Physical Autopsies Still "Gold Standard" for Determining Cause of Death

But according to two autopsy and body imaging experts at The Johns Hopkins Hospital, the notion that “virtopsy” could replace traditional autopsy is simply not ready for scientifically vigorous prime time. The latest virtual imaging technologies -- including full-body computed tomography (CT) scans, magnetic resonance imaging (MRI), ultrasound, X-ray and angiography -- are helpful, they say, but cannot yet replace a direct physical inspection of the body’s main organs.

“The traditional autopsy, though less and less frequently performed, is still the gold standard for determining why and how people really died,” says pathologist Doctor Elizabeth Burton; deputy director of the autopsy service at Johns Hopkins. Burton, who has performed well over a thousand autopsies, says current imaging technologies can help tremendously when used in combination with autopsies. “It’s not a question of either traditional autopsy or virtopsy,” she says. “It’s a question of what methods work best in determining cause of death.”

According to Burton hospital autopsy rates in the United States -- for patients who die of natural causes in hospitals, whose bodies do not have to be examined by the local medical examiner or coroner-- have fallen from a high of about 50 percent in the 1960s to about 10 percent today. At The Johns Hopkins Hospital, she says, the rate remains close to a once-required standard for hospital accreditation of 25 percent, set as an appropriate goal for teaching medical residents and fellows, and auditing clinical practice.

She says many reasons are behind the drop in conventional autopsy rates. Medical overconfidence in diagnostic imaging results partly explains the decline, but is also to blame for the high number of diagnostic errors. “If we chose the right test at the right time in the right people, and followed clinical guidelines to the letter, then modern diagnostic tests would produce optimal results. But we don’t,” says Burton. A misinterpretations of images, lab results, and physical signs and symptoms, help explain the roughly 23 percent of new diagnoses that are detected by autopsy.

In a German study that accompanies the editorial, conventional autopsy and imaging results, as would be seen in virtopsy, were compared for accuracy in 162 people who died in a hospital. Some had just virtopsy, while the others had both virtopsy and conventional autopsy. In the 47 who underwent both procedures, 102 new diagnoses were found; while in comparison, 47 new diagnoses were found among the 115 who underwent virtopsy alone. Study results also showed that virtual autopsy by CT scan failed to pick up 20.8 percent of the new diagnoses, while conventional autopsy missed only 13.4 percent.

Medical problems most commonly missed or not seen by autopsy included air pockets in collapsed lungs (which could have impeded breathing) and bone fractures, and the most common diagnoses missed by imaging were heart attack, pulmonary emboli and cancer.; Source: Johns Hopkins Medicine