Histological artifacts induced by the contrast agent in multi-phase post-mortem CT angiography (MPMCTA): Part II – Pathological tissues

Multi-phase postmortem computed tomography angiography (MPMCTA) is increasingly used in forensic pathology; however, contrast medium injection may induce histo-morphological artifacts. While these artifacts have been previously described in normal tissues, their behavior in pathological conditions remains incompletely characterized. A retrospective study was conducted on 37 cases of sudden death undergoing MPMCTA. A total of 190 histological samples showing pathological alterations, previously excluded from the analysis of normal tissues, were examined. Tissue sections were processed using standard histological techniques and analyzed by experienced forensic pathologists to identify and characterize contrast-related artifacts in the presence of underlying disease. The main categories of artifacts—optically empty spaces (OES), vascular dilatation, hyperemia, and compression of adjacent structures—were consistently observed in pathological tissues. However, their distribution and morphology were frequently modified by the underlying disease. Inflammatory, neoplastic, hemorrhagic, and degenerative conditions were associated with heterogeneous contrast distribution and uneven perfusion patterns. OES were observed both within vascular lumina and in extravascular compartments, particularly in hemorrhagic and necrotic areas. Despite these alterations, the recognition of the underlying pathological processes was generally preserved. Relevant diagnostic pitfalls were identified, particularly in the differential diagnosis with fat embolism, gas-related changes, and cholesterol clefts. MPMCTA induces reproducible histo-morphological artifacts also in pathological tissues, although their distribution and appearance are influenced by the underlying disease. Awareness of these changes is essential to avoid misinterpretation. When properly recognized, contrast-related artifacts do not preclude accurate histopathological diagnosis and support the integrated use of imaging, autopsy, and histology in forensic practice.