Case Report Bone marrow edema induced by a bullet after a self-inflicted accidental firing Nicole Berger a,b,⇑ , Pia Paula a , Dominic Gascho a , Patricia M. Flach a,b , Michael J. Thali a , Steffen G. Ross a , Garyfalia Ampanozi a a Department of Forensic Medicine and Radiology, Institute of Forensic Medicine, University of Zurich, Switzerland b Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Switzerland article info Article history: Received 26 July 2013 Received in revised form 9 September 2013 Accepted 10 September 2013 Available online xxxx Keywords: Bone bruise Postmortem MRI PMMR Postmortem computed tomography PMCT Postmortem computed tomography angiography PMCTA Virtopsy abstract We present a case of a postmortem finding of bone marrow edema in postmortem magnetic resonance imaging (PMMR) indirectly induced by a bullet, which barely missed the bone of a 92 year old man found kneeling in front of his bed of a tidy apartment. Additionally, a selective postmortem computed tomog- raphy angiography (PMCTA) of the left leg was performed, visualizing a laceration of the left femoral vein by the bullet with consecutive contrast media extravasation. A vast pulmonary fat embolism was diag- nosed and together with the blood loss found to be the cause of death. Ó 2013 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Medical imaging is increasingly used in forensic medicine to as- sist or in several cases even replace forensic autopsy [1–4]. Postmortem computed tomography (PMCT) is widely used for its fast and non-invasive procedure and readily available compared to postmortem magnetic resonance (PMMR) imaging, which is more time-consuming and cost-intensive. PMCT and PMMR have different benefits. The depiction of parenchymal pathologies and soft tissue lesions such as edema or hemorrhage is better seen on magnetic resonance imaging (MRI), whereas bony and air-con- taining structures as well as radiodense foreign materials are bet- ter seen on PMCT [5]. In PMMR bone marrow edema is seen as hypo-intense signal alteration in a T1-weighted sequence and as a hyper-intense signal alteration in a T2-weighted sequence. On a histologic level bone marrow edema on MRI corresponds to interstitial edema, bone marrow necrosis and trabecular abnormal- ities [6]. Bone marrow edema has already been described as an intra-vital finding – being a so-called ‘‘vital sign’’, which will not develop in the postmortem or agonal injured bone [7,8]. 2. Case history A 92 years old man (58 kg, 168 cm, BMI 20.5 kg/m 2 ) was found kneeling in front of his bed with a small caliber handgun next to him. Blood was found solely on the mattress and on the blanket, which he was kneeling on. After external examination of the corpse, a gunshot wound was found on the front side in the middle of the upper left leg and three wounds were found in the dorsal part of the left leg, one in the dorsal part of the left upper leg and two in the dorsal part of the lower left leg. In one of the gun- shot wounds in the lower leg a deformed projectile was found and removed (Fig. 1, labeled with 4). Three more cartridges were left in the gun where one of the cartridges was blocking the gun. The time interval between death and postmortem imaging was estimated to be between 2 and 4 days. 2.1. Imaging and autopsy Postmortem CT imaging is routinely performed after arrival of the deceased at our department and prior to autopsy. PMCT was 1344-6223/$ - see front matter Ó 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.legalmed.2013.09.002 ⇑ Corresponding author at: Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland. Tel.: +41 44 255 1111; fax: +41 44 255 4443. E-mail address: nicole.berger@usz.ch (N. Berger). Legal Medicine xxx (2013) xxx–xxx Contents lists available at ScienceDirect Legal Medicine journal homepage: www.elsevier.com/locate/legalmed Please cite this article in press as: Berger N et al. Bone marrow edema induced by a bullet after a self-inflicted accidental firing. Leg Med (2013), http:// dx.doi.org/10.1016/j.legalmed.2013.09.002