His parents requested that a full autopsy not be performed. On Tuesday, during an appearance on the television show “Fox & Friends,” Fred Warmbier said that his son had been “tortured” and described North Korean officials as “terrorists.”
After the interview, President Trump said in a tweet that Mr. Warmbier “was tortured beyond belief by North Korea.”
On Thursday, North Korea’s Foreign Ministry issued a statement denying again that Mr. Warmbier had been tortured and accusing the United States of “employing even a dead person” in a “conspiracy campaign” against North Korea.
Dr. Sammarco’s examination, which was concluded earlier this month, did not find signs of torture but could not rule out the possibility.
“There are a lot of horrible things you can do to a human body that don’t leave external signs behind,” Dr. Sammarco said.
“One of the frustrating things is the lack of information about what happened to him in North Korea,” she added.
In a virtual autopsy, pathologists rely on an examination of the body and on scans to determine what has happened to it. Mr. Warmbier was returned with brain scans done in North Korea in April 2016 and again in July 2016.
M.R.I. scans were done at the medical center after he arrived, which also performed a whole-body CT scan after Mr. Warmbier’s death.
The images clearly showed that his brain had been starved of oxygen and that large tracts of cells had died, Dr. Sammarco said. The medical diagnosis is anoxic-ischemic encephalopathy.
That condition differs from the damage that occurs during a stroke, when a single blood vessel is blocked, said Dr. Lee H. Schwamm, executive vice chairman of neurology at Massachusetts General Hospital.
With an injury like Mr. Warmbier’s, “blood flow is reduced everywhere — the pump is turned off,” said Dr. Schwamm, who reviewed the coroner’s report at The Times’s request.
In the United States, the most common cause is a cardiac arrest, often precipitated by a heart attack. While cardiac arrests are unlikely in healthy young men, they can happen if the victim is malnourished and suffers an imbalance of blood electrolytes, such as potassium, calcium, or magnesium, Dr. Schwamm said.
The damage is quick: It takes just four minutes without blood for brain cells to start to die.
Blood flow to the brain can be interrupted for any number of reasons. The whole-body CT scan did not find injuries associated with hanging, for example, but Dr. Schwamm said the evidence might not be visible if a bedsheet were used and the spine were not dislocated.
Mr. Warmbier had a scar at the base of his neck that was probably caused by the insertion of a tube into his trachea as he was hooked up to a ventilator. This may indicate that he was not breathing on his own for a long period of time, Dr. Sammarco said.
He was weaned from the ventilator in North Korea, though; he was not using it when he was returned.
There were few other signs of injury on Mr. Warmbier’s body. There were no bedsores, and his skin condition was excellent, Dr. Sammarco said. “His muscle volume was pretty good for someone who was bedridden for over a year,” she said.
In the United States, most families would opt for palliative care for a relative in a vegetative state resembling Mr. Warmbier’s, she added. That would consist of providing pain medications and sedatives to soothe them.
Doctors do not know whether these patients suffer from pain and anxiety, Dr. Sammarco said. But they often groan and make jerky movements.
The case has attracted global attention and inflamed international tensions. Dr. Sammarco said she offered to turn the examination over to federal authorities.
“If there were national or international implications, we would be happy to relinquish jurisdiction and cooperate in any way necessary,” she said.
Federal officials declined, she added.
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