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Determination of sex using head and neck CT Poster No.: C-3035 Congress: ECR 2010 Type: Scientific Exhibit Topic: Radiographers Authors: A. S. C. C. Germano , E. Serrao , C. Santos , M. M. F. Baptista ; 1 1 1 2 1 2 Amadora/PT, Coimbra/PT Keywords: Head & Neck, Sex Determination, CT DOI: 10.1594/ecr2010/C-3035 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org Page 1 of 28 Purpose • • • Forensic imaging is an emerging subspecialty in Radiology. It is well known that forensic anthropologists recognize sexually dimorphic features of skull and face remains. The aim of this retrospective study was to evaluate the possibility of sex determination based only on head and neck CT. Methods and Materials Materials: • • • We retrospectively evaluated all patients that underwent head and neck CT (4 MDCT scanner) in the emergency ward, between May 1st, 2006 and May 31st, 2008. Exclusion criteria: - Patients older than 80 or younger than 20 because in young or very old patients sexually dimorphic features aren´t evident; - Obvious bone pathology and/or excessive tooth loss, as this would alter jaw morphology and limit bone characterization; - Protocol of acquisition causing impossibility of CT-3D reconstruction , as we used 3D reconstructions to facilitate morphological evaluation. Thus, a total of 59 patients (37M, 22F, average age 46.7) were used for the purpose of this study. Forensic methods: • • • • • • • Methods used can be either metric or morphological [1,2,4,5,7]. Metric techniques are restricted to the population for which they were developed and tested [1,2,7]. As we had an heterogeneous population, we used only morphological criteria. Skeletal sex determination is based on sexually dimorphic expressions of bony characteristics produced through different [1]: -Patterns -Rates -Periods of growth There is a difference in rate and duration of growth in males and females during adolescence (males have a longer and more intense adolescent growth spurt than females)[1] This difference is the basis of sexual dimorphism in the skull and face [1] This pattern varies between individuals[1] Page 2 of 28 • • • • • A certain amount of overlap is inevitable, as male and female characteristics lie along a continuum of morphological configuration [1,3] First assessment of sex is based in overall size and architecture (rugosity) [1,2,8] Many morphological criteria can be used, including forehead, frontal eminences, supra-orbital ridges, orbits, nasal aperature, nasals, malars, zygomatics, palate, size and shape of mandible, chin shape [1,2,4] Use of fewer, more precisely defined character traits can improve interobserver concordance [2] Clarity of definition, rather than number of traits are critical for effective determination of sex by visual assessment [2] CT methods: • • • • • A radiologist (ES), removed identifying elements from 4 images of each patient (2 scout view front and profile and 2 bone 3D reconstruction front and right oblique rotation) One radiologist (AG) and one forensic doctor (CS) blindly evaluated the CT images and performed a morphological analysis of global size and architecture of the skull and face and of three traits, easily evaluated in CT images: size of mastoid, nuchal crest /external occipital protuberance and mandibular ramus flexure, based on morphological forensic criteria. ES then evaluated the final data and carried out a statistical data analysis using SPSS17. Using forensic criteria, we tried to classify the mandible, mastoid and nuchal crest of each individual in male, female or indeterminate. Based on the overall impression and the three criteria, we than classified each individual. Mandible: • • • • There is a distinct angulation of the posterior border of the mandibular ramus at the level of the occlusal surface of the molars in adult males on page 4 [3] Only manifests consistently after adolescence [3] It is thought to result from the attachment of the muscles of mastication [3] In most females on page 4 the posterior ramus is straight; If there is an angulation, it is higher or lower than the molar occlusal surface [3] Mastoid: • • • The mastoid can be subjectively classified in small, medium or large [2]. Females on page 5 have small mastoids and males on page 6 have large ones [2]. The intermediate sizes are hard to classify [2]. Page 3 of 28 Nuchal crest/external occipital protuberance: • • Nuchal crest is well marked in very muscled occipitals, and so is a male on page 7 characteristic [1,2] It is not evident or not so marked in females on page 8 Images for this section: Fig. 1 Page 4 of 28 Fig. 2 Page 5 of 28 Fig. 3 Page 6 of 28 Fig. 4 Page 7 of 28 Fig. 5 Page 8 of 28 Fig. 6 Page 9 of 28 Results Results: • • • • • The accuracy of sex determination on page was 76.3% regarding observer AG and 67.8% for observer CS. Sensitivity was 0.68-0.72 and specificity 0.67-0.78 between the observers. Age did not have a statistically significant impact in the correct determination of sex(p=0.387). The direction of error for cranial sex criteria favored the female gender, 8 cases of men were assumed as women for observer A (p<0.01), and 12 cases for observer B (p<0.01). Interobserver agreement on page : The observed percentage of agreement was 71%, corresponding to a Cohen´s kappa of 0.42 (p<0.01), indicating moderate interobservers agreement [2,9] Fig. Page 10 of 28 References: A. S. C. C. Germano; Department of Radiology, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, PORTUGAL Fig. References: A. S. C. C. Germano; Department of Radiology, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, PORTUGAL Page 11 of 28 Fig. References: A. S. C. C. Germano; Department of Radiology, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, PORTUGAL Page 12 of 28 Fig. References: A. S. C. C. Germano; Department of Radiology, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, PORTUGAL Page 13 of 28 Fig. References: A. S. C. C. Germano; Department of Radiology, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, PORTUGAL Page 14 of 28 Fig. References: A. S. C. C. Germano; Department of Radiology, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, PORTUGAL Results both observers: • • None of the criteria for sex determination and the final answer was statistically significant, making each of them non-decisive for the final answer/sex impression, for each observer. There was no association between any criteria and the real sex of the patient. Page 15 of 28 Fig. References: A. S. C. C. Germano; Department of Radiology, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, PORTUGAL Page 16 of 28 Fig. References: A. S. C. C. Germano; Department of Radiology, Hospital Professor Doutor Fernando Fonseca EPE, Amadora, PORTUGAL Images for this section: Page 17 of 28 Fig. 1 Page 18 of 28 Fig. 2 Page 19 of 28 Fig. 3 Page 20 of 28 Fig. 4 Page 21 of 28 Fig. 5 Page 22 of 28 Fig. 6 Page 23 of 28 Conclusion • • • • • The accuracy of patient sex determination using morphologic forensic techniques in CT images in our study was inferior to the direct use of these same techniques in human skeletal remains. We used few CT images, the ones we though were essencial for this study but maybe results can be improved with the complete exam and using more criteria. Results were affected by the fact that the radiologists had no knowlegde of forensic criteria before this work and the forensics had no knowlegde of CT, so we think that cooperation between the two specialties is fundamental. As in the literature, our error favored females, which can be explained by the fact that indeterminate individuals failed to express size and shape male characteristics. To our knowledge, this is the first reported attempt to develop a systematic method for sex determination based on head and neck CT images of alone. Solution Please click on the following links: female on page 25 /male on page 26 Images for this section: Page 24 of 28 Fig. 1 Page 25 of 28 Fig. 2: solution: scroll to end of conclusion Page 26 of 28 Fig. 3: solution: scroll to end of conclusion Page 27 of 28 References 1. Rogers TL. Determining the Sex of Human Remains Through Cranial Morphology. J Forensic Sci 2005;50:493-500. 2. Walrath DE; Turner P.; Bruzek J. Reliability test of the Visual Assessment of Cranial traits For Sex Determination. American Journal of Physical Anthropology 2004;125: 132-137. 3. Loth S; Henneberg M. Mandibular ramus Flexure: A New Morphologic Indicator of Sexual Dimorphism in the Human Skeleton. American Journal of Physical Anthropology 1996; 99: 473-485. 4. Maat GJR; Mastwijk RW; Velde EAVD. On the Reliability of Non-metrical Morphological Sex Determination of the skull compared with that of the pelvis in the Low Countries. International journal of Osteoarcheology 1997; 7:575-580 5. Schmitttbuhl M; Minor JM; Taroni F. Sexual Dimorphism of the Human Mandible: Demonstration by Elliptical Fourier Analysis. Int J Legal Med 2001; 115: 100-101. 6. Stephan CN; Norris RM; Henneberg M. Does Sexual Dimorphism in Facial Soft Tissue Dephs Justify Sex Distinction in Craniofacial Identification? J Forensic Sci 2005; 50: 513-518 7. Uytterschaut HT. Sexual Dimorphis in Human Skulls. A Comparison of Sexual Dimorphism in Different Populations. Human Evolution 1986; 1: 243-250. 8. Weiss KM. On the Systematic Bias in Skeletal Sexing. American Journal of Physical Anthropology , 37: 239-250. 9. http://en.wikipedia.org/wiki/Cohen's_kappa Personal Information Page 28 of 28