White paper by the international society of forensic imaging guidelines working group on non-contrast PMCT for decomposed remains

Abstract

Overdose deaths, particularly from opioids and synthetic analogs, continue to rise globally. While some cases present with overt indicators, others lack external signs, complicating initial investigation. Postmortem computed tomography (PMCT) has emerged as a valuable adjunct in these cases, offering radiologic features that may suggest overdose and support triage, even in unsuspected deaths. Characteristic findings—such as cerebral edema, pulmonary edema, and urinary bladder distention—comprise the so-called “overdose triad,” which demonstrates high specificity for overdose-related fatalities. PMCT also detects ancillary features including findings related to pill fragments, signs of body packing, and hypertensive intracerebral hemorrhage. In overdose investigations, PMCT’s high negative predictive value helps exclude internal trauma and skeletal injuries, guiding case management and informing decisions on the necessity for full autopsy. While PMCT findings are not pathognomonic and may be absent in rapidly fatal intoxications, the technique offers considerable value, particularly when integrated with toxicological analysis and full autopsy. The International Society of Forensic Radiology and Imaging (ISFRI) supports the standardized use of PMCT in suspected overdose deaths as part of a comprehensive forensic approach.