Open Access

Feasibility of resuscitation contrast-enhanced postmortem computed tomography using cardiopulmonary resuscitation technique with chest compression immediately after death

  • Kazunori Iizuka1Email author,
  • Namiko Sakamoto2,
  • Seiji Shiotani3 and
  • Atsushi Komatsuzaki4

Received: 6 December 2013

Accepted: 6 December 2013

Published: 10 December 2013



Our purpose was to evaluate image delineation ability of contrast-enhanced post-mortem computed tomography (CEPMCT) using cardiopulmonary resuscitation technique of chest compression, named “resuscitation CEPMCT”.

Materials and methods

Non-traumatically-deceased 15 subjects (7 men; 8 women) aged 19–87 years (mean 61 years) underwent resuscitation CEPMCT. The contrast-enhanced technique, while injecting 100 ml of contrast media from the right cubital vein at a rate of 1 ml/s, chest compression was performed for 2 minutes at a rate of 100 times/min (a total of 200 times). CT attenuation values (Hounsfield Unit: HU) were measured in 8 target vessels: 1) pulmonary artery, 2) coronary artery, 3) ascending aorta, 4) abdominal aorta, 5) celiac trunk, 6) common iliac artery, 7) superior vena cava, and 8) inferior vena cava. One-sided Student’s t-test was performed to assess whether measured values were higher than 140 HU by setting p-value at 0.05.


Measured CT values in the 8 vessels were 1) pulmonary artery: 325 ± 140 HU, 2) coronary artery: 240 ± 73 HU, 3) ascending aorta: 321 ± 127 HU, 4) abdominal aorta: 286 ± 96 HU, 5) celiac trunk: 233 ± 62 HU, 6) common iliac artery: 260 ± 114 HU, 7) superior vena cava: 422 ± 187 HU, and 8) inferior vena cava: 301 ± 142 HU, showing significantly higher values than the threshold value of 140 HU. Resuscitation CEPMCT detected one case of pulmonary arterial thromboemboli death.


Resuscitation CEPMCT using chest compression immediately after death has the possibility of detecting thromboembolus in major vessels, despite the simplicity of the technique.


Post-mortem computed tomography (PMCT) Contrast-enhanced PMCT (CEPMCT) Cardiopulmonary resuscitation (CPR) Chest compression CT attenuation value


Due to the worldwide decline in conventional autopsy rates, the need for and frequency of post-mortem cross-sectional imaging as a complementary, supplementary or alternative method for autopsy have increased worldwide (Brogdon 1998; Swift and Rutty 2006; Oesterhelweg and Thali 2009; Rutty et al. 2012a).

Death cause detection rate of non-traumatic PMCT alone is approximately 30% in general, while PMCT is especially useful in showing fatal hemorrhagic lesions, including cerebral/subarachnoid hemorrhage, aortic dissection, and aortic aneurysmal rupture (Kaneko et al. 2010; Takahashi et al. 2012; Okuda et al. 2013). Thromboembolism of the coronary artery or pulmonary artery is difficult to detect with PMCT; however, contrast-enhanced PMCT (CEPMCT) can detect them (Jackowski et al. 2005; Grabherr et al. 2007; Steffen et al. 2008; Sakamoto et al. 2009; Iizuka et al. 2009; Kikuchi et al. 2010; Ross et al. 2011; Jolibert et al. 2011; Saunders et al. 2011; Roberts et al. 2011; Ross et al. 2012; Rutty et al. 2012b). Several methods of CEPMCT have been developed worldwide. In Western countries, surgical management for embalming is necessary to perform CEPMCT (Morgan et al. 2014). In Japan, CEPMCT is performed by injecting contrast media from the venous route in combination with chest compression. This technique is named “Resuscitation CEPMCT” because the method is similar to that of the cardiopulmonary resuscitation technique (Okuda et al. 2013; Sakamoto et al. 2009; Iizuka et al. 2009; Kikuchi et al. 2010); however, no literature has been published regarding quantitative evaluation of the vascular delineation ability. Herein, we report the image delineation ability of Japanese CEPMCT technique with chest compression, based on retrospectively measured CT attenuation values in major vessels.

Materials and methods


Our subjects were 15 non-traumatically-deceased patients (7 men and 8 women) aged 19–87 years (mean 61 years) who underwent resuscitation CEPMCT with chest compression between September 2009 and March 2010. Each death was confirmed after subject’s arrival in a state of cardiopulmonary arrest at the emergency room (ER) of National Hospital Organization Tokyo Medical Center. Cardiopulmonary resuscitation (CPR) was performed on all subjects by emergency technicians during transport and in the ER by emergency medical physicians for 30 min. in accordance with the 2010 American Heart Association (AHA) Guidelines for CPR (American Heart Association 2010). CPR included continuous external chest compression, artificial respiration with bag-valve mask ventilation following endotracheal intubation, electric defibrillation, peripheral intravenous catheterization following administration of epinephrine at 1 mg, and infusion. Although the family of each subject did not consent to autopsy, they did consent to PMCT and resuscitation CEPMCT. Causes of death were diagnosed based on a comprehensive evaluation of a subjects’ history of present illness, medical history, laboratory results, and PMCT findings, which included aortic dissection (4 cases), cerebral hemorrhage (3 cases), ischemic heart disease (2 cases), pneumonia (2 cases), gastric cancer (1 case), drug toxicity (1 case), and suffocation (1 case) and pulmonary thromboembolism (1 case).


Firstly, PMCT was performed immediately after the confirmation of death using a clinical scanner in the Radiology Department of National Hospital Organization Tokyo Medical Center, with prior approval of the institutional review board. PMCT was performed with an 8-channel multidetector-row CT scanner (Lightspeed Ultra; GE Healthcare, Milwaukee, USA). The imaging parameters for the head, neck, thorax, abdomen, and pelvis were determined for helical scan mode with settings of auto mA (200–400, noise index: 6.0), 120 kV, 0.5 sec/rotation, 1.25 mm collimation, 1.625 pitch, scan speed of 16.75 mm/rotation, and helical thickness of 5 mm.

Secondly, resuscitation CEPMCT was performed as described below. For injecting a contrast media from the right cubital vein, an automatic injector (Dual Shot GX, Nemoto Kyorindo Inc., Japan) was used for the peripheral intravenous catheter retained for infusion during CPR. The contrast media used was iopamidol (Oypalomin 300 Injection Syringe, Konica Minolta Holdings Inc., Japan), which is a non-ionic media generally used in clinical practice. A dose amount of 100 ml was injected at a rate of 1 ml/second. While injecting the contrast media, chest compression was done on the CT table for 2 minutes at a rate of 100 times/minutes (a total of 200 times), in accordance with 2010 AHA Guidelines for CPR (American Heart Association 2010). Scanning parameters for resuscitation CEPMCT were the same as for PMCT.

Intra-luminal CT attenuation values of the following 8 vessels were measured: 1) pulmonary artery trunk (Figure 1a); 2) left main coronary artery (Figure 1b); 3) ascending aorta at the level of the tracheal bifurcation (Figure 1c); 4) abdominal aorta at the level of the diaphragm (Figure 1d); 5) root of the celiac trunk (Figure 1e); 6) right common iliac artery immediately after branching from the descending aorta (Figure 1f); 7) superior vena cava at the level of bifurcation pulmonary artery (Figure 1g); and 8) inferior vena cava at the level of renal vein (Figure 1h). A circle-shaped region of interest (ROI) with the diameter of 3 mm was placed in the center of the subject vessels, except for the 2) left main coronary artery and 5) root of the celiac trunk, where the diameter of the ROI was set at 1 mm.
Figure 1

PMCT of 8 target blood vessels of a 64-year-old man. A red circle indicates a region of interest in which CT attenuation value (HU) was measured. a. Pulmonary artery trunk b. Left main coronary artery c. Ascending aorta at the level of the tracheal bifurcation d. Abdominal aorta at the level of the diaphragm e. Root of the celiac trunk f. Right common iliac artery immediately after branching from the descending aorta g. Superior vena cava at the level of bifurcation pulmonary artery. h. Inferior vena cava at the level of renal vein.

A threshold value setting for detection of thromboemboli

For detection of thromboemboli, a threshold value of 140 Hounsfield Unit (HU) was chosen as the minimally-necessary enhancement value in the vessel. Generally, CT attenuation value of thrombus is 50–80 HU, plaque (mainly fat and fiber) of the coronary artery is less than 120 HU, and plaque (mainly calcification) of the coronary artery is higher than 120 HU (Schroeder et al. 2004). The contrast discrimination threshold (namely, CT value difference by which radiologists never fails to distinguish among tissues) is approximately 20 HU (Ariji et al. 1993). Therefore, theoretically, thrombus without including calcification can be detected when CT attenuation value in the vessel is higher than 140 HU.

The one-sided t test was used to evaluate whether the mean attenuation value of each target vessel was significantly greater than 140HU. A P value of less than 0.05 was considered to be a statistically significant difference.


Mean CT attenuation values of each targeted vessel are shown in Table 1. All of the 8 examined vessels had CT attenuation values of greater than 140 HU. There was no extravasation of contrast media due to postmortem increased permeability of the vascular wall. In one case having thromboemboli of the pulmonary artery, detection of the thrombi was difficult with PMCT (Figure 2a). On a resuscitation CEPMCT image, CT value of the pulmonary arterial trunk was 269 HU, and that of thromboemboli in the pulmonary artery was 54 HU. The filling defects in the pulmonary artery indicated the presence of thromboemboli (Figure 2b).
Table 1

CT attenuation values measured on contrast-enhanced postmortem CT


Case I.D. No.

















Mean ± SD

1. Pulmonary artery
















325 ± 140*

2. Coronary artery
















240 ± 73*

3. Ascending aorta
















321 ± 127*

4. Abdominal aorta
















286 ± 96*

5. Celiac artery
















233 ± 62*

6. Common iliac artery
















260 ± 114*

7. Superior vena cava
















422 ± 187*

8. Inferior vena cava
















301 ± 142*

Notes: CT attenuation values are shown as Hounsfield Unit (HU).

*Significantly greater CT attenuation value than a threshold of 140 HU (p < 0.05).

Figure 2

A 38-year-old man died for thromboembolism of pulmonary artery. Detection of thrombi is difficult with PMCT (a). On a resuscitation CEPMCT image, CT value of the pulmonary arterial trunk was 269 HU, and that of thromboemboli in the pulmonary artery was 54 HU. The filling defects in the pulmonary artery indicated the presence of thromboemboli (b).


The resuscitation CEPMCT technique in the present study using intravenous contrast media injection and chest compression delineated all 8 vessels with CT attenuation values of over 140 HU. A small thrombus might be difficult to detect using enhanced CT, and the negative detection rate of acute pulmonary embolism is reported to be 60% using multidetector CT (Stein et al. 2006). However, CEPMCT is considered capable of detecting relatively large thromboemboli which can be a cause of sudden death. In our study, thrombi were detected in one case of pulmonary arterial thromboemboli death. The formation of postmortem blood clots is closely linked to the length of the agonal interval (Ross et al. 2012). In the case of a sudden death, plasminogen activator is released into the vessel, resulting in increased fluidity of blood (Shiotani et al. 2002). Therefore, PMCT performed immediately after death can differentiate thromboemboli from postmortem coagulation. This infers the feasibility of resuscitation CEPMCT for detection of thromboemboli at least in the pulmonary arteries, which has been difficult to do with PMCT alone.

Chest compression during CPR increases blood pressure, and generates cardiac output of approximately one-third to one-fourth of the normal state of a living body (Jackson and Freeman 1983; Paradis et al. 1989). This phenomenon enables delineation of our resuscitation CEPMCT with chest compression. When chest compression is not applied for CEPMCT, injected contrast media migrates from the right atrium to the inferior vena cava, without flowing into the right chamber or left heart (Morgan et al. 2014). With chest compression, contrast media injected from the upper arm (cubital vein) enters the right atrium, moves into the right ventricle, pulmonary artery, pulmonary vein, left atrium, left ventricle, aorta, with the enhanced image of the arterial route being delineated.

There are two drawbacks to this study. One is that all of the subjects were non-traumatically deceased patients. In traumatic cases where chest compression is not effective, such as multiple rib fracture and significant loss of blood volume from bleeding, contrast-enhancement would be insufficient due to the lack of effective perfusion of the contrast media in the body. Another drawback is that it is uncertain whether the injected amounts, concentrations, and flow rate of the contrast media and the time of chest compression we performed were optimal for resuscitation CEPMCT.

We surmise that increased intravascular CT values would be obtained with increased amounts and concentrations of contrast media. On the other hand, an excessive number of chest compressions will widely diffuse contrast media in the body, which may obscure intra-vascular CT values. The optimum imaging conditions should be further investigated.

In conclusion, resuscitation CEPMCT with the combination of contrast media injection and chest compression immediately after death is believed to be a relatively simple additional technique to PMCT for the detection of vascular disease-related causes of death.

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Authors’ Affiliations

Department of Radiology, National Hospital Organization Matsumoto Medical Center
Department of Forensic Medicine, Hirosaki University Graduate School of Medicine
Department of Radiology, Tsukuba Medical Center
Department of Radiology, National Hospital Organization Tokyo Medical Center


  1. American Heart Association: Advanced cardiovascular life support. In Highlights of the 2010 American Heart Association Guidelines for CPR and ECC. 1st edition. Edited by: Hazinski MF. American Heart Association, Dallas; 2010:13-16.Google Scholar
  2. Ariji Y, Ariji E, Yoshiura K, Kanda S: A study on contrast discrimination of CT images. Oral Radiol 1993, 9: 9-16. 10.1007/BF02349098View ArticleGoogle Scholar
  3. Brogdon BG: Research and applications of the new modalities. In Forensic Radiology. 1st edition. Edited by: Brogdon BG. CBC Press, Boca Raton; 1998:333-338.View ArticleGoogle Scholar
  4. Grabherr S, Djonov V, Yen K, Thali MJ, Dirnhofer R: Postmortem angiography: review of former and current methods. AJR Am J Roentgenol 2007, 188: 832-838. 10.2214/AJR.06.0787View ArticleGoogle Scholar
  5. Iizuka K, Sakamoto M, Kawasaki H, Miyoshi T, Komatsuzaki A, Kikuchi S: Examination of the usefulness of the contrast-enhanced Post mortem CT imaging diagnosis. Innervision 2009, 24: 89-92. (in Japanese)Google Scholar
  6. Jackowski C, Sonnenschein M, Thali MJ, Aghayev E, Von Allmen G, Yen K, et al.: Virtopsy: postmortem minimally invasive angiography using cross section techniques –implementation and preliminary results. J Forensic Sci 2005, 50: 1175-1186.View ArticleGoogle Scholar
  7. Jackson RE, Freeman SB: Hemodynamics of cardiac massage. Emerg Med Clin North Am 1983, 1: 501-513.Google Scholar
  8. Jolibert M, Cohen F, Bartoli C, Boval C, Vidal V, Gaubert JY, et al.: Angioscanner post-mortem : faisabilité de l’abord artériel sous guidage échographique. J Radiol 2011, 92: 446-449. (in French) 10.1016/j.jradio.2011.03.011View ArticleGoogle Scholar
  9. Kaneko T, Hibi M, Ishibashi M, Nakatsuka A, Omori Y, Ishikura K, et al.: Postmortem computed tomography is an informative approach for prevention of sudden unexpected natural death in the elderly. Risk Manag Healthc Policy 2010, 3: 13-20.View ArticleGoogle Scholar
  10. Kikuchi H, Kawahara K, Tsuji C, Tajima Y, Kuramoto T, Shihara M, et al.: Post mortem contrast-enhanced computed tomography in a case of sudden death from acute pulmonary thromboembolism. Exp Ther Med 2010, 1: 503-505.Google Scholar
  11. Morgan B, Sakamoto N, Shiotani S, Grabher S: Postmortem computed tomography (PMCT) scanning with angiography (PMCTA): a description of three distinct methods. In Essentials of autopsy practice. 1st edition. Edited by: Rutty GN. Springer-Verlag, London; 2014:1-21.View ArticleGoogle Scholar
  12. Oesterhelweg L, Thali MJ: Experiences with virtual autopsy approach worldwide. In The virtopsy approach. 1st edition. Edited by: Thali MJ, Dirnhofer R, Vock P. CRC Press, Boca Raton; 2009:475-477.Google Scholar
  13. Okuda T, Shiotani S, Sakamoto N, Kobayashi T: Background and current status of postmortem imaging in Japan: short history of “Autopsy imaging (Ai)”. Forensic Sci Int 2013, 225: 3-8. 10.1016/j.forsciint.2012.03.010View ArticleGoogle Scholar
  14. Paradis NA, Martin GB, Goetting MG, Rosenberg JM, Rivers EP, Appleton TJ, et al.: Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans. Insights into mechanisms. Circulation 1989, 80: 361-368. 10.1161/01.CIR.80.2.361View ArticleGoogle Scholar
  15. Roberts IS, Benamore RE, Peebles C, Roobottom C, Traill ZC: Diagnosis of coronary artery disease using minimally invasive autopsy: evaluation of a novel method of post-mortem coronary angiography. Clin Radiol 2011, 66: 645-650. 10.1016/j.crad.2011.01.007View ArticleGoogle Scholar
  16. Ross SG, Flach PM, Thali MJ: Postmortem angiography. In Forensic Radiology. Edited by: Thali MJ, Viner MD, Brogdon BG. CRC Press, Boca Raton; 2011:449-459.Google Scholar
  17. Ross SG, Thali MJ, Bolliger S, Germerott T, Ruder TD, Flach PM: Sudden death after chest pain: feasibility of virtual autopsy with postmortem CT angiography and biopsy. Radiology 2012, 264: 250-259. 10.1148/radiol.12092415View ArticleGoogle Scholar
  18. Rutty GN, Brogdon G, Dedouit F, Grabherr S, Hatch GM, Jackowski G, et al.: Terminology used in publications for post-mortem cross-sectional imaging. Int J Legal Med 2012a, 127: 465-466.View ArticleGoogle Scholar
  19. Rutty G, Saunders S, Morgan B, Raj V: Targeted cardiac post-mortem computed tomography angiography: a pictorial review. Forensic Sci Med Pathol 2012b, 8: 40-47. 10.1007/s12024-011-9267-0View ArticleGoogle Scholar
  20. Sakamoto N, Senoo S, Kamimura Y, Uemura K: Cardiopulmonary arrest on arrival case which underwent contrast-enhanced postmortem CT. J of Jpn Assoc for Acute Med 2009, 30: 114-115. (in Japanese)Google Scholar
  21. Saunders SL, Morgan B, Raj V, Robinson CE, Rutty GN: Targeted post-mortem computed tomography cardiac angiography: proof of concept. Int J Legal Med 2011, 125: 609-616. 10.1007/s00414-011-0559-4View ArticleGoogle Scholar
  22. Schroeder S, Kuettner A, Leitritz M, Janzen J, Kopp AF, Herdeg C, et al.: Reliability of differentiating human coronary plaque morphology using contrast-enhanced multislice spiral computed tomography: a comparison with histology. J Comput Assist Tomogr 2004, 28: 449-454. 10.1097/00004728-200407000-00003View ArticleGoogle Scholar
  23. Shiotani S, Kohno M, Ohashi N, Yamazaki K, Itai Y: Postmortem intravascular high-density fluid level (hypostasis): CT findings. J Comput Assist Tomogr 2002, 26: 892-893. 10.1097/00004728-200211000-00006View ArticleGoogle Scholar
  24. Steffen R, Danny S, Stephan B, Andreas C, Lars O, Silke G, et al.: Postmortem whole-body CT angiography: evaluation of two contrast media solutions. AJR Am J Roentgenol 2008, 190: 1380-1389. 10.2214/AJR.07.3082View ArticleGoogle Scholar
  25. Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al.: Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006, 354: 2317-2327. 10.1056/NEJMoa052367View ArticleGoogle Scholar
  26. Swift B, Rutty GN: Recent advances in postmortem forensic radiology: CT and MRI applications. Open Forensic Sci J 2006, 4: 355-404.Google Scholar
  27. Takahashi N, Higuchi T, Shiotani M, Hirose Y, Shibuya H, Yamanouchi H, et al.: The effectiveness of postmortem multidetector computed tomography in the detection of fatal findings related to cause of non-traumatic death in the emergency department. Eur Radiol 2012, 22: 152-160. 10.1007/s00330-011-2248-6View ArticleGoogle Scholar


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