Diagnostic performance of postmortem CT versus conventional autopsy in torso gunshot wounds: A systematic review and meta-analysis

Background Firearm-related torso trauma poses forensic challenges, where postmortem computed tomography (PMCT) has emerged as a complementary modality to autopsy. However, diagnostic comparability remains uncertain due to methodological variability. Objective To systematically compare PMCT and autopsy in the evaluation of ballistic injuries to the torso, focusing on entry and exit wounds, wound trajectories, and projectile fragments, and critically evaluate methodological heterogeneity and interpretative factors influencing diagnostic comparability across studies. Methods A systematic review and meta-analysis followed PRISMA and MOOSE guidelines. PubMed, Embase, Scopus, Web of Science, Google Scholar, and OATD up to March 18, 2026, and updated on May 22, 2026. Observational studies comparing PMCT and autopsy in gunshot victims were included. Risk of bias and certainty of evidence were assessed using the Joanna Briggs Institute checklist and GRADE framework, respectively. Random-effects meta-analyses utilized prevalence ratios (PR) and 95% confidence intervals (CI). Results Five studies (137 victims) were included. No statistically significant differences were observed between PMCT and autopsy for entry/exit wounds (PR=0.90; 95% CI: 0.64–1.30; I²=0%), wound trajectories (PR=0.88; 95% CI: 0.54–1.43; I²=87.5%), or projectile fragments (PR=1.00; 95% CI: 0.69–1.45; I²=0%). Certainty of evidence was very low across all outcomes due to methodological limitations and inconsistency. Trajectory heterogeneity was linked to variable acquisition/reporting practices. Conclusions This meta-analysis found no significant difference between PMCT and autopsy in assessing torso ballistic injuries. Due to the very low certainty of evidence, PMCT should not replace autopsy but serve as a critical complementary tool for permanent digital documentation and judicial review.