential slices to complete volumes as the body passes through a rotating CT gantry with multiple detectors. These sets of slices can be computer reconstructed as new sets of two-dimensional images in multiple planes. CT scanning software is capable of taking information from two-dimensional data sets and reconstructing three-dimensional images of the body or its parts, like the skeleton. All CT information is digital and is processed and stored through a computer network, known as a picture archiving and communication system (PACS), that allows for data to be shared and reviewed by multiple individuals. CT is ubiquitous in modern premortem health care and the postmortem computed tomography (PMCT) equipment and software are similar to those used. One difference is lack of concern for radiation exposure of the subject in PMCT.

Compared to radiographs, there was a relative delay in implementation of CT in the postmortem setting until the early 2000s. In 2004, PMCT was incorporated into the standard autopsy procedure of the Armed Forces Medical Examiner System. Shortly after, the Institute for Forensic Medicine of the University in Berne developed the minimally invasive autopsy they called Virtopsy. PMCT is explicitly incorporated into the Coroners Act of Victoria State 2008 and is an important component of the preliminary examination process, where a pathologist reviews the circumstances of death, pre-existing medical history, whole body CT images, external appearances of the body, and toxicological screen results, so that a recommendation to the coroner may be formulated regarding the likely cause of death and necessity for autopsy. Implementation of PMCT in other forensic venues in the world, including the United States, has been reported in medical literature as its routine practice rapidly spreads.The International Society of Forensic Radiology and Imaging (ISFRI) is a nonprofit international professional organization whose objective is to strengthen and develop the field of postmortem forensic radiology and imaging, including implementation of PMCT technology.

The state-wide centralized Office of the Medical Investigator (OMI) in Albuquerque, New Mexico, that is associated with the University of New Mexico (UNM) has been using PMCT since 2010. The Radiology-Pathology Center for Forensic Imaging supports forensic research, education, and the clinical service at the OMI. While using PMCT as an autopsy adjunct, many death investigations were able to be focused and the autopsy limited in scope, often to just review circumstances, PMCT, an external examination, and toxicology. For 2021, 98% of all decedents that were examined at the OMI received a head-to-toe CT scan. With the use of PMCT and guided by Standard Procedures of the Office, for 2021, only 34% of all jurisdictional cases required an internal examination. Breakdown per manner of death reveals that 99% of homicides, 91% of undetermined, 44% of suicides, 32% of accidents, and 22% of natural certified deaths received a full autopsy (with internal examination). These numbers show that with PMCT, limited autopsy (external examination only) has surpassed full autopsies at the New Mexico OMI.

Forensic pathologists should be aware of their own limitations in PMCT interpretation. It is strongly encouraged to have a radiologist available for consultation when needed. Regardless, the CT scan interpretation is always performed by a physician (medical or osteopathic doctor) who is board certified and licensed to practice medicine in the state. The changes that are evident on PMCT for determination of cause and manner of death are usually significant enough to cause death and, therefore, tend to not be subtle. Radiologists are adept with the diagnosis of natural disease and are more skilled at recognizing subtle changes in the internal organs. Forensic pathologists are usually more familiar and aware of postmortem changes and have the ability to correlate PMCT with autopsy findings. In the future, it is anticipated there will be formalized subspecialty training programs in forensic radiology that will enhance standardization of PMCT interpretation.

The implementation of routine practice of PMCT by forensic pathologists has been previously studied. Both autopsy and PMCT standing alone are imperfect in recognizing all pathological findings. Experience to date recognizes each to have strengths and limitations that, taken together, complement each other. Both methods successfully identify critical findings sufficient for establishing cause of death in many cases of blunt force injury and firearms injuries. Ideally, as medical examiner offices acquire CT scanners, forensic pathologists would have access to a consulting radiologist. However, forensic pathologists who routinely utilize PMCT over time can acquire sufficient knowledge to interpret images for use in their establishment of cause and manner of death.

Cause and Manner of Death

One of the main roles of a medicolegal death investigation is the determination of cause of death and manner of death. Such determination considers the circumstantial evidence from investigative information, examination of the body, and ancillary testing. The type of examination can vary widely depending on the standard operating procedures of the medical examiner or coroner office and can range from medical or investigative reports review without a physical examination of the body, to an external examination of the body (for trauma or any other skin findings) without internal examination, to a full autopsy (including internal examination). Ancillary testing refers to additional supporting studies that assist with the determination of cause of death and manner of death and include toxicology, microbiology, clinical chemistry, and/or postmortem imaging.

Cause of death is the injury or disease that creates a physiologic derangement that results in death; it is the “why” the person is dead. Some examples of cause of death include a gunshot wound, blunt force trauma, sharp force injury, atherosclerotic cardiovascular disease, and cancer, among others. Manner of death refers to the medicolegal opinion in regard to the fashion or circumstances that led to death—it is the “how.” A majority of states have defined five manners of death: natural, accident, suicide, homicide, and undetermined. It is to be emphasized that the classification of homicide for the purposes of death certification is a “neutral” term and neither indicates nor implies criminal intent, as would be defined and used in criminal and civil law. The determination of cause of death and manner of death is a medical opinion primarily used to fill out a death certificate for legal documentation that a specific individual has died, providing information for mortality statistics and fulfilling other needs that involve public health and safety issues. We will now describe some examples of the current utilities and limitations of PMCT scanning associated with some manners of death.

Natural Deaths

Natural deaths are due to disease and/or the aging process, including cardiovascular disease, cancer, infections, dementia, and others. PMCT can be of some help in natural deaths and is much superior to conventional radiographs. While it enhances detection of some pathology, it is not able to identify many of the anatomic details that are evident during an internal examination.

The most common cause of death in the United States is hypertensive and atherosclerotic cardiovascular disease. The atherosclerotic portion refers to hardening and narrowing of the arterial vessels of the body; this diminishes the amount of oxygen available to tissues. On PMCT atherosclerosis can be seen as hyperdense calcifications of the coronary arteries, aorta, and other arteries. The hypertensive portion of the name refers to long-term high blood pressure that affects the organs (mainly the heart and kidneys). Cardiomegaly is the term for an enlarged heart, which is the consequence of pumping against high pressure and can be seen on PMCT and measured. Long-term kidney disease can be inferred in PMCT though perinephric fat stranding: swelling and threads of tissue from the kidney that go into surrounding fat. Kidneys can also be small or atrophied. Diabetes mellitus may overlap with heart disease and give similar kidney findings. Analysis of the eye fluid may reveal high glucose in the setting of complications of diabetes and/or diabetic ketoacidosis. Both radiographs and CT scan without contrast cannot sufficiently evaluate for coronary artery or renal disease. Some of the limitations of evaluation of heart disease without an autopsy with organ dissection include inability to determine a percentage of coronary artery occlusion documented by cross-sectioning of the coronary arteries during internal examination or the presence of a coronary thrombus in myocardial infarction. Certain clinical scores used for living patients have been implemented, such as the coronary calcium score for cardiovascular risk assessment, but this is still a novel approach that needs further research, standardization, and implementation.

Cancer is the second most common cause of death worldwide. If large or metastatic, they can be seen as nodules in organs. In conjunction with clinical and pathological premortem diagnosis, they can be attributed to oncologic disease. However, an accurate diagnosis and documentation (particularly if the first time) requires a full autopsy with careful dissection of internal organs and taking samples to be evaluated under the microscope.

For the past three years, COVID-19 infection has been the third most common cause of death in the United States. If flu-like symptoms are reported or lung opacities are present on PMCT, a nasopharyngeal swab can be performed to evaluate for COVID-19 virus. Persistence and stability of COVID-19 positive samples have been confirmed in the postmortem setting even in the presence of decomposition. In terms of the radiological characteristics of the pulmonary opacities, the COVID findings are ground-glass opacities or a combination of ground-glass opacities and air space diffuse consolidation uniformly affecting both lungs. However, these changes are overall indistinct from other viral infections, can be subtle or nonspecific, or can be superimposed with bacterial infections. Consequently, PMCT has not proved to be definitive. Diagnosis of infection is based on the use of cultures for microbiology to identify the bacteria or virus that is causing disease and may require the organs to be sampled during internal examination or targeted biopsy and for inflammatory cells and organ damage to be seen under the microscope.

Both infectious diseases (including tuberculosis and fungal infections) and cancer can appear as nodules in the lungs, liver, and bones and can be challenging to distinguish from each other. Diagnosing certain infectious diseases may be very important for public health reasons and autopsies with microbiology sampling and tissue collection may be warranted. PMCT-guided biopsy allows the performance of minimally invasive autopsy for recovery of key tissue for microscopic examination. For cause of death determination, the results were similar to that of conventional autopsy. With this technique, needles are introduced under CT guidance, and small samples of tissue that can be used for microbiology and microscopy are extracted. PMCT guidance assures through imaging that the correct region of interest has been sampled. This technique is routinely performed with living patients.

Chronic liver disease and cirrhosis is the ninth-leading cause of death and can be associated with long-term alcohol use. The liver can be evaluated for fatty change, or liver steatosis, via PMCT, through the measurement of tissue density (for which the liver parenchyma is less than 40 Hounsfield units (HU)). The fatty liver also appears darker than usual when viewed on the abdominal window of the CT scan. The liver can be enlarged or small and have irregular borders, an indication of cirrhosis (scarring). Other findings commonly associated with ethanol include the presence of pancreatic calcifications and brain atrophy. Patients with cirrhosis will often accumulate fluid that can be documented in the abdomen (ascites) or the chest (pleural effusions).

Cardiac and vascular CT imaging in live patients is typically performed while injecting contrast material. Given that the heart is not pumping in the postmortem setting, the vast majority of postmortem CT scans do not use intravenous contrast material, so the visualization of critical tissue is limited for certain conditions. While contrast-injected PMCT is possible, it requires extra effort in terms of expertise, additional dissection, and time consumption and is not in general PMCT use. Where limited/selective contrast-injected PMCT has been employed, like the cerebral circulation, some success has been reported.

Due to this consideration, there are certain common conditions that cannot be routinely evaluated with PMCT, most importantly pulmonary embolism (PE), which can only be accurately diagnosed during autopsy by documenting a large premortem thrombus in the pulmonary arteries.

In summary, the forensic pathologist has options when there is extensive evidence of natural disease on PMCT and the decedent has a well-documented medical history. As long as there are no suspicious circumstances or concerns, autopsy can be limited when an external examination plus PMCT suffice to determine cause of death.

Accidental Deaths

Accident applies when an injury or poisoning causes death and there is little or no evidence that the injury or poisoning occurred with intent to harm or cause death. Accidental deaths include a vast number of causes, including blunt force trauma due to motor vehicle collisions or falls, drug overdoses, thermal injuries from non-arson fires, drownings, and exposure to cold or heat.

One of the most useful strategies for PMCT is the evaluation of bones and detection of internal hemorrhage for documentation of blunt force trauma. Head trauma can be documented with fractures of the skull, air around the brain (pneumocephalus), and bleeding inside the head (intracranial hemorrhage). The type of intracranial hemorrhage can be documented by location and configuration as epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, intraparenchymal hemorrhage, or intraventricular hemorrhage. All of them have their own clinical characteristics and mechanisms and all of them can be potentially fatal. Neck trauma can be documented as fractures or dislocations (displacement) of the cervical spine. Basic PMCT axial images can be reconstructed in sagittal and coronal planes for better visualization. These are also used for court presentation.

As a generality, when there are fractures of the skull or cervical spine, given the proximity to the brain and spinal cord, trauma is considered very severe and potentially lethal by itself. Therefore, documentation of such degree of trauma may be sufficient to explain death, and in the appropriate context may suffice without the performance of an internal examination.

Thoracic trauma can be documented as rib fractures and blood or air inside the chest or abdominal cavities (hemothorax, pneumothorax, hemoperitoneum, pneumoperitoneum). A fracture that is not routinely visible during standard autopsy and that suggests high-velocity trauma is the wing-bone (scapular) fracture. Facial bone fractures are better characterized through PMCT and can also be missed during autopsy. Extremity trauma can be conveniently evaluated by whole-body PMCT, which detects fractures of the arms and legs. On external exam, where deformities can be palpated and noted, particularly on displaced and comminuted trauma, autopsy detects fractures. However, autopsy can easily miss fractures, which is why radiographs or PMCT has been employed with autopsy. For other types of accidental deaths, such as drug overdoses, ruling out lethal trauma is very important. A negative external examination, the absence of suspicious circumstances surrounding death, a positive urine drug screen available at the time of examination (with subsequent confirmatory testing), and a PMCT with no evidence of trauma can allow the forensic pathologist to not perform an internal examination. However, other considerations apply for different circumstances and causes of death. Drownings and hyperthermia are diagnoses of exclusion, hypothermia can give certain valuable internal examination findings such as Wischnewsky spots, and fire deaths are notoriously known to disguise homicides. Full autopsies with internal examinations are recommended for such and other scenarios.

Suicidal Deaths

Suicide results from an injury or poisoning as a result of an intentional, self-inflicted act committed to do self-harm or cause the death of oneself. Suicides can occur by different means. PMCT for self-inflicted gunshot wounds can help determine the bullet path, associated injuries, and retained projectiles. Gross evaluation of the surface gunshot wound is the accepted method for determining entrance versus exit and can help with the determination of range of fire. Combining a detailed external exam and PMCT can give enough information needed to certify a self-inflicted gunshot wound. The presence of a retained projectile would indicate the need for retrieval through autopsy procedures, which can vary from a small skin incision, to partial examination of the body or full autopsy with internal dissection of organs, depending on the standard procedures of the office and the pathologist’s level of comfort.

For hanging deaths, PMCT can help evaluate for additional trauma; however, the presence of muscle hemorrhages in the neck or injuries to the airway requires a layered anterior neck dissection performed during internal examination. PMCT can detect fractures of the hyoid bone or thyroid cartilage but lacks specificity.

Overall, determination of suicidal deaths heavily relies on circumstantial evidence, and if there is any suspicion from family, law enforcement, or death investigation, a full autopsy, including internal examination with evidence collection, should be performed. Features may be discussed in isolation, but in practice, forensic pathologists have to consider details in combination to make the manner-of-death determination.

Undetermined Deaths

Undetermined or “could not be determined” is a classification used when the information pointing to one manner of death is no more compelling than one or more other competing manners of death in thorough consideration of all available information.

One of the common populations that are subject to this manner of death is infant deaths. For babies and children, because their body is small and their internal organs lack fat, the overall utility of PMCT is relatively limited. Studies are currently scarce, but certain guidelines have been developed for standardization. Evaluation of trauma, both acute and chronic, is extremely important for this vulnerable population. Therefore, the general recommendation is for PMCT and a full autopsy with internal examination, microbiology studies, toxicology analyses, and microscopic studies to be complemented with postmortem skeletal surveys (PMSS) using radiographs, as some fractures are better characterized by radiographs in certain body positions. This is a set of multiple (14 to 28) radiographs that survey the entire skeleton in views that optimize fracture visualization. The reading of a PMSS can be very challenging and may require consultation with a radiologist with specific experience in PMSS. Radiographic imaging in deceased children yields significant artifacts, which may hamper image interpretation. The use of “babygrams,” which is an abbreviated skeletal survey that seeks to encompass the entire infant or young child on only one or two X-ray images, is highly discouraged.

Other types of cases that are commonly certified as undetermined are advanced decomposed remains, including skeletal remains (bones only). In these cases, CT scan can help document skeletal trauma. In addition to performing a full autopsy, a forensic anthropologist, who has expertise in evaluating bones for perimortem trauma, can be consulted.

Overall, the certification of manner of death as undetermined requires the pathologist to use all the available tools to rule in and out possible injuries and pathologies. Therefore, a full autopsy with internal examination is generally warranted before certifying a death as undetermined. These are challenging cases and having PMCT allows for future per-review to be performed and for additional information to be obtained that may not be acquired during autopsy procedures.

Homicidal Deaths

Homicide occurs when death results from a volitional act committed by another person to cause fear, harm, or death. With few exceptions, homicides should have a full autopsy with internal dissection of organs and evidence collection and, as such, PMCT is just one of the tools used for the determination of cause and manner of death.

PMCT of gunshot wound victims allows the forensic pathologist to prepare a plan for external and internal examinations of the autopsy that assists in determining the number of gunshot wounds and their wound paths within the body and facilitates the location and retrieval of retained projectiles. With the digital measurement option available in the CT software and the option to reconstruct different planes, the precise location of the retained projectiles can be documented. After autopsy, these data are available for later review and analysis by peers. The beveling of the bone fracture, especially in the skull, on PMCT (depending on whether the bone fragments fracture internally or externally) may aid in the determination of entrance versus exit. However, this is not an infallible determination as trajectory can create misleading beveling in tangential gunshots that produce “keyhole” defects. Consequently, external examination of the surface gunshot wound at the autopsy table remains the gold standard for determination of entrance versus exit. Certain ammunition features that can be suggested from radiographs also can be seen with PMCT, such as high-velocity, fragmenting rifle ammunition that gives a characteristic “snowstorm” pattern. Also, fragments from shotgun wounds will vary by shot type: multiple and smaller birdshot BBs versus fewer larger buckshot BBs versus a single slugshot. Besides carefully crafted generalities, conclusions regarding range of fire and caliber of the gun cannot be determined by postmortem imaging alone. Rare anecdotal case exceptions exist that support in-vivo CT use by ballistic experts (where autopsy is not a feasible option).

Sharp force injuries may show air (emphysema) of the soft tissues and retained knife tips, which can be recovered during autopsy. These same principles apply to radiographs. Additionally, if there is injury to the venous system, air in the right heart may be identified.

Inflicted, blunt force trauma, in some cases, may be observed on PMCT, but PMCT is not sensitive to soft-tissue injury. Certain other types of injuries, such as smothering, also cannot be appreciated on PMCT. Accurate dating of injuries, such as intracranial hemorrhage, which can be of importance in the litigation process, requires gross and microscopic evaluation of the injuries. Also, bleeding in the soft tissues of the posterior neck, wrists, back, or ankles, such as in in-custody, physical restraint, or torture deaths, may require additional autopsy procedures that are not accurately depicted by PMCT.

In summary, the combination of PMCT and autopsy together is deemed optimal when investigating homicidal events.

Medical Intervention

PMCT helps document medical and surgical interventions. These can be related to resuscitation efforts in the field or interventions performed at the hospital. Some of the potential uses include documentation of the appropriate localization and positioning of medical therapy, such as airway devices, chest tubes, or intravascular access. Remote surgery can be documented in the form of surgical hardware, surgical staples, and absent organs. Complications of surgery such as air or bleeding in the organs can be noted, but a full autopsy with internal examination and review of pertinent medical records and other ancillary testing is required to get a complete understanding of the contribution the medical procedure may have had to death and to document underlying baseline natural disease.

Artifacts from cardiopulmonary resuscitation (CPR) are of particular interest, given the high incidence of iatrogenic injuries due to chest compressions in the form of rib fractures, hemorrhage and air inside the chest, and others such as liver lacerations and hemoperitoneum. While many artifacts of medical intervention can be recognized with the CT scan, autopsy with internal examination may show additional findings not visible on PMCT. Resuscitation can be provided by bystanders, by emergency medical services, or in hospital. The challenge arises when there needs to be interpretation of such findings in the context of potential premortem, non-iatrogenic injury. What type of trauma and the extent to which the trauma can be entirely attributed to resuscitation efforts are matters of medical opinion and can be extremely hard to elucidate (and sometimes there is no way to be certain).

When viewing PMCT, one encounters some characteristic imaging findings that should not be interpreted in the same way they would be on the CT scan of a live patient. Radiologists who routinely interpret antemortem clinical studies and are not used to postmortem cases should be aware of such intricacies.

Postmortem Changes

One of the challenges for imaging experts that are not used to interpreting postmortem images is recognizing which changes in the body have occurred as a result of cessation of life. These are described as postmortem changes. In general, as the body decomposes, bacteria grow in the body and produce air and gases that appear as low density compared to tissue. Visually, decomposition gives the skin a green discoloration (marbling) and creates crepitus of tissues on palpation. Internally, organs and vascular structures accumulate air, which appears as distinct collections, and putrefactive fluid accumulates within body cavities. As decomposition progresses, the brain liquifies, the heart becomes floppy, and the organs shrink. Eventually, soft tissues and organs are completely autolyzed and disappear to the point of complete skeletonization of the body, meaning that eventually only bones remain.

Understanding these normal changes that occur with death and correlating them with the pathologist’s examination will hopefully help to determine through experience and study what corresponds to a premortem significant finding versus a postmortem artifact.

Peer Review

An additional consideration is the ability of PMCT to be peer-reviewed by another expert. The images are digital data that can be saved on a CD/DVD or a USB drive and, with included software for viewing, can be opened on a standard computer. The advantage of PMCT review is that it allows evaluation of all original material by another expert, which is not the case for autopsy, as having the photos and the autopsy report may not entirely represent the on-par experience as performing the autopsy by the original pathologist.

Families Opposed to Autopsy

Traditional values from a cultural or religious standpoint may affect beliefs in relation to the autopsy procedures. Certain Native American communities oppose autopsies on their tribal members, as they believe in the integrity of the body. Furthermore, the bodies are released directly to their families (not funeral homes), and some believe burial should be within a certain amount of time (e.g., before sunset). As part of respecting their wishes, accommodating their needs is extremely important, and performing a PMCT in conjunction with an external examination has been very useful in accurately determining cause of death and manner of death without disrupting their belief system. Similar restrictions may apply to other communities, such as Orthodox Jews. Autopsies for research and educational purposes may be a particular point of contention within a subset of Christian, Muslim, and Eastern religion devotees. Families may have their own reservations independent of creed, and having a good relation and communication are pivotal for such cases. Having jurisdiction over the body does not mean that other factors cannot be taken into consideration when deciding which exam needs to be performed in the postmortem setting.


Identification of decedents is also facilitated by the presence of a complete PMCT scan; for example, presence of teeth allows for reconstruction of a panoramic image, which can be compared to premortem dental records by a forensic odontologist for scientific identification. Also, PMCT demonstrates the presence of certain unique identifiable characteristics such as surgical hardware that a radiologist may compare to premortem imaging to help with identification of remains. Certain skull characteristics, such as the sinuses, have shown to be quite personal and unique, and also have been used. A recent small study suggests that identification of human remains comparing premortem and postmortem imaging could be performed with relative ease by a forensic pathologist, even with limited CT experience.

Use of PMCT in Court

The PMCT images are a fair and accurate representation of the injuries sustained. They potentially provide powerful and easily comprehensible visual evidence before a judge or jury. PMCT, including the possibility of two- and three-dimensional reconstruction, has been used before for criminal prosecution and admitted as evidence to demonstrate victim injuries to the jury. Another court option is for PMCT to be shown as a “demonstrable aid.”

Why Doesn’t Every Forensic Pathologist Use PMCT?

Implementing PMCT into most medicolegal death investigations has been limited. One of the main limitations is cost. The CT machine itself, even for refurbished machines, costs hundreds of thousands of dollars. Establishment of PMCT requires expertise to set up, with dedicated floor space and radiation shielding. Routine technical maintenance, storage of images on a PACS, and repair contracts are required.

Operation of the CT equipment is optimally done by CT technologists trained to operate the system, familiar with image processing and reconstruction, and able to troubleshoot frequent issues. There are also theoretical risks associated with staff exposure to radiation, and CT technologists are trained in radiation safety. Offices doing PMCT have looked for less-expensive operational alternatives such as training autopsy personnel to operate a scanner. State laws vary as to requirements for operation of radiation-producing equipment. However, probably the biggest challenge is that forensic pathologists are not ubiquitously trained to be proficient in PMCT interpretation, and that can be a daunting prospect to overcome. If not properly trained during fellowship (which few institutions do), then continuing education through online and in-person courses may be a feasible option. Support by consulting radiologists trained in PMCT adds cost and also may be a limited option for certain offices. Furthermore, forensic pathologists may fear that CT scan technology will become a replacement for autopsy, which has been the gold standard of the profession for centuries. The determination of cause and manner of death is an intellectual process that requires the blended incorporation of several scientific tools and an understanding of pathology that goes beyond the technical performance of the internal examination.

PMCT to Become Omnipresent

Overall, we anticipate that PMCT will continue to be implemented in medicolegal jurisdictions throughout the United States, as is already the case in many regions of the world. We expect its use will modify some autopsy practices and facilitate the determination of cause of death and manner of death but will not replace the forensic pathologist. As this process continues, forensic pathologists, forensic experts, and lawyers should be aware of and become familiar with the general concepts of PMCT technique as its introduction to the world of forensics is becoming omnipresent.

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    Daniel F. Gallego

    University of New Mexico

    Daniel F. Gallego, MD, is a forensic pathologist at the Office of the Medical Investigator and an assistant professor in the Department of Pathology at University of New Mexico (UNM). He is also an assistant program director of the UNM Pathology Residency program.

    Edward L. Mazuchowski

    HNL Lab Medicine

    Edward L. Mazuchowski, MD, PhD, is chief, Forensic Pathology at HNL Lab Medicine in Allentown, Pennsylvania. Howard T. Harcke, MD, is a retired forensic radiologist for the Armed Forces Medical Examiner System at Dover Air Force Base in Delaware.

    Howard T. Harcke

    Armed Forces Medical Examiner System at Dover Air Force Base

    Howard T. Harcke, MD, is a retired forensic radiologist for the Armed Forces Medical Examiner System at Dover Air Force Base in Delaware.

    Heather S. Jarrell

    University of New Mexico

    Heather S. Jarrell, MD, is chief medical examiner and associate professor of pathology at the Office of the Medical Investigator and University of New Mexico in Albuquerque, New Mexico.