Minimally invasive autopsies: a promise to revive the procedure
Another aspect is the important role of autopsies in medical education. They provide a unique situation to observe the systemic manifestations of different diseases, giving a basis for the solid integration of medical knowledge. Further important aspects of autopsies include monitoring the quality of clinical service, identifying new diseases or new manifestations of already known diseases, evaluating the effectiveness of therapy strategies, and establishing causes of death.
One possible reason for the decline of conventional autopsies is the advance in imaging techniques that could theoretically provide in vivo diagnoses without the necessity of an autopsy to confirm them. For instance, angiographies performed in vivo may provide more detailed information on vessel structural alterations than a routinely performed autopsy. Another supposed reason for autopsy denial is that families do not like the invasiveness of the procedure.
Some forensic institutes have taken advantage of image techniques like computed tomography (CT), x-rays, and angiography to perform non- or minimally invasive autopsies: the so-called virtopsies (or virtual autopsies). There is accumulating evidence that for forensic autopsies, virtopsies are equally satisfactory when compared to conventional autopsies. In such situations where it is important to accurately detect fractures and hemorrhages, the combination of post-mortem CT and angiography is being substituted for the conventional autopsy. At the same time, the progressive development of technologies in medical imaging techniques has resulted in an increase in spatial, contrast, and functional resolution to deal with medical diagnoses. There is also a need to validate these new technologies on clinical and pathological bases. Although it seems logical that the increased capacity to observe biological alterations results in better correlation, validations are, in general, conceptually performed on a daily basis with equipment use, but without in-depth studies of clinical correlation, and notably, histological validation. There are few medical research centers to carry out this very necessary validation in the world..
In spite of several scientific contributions
For non-forensic medical autopsies, the role of imaging techniques to substitute conventional autopsy is not yet clear. In 2012, Roberts et al.
Wichmann et al.
The use of MDCT coupled with MDCT-angiography for the investigation of sudden cardiac death related to atherosclerotic coronary artery disease was tested by Michaud et al.
The use of fine needle biopsies in minimally invasive autopsies (MIA) has been tested in some feasibility studies in small groups of patients or in cases of selected pathologies (acute cardiovascular deaths). One group tested the diagnostic performance of MIA for detecting the common causes of death using fine needle biopsies and CT scans.
At the Faculty of Medicine of the University of São Paulo we started a large study focusing on the application of modern image techniques in autopsy. The project was called BIAS (Brazilian Image + Autopsy Study) addressing the feasibility of MDCT + MDCT-angiography + image-guided fine needle biopsies in a large subset of patients. We also aim to test, in an academic setting, whether MIA is equally satisfactory to answer important questions that can be provided by a conventional autopsy, such as quality of care and adequacy of diagnostic/therapeutic interventions.
Our hypothesis is that the concordance level of MIA and conventional autopsy is high for many different pathologies, and that MIA could be an alternative option to increase the autopsy rates. We hypothesize that conventional autopsies might provide more (major/minor) diagnoses than MIAs, but that MIAs are superior to map cardiovascular alterations, hemorrhages, and misuse of medical devices. We also expect that for coroner autopsies, MIAs will be able to detect the cause of death in the majority of cases and thereby decrease the economic burden of a full, conventional autopsy in such a large service. Finally, at the end of our study, we hope that the use of autopsy could be “revived”, and that, again, death can teach us to better manage the life of our patients.