Multiphase post-mortem CT angiography (MPMCTA) in sudden natural death: diagnostic contribution and workflow impact in a forensic autopsy series

: Post-mortem computed tomography (PMCT) is increasingly used in forensic investigations as a non-invasive screening tool; however, its ability to assess the vascular system remains limited. Multiphase post-mortem computed tomography angiography (MPMCTA) was developed to overcome these limitations, but its contribution to routine medico-legal investigations requires further evaluation. This monocentric observational study included 37 non-hospitalized individuals who died suddenly and underwent non-contrast PMCT, MPMCTA, and subsequent blinded medico-legal autopsy with histological and toxicological examinations at the Legal Medicine Institute of the University of Modena and Reggio Emilia. Imaging findings were correlated with autopsy and histological results. MPMCTA showed a high degree of concordance with autopsy for major vascular lesions, enabling accurate pre-autopsy visualization and localization of coronary thrombosis, aortic rupture/dissection, pulmonary arterial filling defects, and neoplastic vascular involvement. By contrast, several pathological conditions, including myocardiosclerosis, myocarditis, pneumonia, and some cases of acute or previous myocardial infarction, could only be definitively diagnosed through histological examination. These findings support the role of MPMCTA as a valuable adjunct to conventional autopsy in cases of sudden natural death. By improving the pre-autopsy assessment of vascular pathology, MPMCTA may facilitate lesion localization and support a more targeted post-mortem investigation.