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168 Chapter 9 Practical limitations and considerations The current method had complex logistics due to the use of both MRI and CT scanners and the image-guided biopsies from the corpse, if consented, including the brain. The bodies were transported from the morgue through the hospital to the radiological department and back, they had to be properly covered in order not to scare personnel, patients or visitors. Because fluids may leak when taking tissue biopsies, the body was put in a body bag. This bag should not contain any metal to be suitable for the MRI scanner. Because MRI scans are time consuming, and (therefore) relatively expensive, we chose to scan from the head to the pelvis, to include all vital organs, and skip the legs. The lower extremities were scanned with CT only, which took only a few seconds. During regular working hours the scanners were occupied for scanning patients, so the MIA scans had to be done in the evenings. In our cohort 17 cases were excluded due to logistic reasons (including two cases with another MIA scheduled on the same day), and in six cases next-of-kin did not accept further delay of CA. Though MIA is a joint effort between radiologists and pathologists, the accuracy of the procedure heavily depends on the availability of skilled radiologists, because they have to identify the pathologies that have to be biopsied, as imaging is the substitute for gross examination. Currently there are only a few clinical radiologists with experience in post-mortem imaging. 254 In particular they have to be familiar with, often subtle, post- mortem changes on both CT and MRI, which may be overinterpreted as pathological changes. 255 The biopsies of the torso were performed by MIA researchers, who had limited experience in obtaining CT-guided biopsies. Nevertheless, sampling errors occurred in only 17 of the 655 biopsies (2.6%), and just four of these led to a missed diagnosis. Like for CA, histologic examination of the brain was only possible if next-of-kin had given explicit consent for brain biopsies. These biopsies were taken under stereotactic guidance in cooperation with neurosurgeons on call. If MIA were to be clinically implemented as a routine, scanners should be available for MIA during regular working hours. However, having an MRI and CT scanner for post- mortem use only, would probably be too expensive. ‘Second-hand’ scanners, on the other hand, might not be. Moreover, more radiologists have to be properly trained and professional guidelines have to be developed. 256 The same applies to radiology technologists, and especially for the ones operating the MRI scans, because those require more dedicated protocols. Also, the MIA biopsies are probably best taken by those who are experienced already based on their clinical work. Radiologists are the most likely candidates.