The Egyptian Journal of Radiology and Nuclear Medicine (2012) 43, 211–217

Egyptian Society of Radiology and Nuclear Medicine The Egyptian Journal of Radiology and Nuclear Medicine

www.elsevier.com/locate/ejrnm www.sciencedirect.com

ORIGINAL ARTICLE ‘‘Calvarial Butterfly’’ new multidetector computed tomography (MDCT) virtual osteoscopic (VO) fingerprint for identification

Abbas H.M.N. Moustafa a,*, Hayedi M. Megahed b a Radiology Department, El-Minia University, Egypt b Forensic Medicine & Toxicology Department, Alexandria University, Egypt

Received 21 February 2012; accepted 21 March 2012 Available online 17 April 2012

KEYWORDS Abstract Purpose: The battle between criminal associations and law enforcement still rages to this Identification; day, providing ever more elusive ways to mask away the characteristics which will lead criminals, Fingerprint; eventually, to justice. So we tried to find an easy way using one of the MDCT applications namely Virtual osteoscopy; ‘‘virtual osteoscopy’’ to create a new internal ‘‘fingerprint’’ that could not be manipulated by any Calvarium; means. MDCT Methods and material: Virtual osteoscopic evaluation (post-processing technique) of the calvarial bones of 1120 patients was carried out using the available software ‘‘Syngo’’ from Siemens Medical Technology – Erlangen – Germany; following routine MDCT evaluation of the brain due to differ- ent complaints. The generated images were reviewed, analyzed and the results were tabulated. Thor- ough evaluation of the axial cuts regarding any abnormalities including skull features, skull vault thickness, paranasal sinuses, brain lesions or normal variants which may be kept as a reference hand in hand with the virtual osteoscopic findings of the Calvarial Butterfly.

* Corresponding author. Address: 27, Abd El-Kader Ragab Street, Beside Al-Malaki Hospital, Roushdy, Alexandria, Egypt. Tel.: +20 112817541; fax: +20 35414107. E-mail address: [email protected] (A.H.M.N. Moustafa).

0378-603X Ó 2012 Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V. All rights reserved.

Peer review under responsibility of Egyptian Society of Radiology and Nuclear Medicine. http://dx.doi.org/10.1016/j.ejrnm.2012.03.004

Production and hosting by Elsevier 212 A.H.M.N. Moustafa, H.M. Megahed

Results: The generated data were tabulated regarding the patterns of the generated Butterfly-like structure representing the external features of the diploic space marrow cavity at the occipital protuberance level. From the examined patients it was shown that each individual had a unique Butterfly-like structure having distinct external features, patterns as well as calculated volumes. Conclusion: The 3D virtual endoscopic models with the generated Butterfly-like appearance (i.e. virtual osteoscopy) at the occipital region will play a major role in the cases of identification and anthropology in both in vivo and in vitro cases and will solve a lot of forensic medicine mysteries. Ó 2012 Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V. All rights reserved.

1. Introduction 2. Aim of the work

Despite the several methods for identification of human re- The aim of this study is to introduce a new identification tool mains are now well established worldwide including facial fea- to the already present ones, in order to enrich this challenging tures, scars, birthmarks, tattoos, fingerprints, palm and field in a trial to solve the forensic mysteries. footprints all rest on preservation of the soft tissue compo- nents of the body in question, still some cases cannot be pin- pointed. These methods are discarded when the remains are 3. Materials and methods so decomposed, macerated, burned or fragmented that the sur- face topography is unrecognizable or lost its features. Bone is To our knowledge, it is the first time to employ the virtual the final part of the body to be disintegrated; subsequently the endoscopy in the bony skeleton. The virtual endoscope was Calvarial Butterfly which is an osseous part of the bony calvar- placed within the bony mass of the long axial bony skeleton ium will remain for a long time. This assumption is fortified by including the femur and humerus. the long lasting bony remnants seen since thousands of years The virtual osteoscopic view of the long bones of the axial without significant damage. At that time medical and dental bony skeleton revealed the ‘‘cave-like appearance’’ with its radiological methods may be the sole clue for forensic mystery lower border represents the inner wall of the bone lining the solving. The identification of human remains is of paramount marrow cavity of the shaft, while its superior aspect (roof) rep- importance in medicolegal investigations. The comparison of resents the outer wall of the cortex, i.e. we are navigating with- antemortem and postmortem radiographic records is one of in the bony mass of the bone shaft. The threshold was chosen the main techniques used to achieve a positive identification more or less identical to that of the factory pre-set used for the (1–3). virtual angioscopy (ranging between 300 and 800 HU) (Fig. 1). Virtual reality in the field of diagnostic radiology was first The resultant images are encouraging us to proceed and introduced by David Vining, who presented his initial experi- navigate within the bony calvarium. It was noticed that there ence of virtual bronchoscopy at the RSNA in the year 1993. is an internal constant ‘‘butterfly-like’’ structure within the di- Following that several researchers introduced many applica- ploic space at the level of the occipital protuberance, represent- tions on the same theme, including virtual colonoscopy, virtual ing the outer surface of the intradiploic marrow space. This angioscopy and virtual autopsy. Recently virtual anthropology directed our curiosity toward proceeding into its investigation. (VA) has been used to solve different problems that could not The current study was carried out over 1120 consecutive be properly addressed using conventional anthropological ap- patients, their ages ranged between 12 and 79 years old with proach. Mainly when dealing with mummies (especially with a male to female ratio 3:1; examined by MDCT of the brain the Pharaonic Egyptian mummies), the virtual approach is for several pathological entities. The examination was carried the only solution to carry out a detailed analysis of the skele- out on Siemens AG Emotion 6 slices, Erlangen – Germany. ton without compromising the integrity of the physical re- The virtual endoscope with the same parameters for the vir- mains. Three-dimensional (3D) digital models of the physical tual angioscopic evaluation was used to examine the bony cal- object allow for virtual manipulation, simulation, and bone varium using the available ‘‘Syngo’’ workstation using the pre- sectioning, etc., in a virtual space, therefore preserving the ori- set parameters for the virtual angioscopic evaluation. The vir- ginal object from invasive procedures. Furthermore, the devel- tual endoscope is placed within the diploic space of the bony opment of sophisticated software and hardware contributes calvarium at the occipital region in a midline location with the not only to an increase in the amount of data available for sci- virtual eye piece located toward the outer table while the vir- entific analysis, but also improves the quality and objectiveness tual lens direction inclined upward toward the orbit facing the of the research. However, up to our knowledge nobody em- inner table of the occipital wall (Fig. 2). Virtual osteoscopy ployed the virtual endoscopy in the skeletal system, i.e. virtual technique was carried out from different perspectives and osteoscopy (4–12). the resultant images of the generated ‘‘butterfly’’ were thor- The utilization of high-dimensional medical imaging in oughly reviewed. Actually there is a technical difficulty in the investigation of major fatality incidents is valuable. It putting the virtual osteoscope at the inner table as there is is a mean for non-invasive virtual autopsy or as a tool to not enough potential space for it from one hand, and from conduct anthropological measurements and reconstruction the other hand it is attached to inner table and subsequently of skeletal tissues in order to facilitate the identification pro- it will not give a meaningful virtual endoscopic (virtual osteo- cess (13–21). scopic) image. ‘‘Calvarial Butterfly’’ new multidetector computed tomography (MDCT) 213

Fig. 1 (A) Virtual osteoscopic view of the left humerus showing ‘‘cave-like appearance’’, i.e. navigation within the bony mass of the medial aspect of the proximal left humerus. (B) Coronal maximum intensity projection MIP view of the left humerus to show the virtual endoscopy triangle; its apex seen superiorly where the virtual eyepiece is noted (arrow) and the broad base represents the virtual lens.

Fig. 2 (A) Virtual osteoscopy technique showing axial MDCT slice at the level of the occipital protuberance with the virtual endoscope in place. (B) Bone window setting of the bony calvarium (occipital bone) showing marrow within diploic space at the occipital region (orange arrow).

4. Results There were no special predilections toward the morpholog- ical types of the butterfly in both sexes. The calculated volumes The generated Butterfly-like structure was present in all virtual were greatly different on an individual basis to the degree that osteoscopic examinations of the occipital bone without the ab- no single volume was identical to another using the automated sence even in single examined patients. It was single of no evi- volume calculator software pre-set on the workstation. (i.e. un- dence of duplicate or multiple butterflies at the vicinity. ique) (Figs. 4 and 5). Despite the different morphological appearances of the Butter- fly-like structures, there were four common types regarding 5. Discussion their configuration. The 1st one and the most common was the four-winged butterfly constituting about 61.96% of our Identification of victims involved in major fatality incidents has virtual osteoscopic examined patients, followed by the six- become an increasingly important issue in the aftermath of the winged type constituting 30.98%. Moreover, about 4.02% terrorist attacks that is occurring every now and then. In the have a broad body with small wings and lastly the 4th category near future, the efficiency of the data flow in major disaster of different bizarre shaped morphological appearance, yet with management will be of much more importance due to the intimate resemblance of butterfly configuration constituting increasing risk of victims in major fatality incidents, and subse- 3.04% (Fig. 3, Table 1). quently the increasing amount of data. Computational meth- No other Butterfly-like structures could be demonstrated ods in disaster victim identification will therefore be a within the rest of the bony calvarium. potential area in major fatality investigations. The introduction 214 A.H.M.N. Moustafa, H.M. Megahed

Fig. 3 Four different morphological subtypes of the virtual osteoscopic butterfly-like structures (type I upper left: four winged, type II upper right: six winged, type III lower left: broad body and type IV lower right: bizarre shaped).

from justice. These techniques can only change the external Table 1 The Calvarial Butterfly pattern distribution and their features; however, the internal features would remain the percentage in the examined group (n = 1120). same. These internal features that may be constant include Type Pattern Number % normal variants, abnormal calcifications and chronic patho- Type I Four-winged butterfly 694 61.96 logical lesions, as well as the Calvarial Butterfly which could Type II Six-winged butterfly 347 30.98 be easily depicted by computed tomography. Subsequently Type III Broad body, small winged 45 4.02 the in vivo techniques are an extremely important tool for Type IV Bizarre shaped morphology 34 3.04 the physical anthropological procedure in order to trace the Total 1120 100 criminals trying to escape from trial (9–12,15–28). The current study hanged upon the navigation within the bony calvarium and to pick up the Calvarial Butterfly seen of computed tomography into the field of diagnostic radiology within the occipital bone. The Butterfly was classified morpho- was of great impact and its significance is still in evolution. The logical into four different categories: the 1st type (most com- advent of multidetector technology and its new applications, mon) is the four-winged butterly, followed by the 2nd type especially the volume rendering techniques (VR) with special six-winged butterfly, then come the broad body short winged emphasis on the virtual reality, has been the cornerstone for (the 3rd type) and lastly the bizarre shaped configuration yet many new clinical and diagnostic techniques (1–6). with intimate resemblance of the butterfly configuration. Each Identification of individuals plays a major role in the field butterfly is unique for every individual; no one showed match- of Forensic & Legal Medicine. Several methods of identifica- ing with another; having special bumps, lumps, sharp projec- tion are well established, including fingerprints, blood group- tions as well as the thickness of each wing and lastly the ing, external features, voice printing, etc. Several researches overall estimated volume. These findings were confirmed by have been conducted to introduce a new identification tool the fusion of images which is a software capability on the avail- to the already present one, in order to enrich this challenging able workstation, i.e. new fingerprint for identification. Taking field (2,5–8). all these criteria into consideration hand in hand with the gen- Natural massive disasters, terrorist bombings and catastro- erated VR butterfly which will be kept and saved in mega com- phes hand in hand with the tremendous development in the puters, will act as a solid and reliable fingerprint which is field of reconstructive and plastic surgery will change the exter- unique for each person by solid criteria that are difficult to nal features of the individual and subsequently will result in es- be manipulated. The generated data of the MDCT-VO could cape of the international criminal and mafia organizations be matched with the stored data on the mega computer using ‘‘Calvarial Butterfly’’ new multidetector computed tomography (MDCT) 215

Fig. 4 Virtual osteoscopy of the occipital bone for different patients showing the discrepancy of the shape, morphology and features of the occipital Butterfly which is unique for each individual, i.e. fingerprint. the fusion software to fuse the generated Calvarial Butterfly MDCT of the head and the storage of the generated data with the stored one for matching/mismatching as well as volu- are considered minimal when compared to the benefit that metric calculation of the Butterfly in cubic millimeters will be a might be obtained from tracing these criminals. Lastly we hope fortifying evidence for identification. that no criminal will escape justice once again and a lot of The technique is easy and accessible, only the examination forensic mysteries will be solved. might be obtained with fraction of a minute. The post process- This can be used as internal fingerprint that cannot be mod- ing techniques including the VR techniques and virtual osteos- ified, manipulated or changed by any means and subsequently copy are easily obtained and reproducible especially with the the anthropological studies will be enriched by adding this tool advent of the new software either on the CT machine or along to the already existing ones. We can say now that many crim- the supplied workstation which is connected to the CT ma- inals will not escape justice after changing their external fea- chine via a local area network (LAN). The colored plates are tures as a result of using the new technique. not essentially as all the details are easily seen on the gray scale The importance of identification of unknown skeletons rose printed materials. following the wide use of MDCT and the routine storage of the The importance of the current study rests on keeping such MDCT data by the PACS systems and subsequently the stor- data in a mega computer archive for any criminal or mafia age capacity problem has been significantly solved. The tech- member arrested once in his life which is considered a golden nique may be quite useful if the CT of the unknown skull opportunity to obtain his ‘‘Calvarial Butterfly’’ using our tech- could be compared to the CT of the head of certain suspected nique hand in hand with the other identification clues. Such persons in case they have had antemortum CT of the head. The information will help to trace this victim antemortem if he increasingly widespread use of PACS facilitates the application was able to change his external features using the tremendous of this new technique. art of medical concealment which is plastic surgery, or even The resultant images of the ‘‘Butterfly’’ were thoroughly post mortem if his external features are disfigured, burnt or studied and it was noticed that every patient has his unique macerated. With the advent of MDCT technology the radia- ‘‘Butterfly’’ regarding its size, morphology and special charac- tion dose could be reduced to a minimum in a sense that the ters and this can be used as internal fingerprint that cannot be detailed structures of the brain are not our focus, and subse- modified, manipulated or changed by any means and subse- quently low exposure factors could be employed to obtain quently the anthropological studies will be enriched by adding the images and virtual osteoscopic view. On the other hand, this tool to the already present one. tracing of these criminal individuals is far important for the en- We tried to navigate within different bones in the body tire community as compared to the harm of radiation that may including long bones, pelvis and spine as well as the other por- be given to them; however, the radiation dose given to Head tions of the bony calvarium did not show any distinguished fin- MDCT is neither fatal nor significantly hazardous. Cost of gerprint-like appearance. 216 A.H.M.N. Moustafa, H.M. Megahed

Fig. 5 Virtual osteoscopy of the occipital bone for another nine patients showing the different spectrum and discrepancy of the shape, morphology and features of the occipital Butterfly.

6. Conclusions and recommendations References

Several trials were attempted to navigate within different bones (1) Kahana T, Hiss V. Identification of human remains: forensic radiology. J Clin Forensic Med 1997;4(1):7–15. in the body including long bones, pelvis and spine as well as (2) Martel W, Wicks JD, Hendrix RC. The accuracy of radiologic the other portions of the bony calvarium did not show any dis- identification of humans using skeletal landmarks: a contribution tinguished fingerprint-like appearance. of forensic pathology. Radiology 1977;124:681–4. We can say now that no single criminal will escape justice (3) Mulligan ME, McCarthy MJ, Wippold FJ, Lichtenstein JE, anymore even after changing his external features using the Wagner GN. Radiologic evaluation of mass casualty victims: tremendous development in the field of plastic surgery if lessons from the Gander, Newfoundland, accident. Radiology we can trace him/her once with keeping the butterfly ‘‘finger- 1988;168:229–33. print’’ within a dedicated file and hence the importance of (4) Vining David J. Virtual endoscopy: is it reality? Radiology storing radiographs over prolonged periods of time and of 1996;200:30–1. efficient record keeping methods to enable prompt retrieval (5) Deschamps T, Cohen LD. Fast extraction of minimal paths in 3D images and applications to virtual endoscopy. Med Image Anal of different radiological modalities examinations specially in 2001;5(4):281–99. mass disaster situations in order to solve the mysteries of (6) Hoppe H, Quattropani C, Spreng A, Mattich J, Netzer P, Dinkel forensic medicine with the emphasis of identification of inter- H. Virtual colon dissection with CT colonography compared with national criminal organizations. Last but not lease coopera- axial interpretation and conventional colonoscopy: preliminary tion between forensic officers and the radiologists will results. AJR 2004;182:1151–8. ultimately revolutionize the challenging and ever evolving (7) Dedouit F, Telmon N, Costagliola R, Otal P, Joffre F, Rouge´D. field of medicine. Virtual anthropology and forensic identification: report of one case. Forensic Sci Int 2007;173(2):182–7. ‘‘Calvarial Butterfly’’ new multidetector computed tomography (MDCT) 217

(8) Thali MJ, Yen K, Schweitzer W, et al. Virtopsy, a new imaging MR imaging, anatomic, and pathologic findings. Radiology horizon in forensic pathology: virtual autopsy by postmortem 2001;221:340–6. multislice computed tomography (MSCT) and magnetic reso- (20) zur Nedden D, Knapp R, Wicke K, et al. Skull of a 5300-year-old nance imaging (MRI): a feasibility study. J Forensic Sci mummy: reproduction and investigation with CT-guided stere- 2003;48(2):386–403. olithography. Radiology 1994;193:269–72. (9) Marx M, D’Auria S. CT examination of eleven Egyptian (21) Benazzi S, Bertelli P, Lippi B, Bedini E, Caudana R, Gruppioni mummies. RadioGraphics 1986;6:321–30. G, et al. Virtual anthropology and forensic arts: the facial (10) Hoffman H, Torres WE, Ernst RD. Paleoradiology: advanced CT reconstruction of Ferrante Gonzaga. J Archaeol Sci in the evaluation of nine Egyptian mummies. RadioGraphics 2010;37:1572–8. 2002;22:377–85. (22) Benazzi S, Fantini M, De Crescenzio F, Mallegni G, Mallegni F, (11) Previgliano CH, Ceruti C, Reinhard J, Araoz FA, Diez JG. Persiani F, et al. The face of the poet Dante Alighieri recon- Radiologic evaluation of the Llullaillaco mummies. Am J structed by virtual modelling and forensic anthropology tech- Roentgenol 2003;181(6):1473–9. niques. J Archaeol Sci 2009;36:278–83. (12) Jansen Roel J, Poulus Martin, Venema Henk, Stoker Jaap. Scenes (23) Benazzi S, Stansfield E, Milani C, Gruppioni G. Geometric from the past: high-resolution spiral CT of Egyptian scarabs. morphometric methods for three-dimensional virtual reconstruc- RadioGraphics 2002;22:63–6. tion of a fragmented cranium: the case of Angelo Poliziano. Int J (13) Marx M, D’Auria S. Three-dimensional CT reconstructions of an Legal Med 2009;123:333–44. ancient human Egyptian mummy. AJR Am J Roentgenol (24) Cattaneo C. Forensic anthropology: developments of a classic 1988;150:147–9. discipline in the new millennium. Forensic Sci Int (14) Harcke H Theodore, Bifano Joseph A, Koeller Kelly K. Forensic 2007;165:185–93. radiology: response to the Pentagon attack on September 11, (25) Cesarani F, Martina MC, Grilletto R, Boano R, Donadoni 2001. Radiology 2002;223:7–8. Roveri AM, Capussotto V, et al. Facial reconstruction of a (15) Magid D, Bryan BM, Drebin RA, et al. Three-dimensional wrapped Egyptian mummy using MDCT. Am J Roentgenol imaging of an Egyptian mummy. Clin Imaging 1989;13:239–40. 2004;183:755–8. (16) Vahey T, Brown D. Comely Wenuhotep: computer tomography (26) Fenton TW, Heard AN, Sauer NJ. Skull-photo superimposition of an Egyptian mummy. J Comput Assist Tomogr 1984;8: and border deaths: identification through exclusion and the 992–7. failure to exclude. J Forensic Sci 2008;53:34–40. (17) Murphy Jr William A, Nedden Dieter zur, Gostner Paul, Knapp (27) Quatrehomme G, Balaguer T, Staccini P, Alunni-Perret V. Rudolf, Recheis Wolfgang, Seidler Horst. The iceman: discovery Assessment of the accuracy of three-dimensional manual cranio- and imaging. Radiology 2003;226:614–29. facial reconstruction: a series of 25 controlled cases. Int J Legal (18) Messmer JM, Fierro MF. Radiologic forensic investigation of Med 2007;121:469–75. fatal gunshot wounds. RadioGraphics 1986;6:457–73. (28) Vandermeulen D, Claes P, Loeckx D, De Greef S. Computerized (19) Sta¨bler Axel, Eck Jurik, Penning Randolph, Milz Stefan P, Bartl craniofacial reconstruction using CT-derived implicit surface Reiner, Resnick Donald, et al. Cervical spine: postmortem representations. Forensic Sci Int 2006;159S:164–74. assessment of accident injuries – comparison of radiographic,