Diagnostic Performance of Virtopsy in Detecting Systemic Venous and Arterial Gas Embolism: A Systematic Review of Postmortem Computed Tomography Correlated with Autopsy and Postmortem Computed Tomography Angiography

Postmortem computed tomography (PMCT) has become an increasingly important tool in forensic medicine because it allows rapid, noninvasive examination of the body shortly after death. One of its most valuable applications is the detection of gas embolism (GE), a potentially fatal condition in which gas bubbles obstruct blood vessels and impair circulation. Diagnosing GE after death is often difficult because gas may also accumulate naturally during decomposition or be introduced during resuscitation procedures, creating uncertainty during forensic investigations. This review evaluated fourteen studies published between 2010 and 2023 that investigated the usefulness of PMCT in identifying fatal GE across different settings, including diving accidents, traumatic injuries, medical procedures, and hospital-related incidents. The studies included adult cases in which PMCT was performed within 48 hours after death and compared imaging findings with traditional autopsy results, sometimes supplemented by specialized techniques such as underwater cardiac dissection. Across most studies, PMCT demonstrated greater sensitivity than autopsy alone for detecting intravascular gas, particularly when imaging was performed early after death. The highest agreement between PMCT and autopsy findings was observed within the first 12 hours postmortem, before significant decomposition-related gas formation occurred. Several imaging characteristics helped distinguish true ante-mortem embolism from postmortem artifact, including gas predominantly located within arterial circulation and markedly low CT attenuation values. The findings collectively suggest that PMCT is a highly useful adjunct in forensic investigations of suspected GE when applied promptly and interpreted alongside conventional autopsy findings. Combining early imaging with meticulous postmortem examination improves diagnostic confidence, reduces the risk of misinterpretation caused by decomposition, and strengthens forensic documentation and cause-of-death determination.