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By Todd Neale, Senior Staff Writer, MedPage Today Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse PlannerA minimally invasive approach using postmortem MRI may represent a viable alternative to a conventional autopsy in fetuses, children, and teens.Note that the concordance between whole-body MRI and postmortem exam was greatest in fetuses and declined with increasing age among the children.A minimally invasive approach using postmortem MRI may represent a viable alternative to a conventional autopsy in fetuses, children, and teens, researchers found.
In fetuses and individuals 16 and younger, a minimally invasive autopsy that included MRI identified the same cause of death or major pathological abnormality that a conventional autopsy did in 89.3% of cases, according to Sudhin Thayyil, PhD, of University College London, and colleagues.
The concordance was greatest in fetuses and declined with increasing age among the children, the researchers reported online in The Lancet.
"Thus, minimally invasive autopsy could be a suitable alternative to conventional autopsy for detection of cause of death or major pathological lesions in selected cases for which an invasive postmortem examination is unacceptable," they wrote.
It is important to closely involve parents in the process of establishing a minimally invasive autopsy program, "and contrary to popular belief, bereaved parents often view this involvement positively," they added. "Future studies should examine the clinical, psychological, epidemiological, and economic effect of minimally invasive autopsy."
In recent years, rates of autopsy have fallen in developed countries for a variety of reasons, including objection by the families of the deceased.
Some studies have evaluated postmortem MRI as a more acceptable alternative to conventional autopsy, but there is limited evidence regarding its accuracy.
In the current prospective study performed at two London centers, Thayyil and colleagues compared autopsy performed using postmortem, whole-body MRI with or without other minimally invasive tools with that performed by conventional means for 400 cases -- 69% were fetuses and 31% were children 16 or younger.
The average time from death or delivery and the postmortem MRI was 4.5 days. The images were interpreted by pediatric radiologists -- one each for the nervous, cardiovascular, pulmonary and abdominal, and musculoskeletal body systems for each case.
Compared with conventional autopsy, the accuracy of the minimally invasive approach for identifying the cause of death or a major pathological change varied according to the age of the cases: 94.6% for fetuses at 24 weeks of gestation or less95.7% for fetuses at more than 24 weeks of gestation81% for newborns 1 month or younger84.9% for infants age 1 month to 1 year53.6% for children older than 1 year
"The lower concordance in children than fetuses was mainly due to undetected pneumonia and myocarditis," the researchers noted.
"This finding is expected, and is almost certainly related to the changing pattern of underlying pathological changes associated with autopsy across this age range, from mostly structural anomalies in fetuses to mostly infective causes in infancy and older children," they wrote.
A radiologist and a pathologist who did not know the results of the autopsy used a set of predefined criteria to determine whether the minimally invasive approach would have been sufficient for each case; they determined that a full autopsy might not have been necessary in 41% of cases. The minimally invasive and conventional approaches yielded similar findings in 99.4% of those cases.
The authors acknowledged some limitations of the analysis, including the uncertain applicability to less specialized settings, the inclusion of only those cases for which consent for conventional autopsy was obtained, and the lack of information on the economic aspects of postmortem MRI.
"Although minimally invasive autopsy can be less expensive than conventional autopsy, the overall cost of postmortem services might rise because parents who decide against autopsy might want a minimally invasive autopsy, which paradoxically increases the workload for both pathologists and radiologists," Thayyil and colleagues wrote.
Despite those limitations, however, the researchers "have presented a starting point for development of a robust system for postmortem diagnosis using various modalities (i.e., pathology, radiology, laboratory testing) and a system of interdisciplinary consultation and collaborative diagnosis, mimicking systems for optimum diagnostic assessment of living patients," according to Corinne Fligner, MD, and Manjiri Dighe, MD, both of the University of Washington in Seattle.
"Some deaths could be assessed with minimally invasive autopsy," they wrote in an accompanying editorial, "but some investigations will mandate use of conventional autopsy."
The paper is an independent report commissioned and funded by the Policy Research Program in the U.K. Department of Health. The study was also supported by grants from the British Heart Foundation, Wellbeing of Women and Stillbirth and Neonatal Death charities, and Foundation for the Study of Infant Deaths.
Thayyil has received a Clinician Scientist Award from the National Institute for Health Research. His co-authors reported support from the National Institute for Health Research, the Foundation Leducq, the Higher Education Funding Council for England, and the Great Ormond Street Hospital for Children NHS Foundation Trust Charity.
The study authors and the editorialists reported that they had no conflicts of interest.
Todd Neale
Senior Staff Writer
Todd Neale, MedPage Today Staff Writer, got his start in journalism at Audubon Magazine and made a stop in directory publishing before landing at MedPage Today. He received a B.S. in biology from the University of Massachusetts Amherst and an M.A. in journalism from the Science, Health, and Environmental Reporting program at New York University.
