ORIGINAL ARTICLE Accuracy of targeted post-mortem computed tomography coronary angiography compared to assessment of serial histological sections B. Morgan & M. J. Biggs & J. Barber & V. Raj & J. Amoroso & F. E. Hollingbury & C. Robinson & G. N. Rutty Received: 6 September 2012 / Accepted: 18 October 2012 / Published online: 10 November 2012 # Springer-Verlag Berlin Heidelberg 2012 Abstract Post-mortem computed tomography with coro- nary angiography (PMCTA) could have a role in the inves- tigation of sudden natural death. This study assesses the accuracy of targeted coronary PMCTA, using both air and iodinated contrast media, to provide sensitivity and speci- ficity for critical stenosis (CS) on a segmental basis, based on a gold standard of 3–5 mm serial sections of the coronary arteries using macroscopic and histological techniques. As- sessment of stenosis at 1 mm intervals on PMCTA was compared with the data from pathological analysis. Stenosis was defined as “critical” when the stenotic region reaches ≥75 %. Regions were defined every 20 mm or by a clear change in stenosis. Discrepancies were defined as signifi- cant if only one test showed CS. Five cases with 25 vessels with 124 regions were assessed. PMCTA was unable to identify plaque hemorrhage or dissection (but this was nor- mally associated with CS). Eighteen segments had signifi- cant discrepancies, giving a sensitivity and specificity of 50 and 91.5 %. When an alternative gold standard was con- structed by excluding regions beyond a CS (five cases), taking PMCTA as correct where a heavily calcified vessel opens under contrast injection (four cases), and correcting for misregistration of distance (one case), the sensitivity rose to 85.7 %. There was complete agreement when the right or left coronary arteries are assessed as a whole. This study shows that PMCTA is not a perfect replacement for histo- logical examination of coronary vessels, but may have a role in routine post-mortem investigation. Keywords Forensic . Post-mortem computed tomography . Angiography . Coronary arteries . Histology . PMCTA Introduction Invasive autopsy may be required to determine the cause of sudden unexpected death. The legal burden of proof re- quired to give a cause of non-suspicious natural death in England and Wales is based on the balance of probabilities. This is in contrast to the standard required for a criminal court, which is beyond reasonable doubt [1]. Invasive au- topsy is generally considered the gold standard for deter- mining the cause of death, although the extent and thoroughness of the examination can vary [2]. Post-mortem computed tomography (PMCT) is increas- ingly used in post-mortem investigation but has two major weaknesses: firstly, as soon as death occurs, post-mortem changes develop that reduce tissue definition; secondly, the absence of a functioning circulation precludes standard contrast-enhanced techniques which are routinely used in clinical practice and essential to diagnose arterial disease. Without the ability to diagnose coronary artery disease (CAD), the most common cause of non-suspicious sudden Bruno Morgan and Guy Rutty contributed equally to this paper. B. Morgan (*) : V. Raj : C. Robinson Imaging Department, University Hospitals of Leicester, Leicester Royal Infirmary, Leicester LE2 7LX, UK e-mail: Bm11@le.ac.uk M. J. Biggs : J. Barber : J. Amoroso : F. E. Hollingbury : G. N. Rutty East Midlands Forensic Pathology Unit, University of Leicester, Robert Kilpatrick Building, Leicester LE2 7LX, UK Int J Legal Med (2013) 127:809–817 DOI 10.1007/s00414-012-0790-7