Haemorrhages into the back and auxiliary breathing muscles after death by hanging

A case of hemorrhage at the junctions of the posterior intercostal arteries-a vital sign?

The authors present the case of a 58-year-old man found hanging from a radiator by his shoelaces. The time of death was approximately 6 h before the body was discovered. An autopsy was performed approximately 24 h after the body was found, which revealed hemorrhages in the thoracic aorta at the junctions of the posterior intercostal arteries. Before autopsy, a routine whole-body CT scan was performed. Histologic examination of the aorta and the posterior intercostal arteries revealed a fresh hemorrhage into the tunica adventitia of the aorta. To our knowledge, there is no case description of such findings in hanged persons in the literature. Conclusion: Hemorrhages into the tunica adventitia of the junction of the posterior costal arteries may occur in association with suicidal hanging. The significance of these hemorrhages as a sign of vitality may be debated.

A Case of Hanging with Limited Specific Postmortem Brain Imaging

In Japan, the number of autopsies has steadily decreased. Therefore, postmortem imaging methods have positioned as valuable supplemental or complementary tools in autopsy procedures. We clinicians are increasingly faced with the need to infer cause of death from postmortem imaging findings. We report computed tomography (CT) and magnetic resonance imaging (MRI) findings of a 41-year-old man who committed suicide by hanging. CT revealed fractures of the left superior horn of the thyroid cartilage. Head MRI showed high signal intensity in the basal ganglia on the T1-weighted image and high-intensity rims along the cerebral cortex on the diffusion-weighted image; however, these were considered normal postmortem changes. There were no significant findings in the heart, major blood vessels, or abdominal organs. The contents of the stomach were minimal, and no tablets or other evidence suggestive of drug overdose were identified. Traumatic changes were not observed. Based on the scene and his circumstances, it was speculated that he died by hanging and an autopsy was not performed. This case highlights the importance of understanding normal postmortem brain imaging changes to estimate the true cause of death.

Intramuscular hemorrhages in the pathway of an electric current through the body - two case reports

Intramuscular hemorrhages at autopsy can have a variety of traumatic as well as non-traumatic causes, but their recognition in electrical deaths is almost a rarity. We report on two autopsy cases of electrical fatalities, the first relating to a portion of the right upper human extremity, consisting (only) of the forearm and hand, while the other case relates to a female child who died after a high voltage electrical shock. In both cases, layered dissection of the upper limb revealed fresh intramuscular hemorrhages in the skeletal muscles that could be topographically related to the path taken by the current through the body. Externally visible electric marks were present in both cases. The hemorrhages were most likely caused by current-induced tetanic muscle contractions, producing an internal muscle trauma with rupture of fibers and bleedings. In complex situations, such as inconspicuous marks or a complete lack of visible signs on the body, the finding may be helpful in solving the case in consideration of the case history and circumstances. The vitality, topography, and pattern of the hemorrhages are discussed in the light of the available literature.

Rektale Blutungen beim Erhängen – seltene Befunde mit Verwechslungsgefahr

Bei der Obduktion von erhängt aufgefundenen Personen kommt dem Nachweis der Vitalität des Hängens und dem Ausschluss der Beteiligung von dritter Hand eine besondere Bedeutung zu. Jedoch kann es in einigen Fällen durch die Position des Leichnams zu postmortalen Befunden kommen, die für die Obduzenten erschwert zu interpretieren sein können. So sind in der Literatur seltene Fälle von rektaler Blutstauung mit Schleimhauteinrissen beschrieben, die als Folgen sexueller Handlungen fehlinterpretiert werden können.

Es wird über zwei Fälle von jungen Männern berichtet, die jeweils in sitzender Position an einer Türklinke erhängt aufgefunden wurden. Sowohl bei der polizeilichen als auch der rechtsmedizinischen Leichenschau fielen rektale Blutantragungen und Befunde auf, die zunächst an eine möglicherweise auch gewaltsame anale Penetration denken ließen.

Bei den durchgeführten gerichtlichen Sektionen konnte dann festgestellt werden, dass diese Befunde durch eine ausgeprägte rektale Blutstauung hervorgerufen wurden. Zusätzlich zeigten sich bei einem Leichnam Einblutungen der Dünndarmwand und eines Hodens.

Es werden sowohl die makroskopischen als auch die histologischen Befunde vorgestellt und in Zusammenschau mit der Auffindesituation und den bereits in der Literatur beschriebenen Fällen diskutiert.

[Morphological features of non-traumatic intramuscular hemorrhage]

The formation of non-traumatic intramuscular hemorrhages does not depend on the cause of death. They usually occur in the muscles attached to the rib cage, which are or may be involved in the inhalation process (84.6%). More often, non-respiratory muscles are damaged (66%), less often auxiliary respiratory muscles (15.5%), extremely rarely - the main respiratory muscles (3.3%). In hypothermia, the majority of hemorrhages are formed in the iliopsoas muscles (13.9%). The main reason for the appearance of hemorrhages is muscle overstrain in the agonal period due to increased respiratory activity and seizures. The motor activity of the upper extremities during drowning, prolonged static muscle tension during hypothermia may matter. A microscopic picture usually indicates the formation of hemorrhages shortly before death, and occasionally signs of anxiety are noted.

Autopsy findings of suicidal hanging in Mugla, Turkey

Introduction: External and internal autopsy findings of suicidal hanging were evaluated retrospectively in Muğla, Turkey. The relations between macroscopic autopsy findings and age, gender, nature of the ligature, position of the knot, and the ligature marks were assessed. The aim of this study was to describe autopsy findings of the hangings and discuss the regional differences. Method: The reports of 175 hanging autopsies between 2013 to 2018 were evaluated retrospectively. Macroscopic external and internal findings were evaluated and compared statistically. Results: Among the 2534 autopsies, the cause of death was suicide by hanging in 175 cases (6.9%). The male-to-female ratio was 3:1, 76%(n = 133) of the cases were male, 24% (n = 42) were female, the mean age was 44.9(SD = 19.3) years. Suicide by hanging was most prevalent in the 25-44 age group and among men. Complete hanging was more common than incomplete hanging, and softer materials were more commonly used in incomplete hangings. Females utilized soft materials more than males. Males used atypical hanging more than females. Bilateral hemorrhage in the neck muscles was more common with typical hanging. There was a significant relationship between tongue protrusion and hemorrhage at the clavicular head of sternocleidomastoid muscle. Conclusion: In this study, which includes a large series, some regional and gender differences were observed. Careful and detailed macroscopic examination was important to diagnose antemortem vitality findings.

Epidemiological analysis of intramuscular hemorrhage of respiratory and accessory respiratory muscles in fatal drowning cases

The postmortem diagnosis of drowning death and understanding the mechanisms leading to drowning require a comprehensive judgment based on numerous morphological findings in order to determine the pathogenesis and epidemiological characteristics of the findings. Effortful breathing during the drowning process can result in intramuscular hemorrhage in respiratory and accessory respiratory muscles. However, the characteristics of this phenomenon have not been investigated. We analyzed the epidemiological characteristics of 145 cases diagnosed as drowning, in which hemorrhage, not due to trauma, was found in the respiratory muscles and accessory respiratory muscles. Hemorrhage was observed in 31.7% of these cases, and the incidence did not differ by gender or drowning location. The frequency of hemorrhage was significantly higher in months with a mean temperature below 20°C than in months above 20°C, suggesting a relationship between the occurrence of hemorrhage and low environmental temperature. Moreover, the frequency of hemorrhage was significantly higher in the elderly (aged ≥65 years) compared to those <65 years old. In the elderly, the weakening of muscles due to aging may contribute to the susceptibility for intramuscular hemorrhage. Moreover, these intramuscular hemorrhages do not need to be considered in cases of a potential bleeding tendency due to disease such as cirrhosis or medication such as anticoagulants. Our results indicate that intramuscular hemorrhage in respiratory and accessory respiratory muscles can serve as an additional criterion to differentiate between fatal drowning and other causes of death, as long as no cutaneous or subcutaneous hematomas above the muscles with hemorrhages are observed. In addition, the epidemiological features that such intramuscular hemorrhage is more common in cold environments and in the elderly may provide useful information for the differentiation.

Hypo-Expression of Flice-Inhibitory Protein and Activation of the Caspase-8 Apoptotic Pathways in the Death-Inducing Signaling Complex Due to Ischemia Induced by the Compression of the Asphyxiogenic Tool on the Skin in Hanging Cases

The FLICE-inhibitory protein (c-FLIPL) (55 kDa) is expressed in numerous tissues and most abundantly in the kidney, skeletal muscles and heart. The c-FLIPL has a region of homology with caspase-8 at the carboxy-terminal end which allows the molecule to assume a tertiary structure similar to that of caspases-8 and -10. Consequently, c-FLIPL acts as a negative inhibitor of caspase-8, preventing the processing and subsequent release of the pro-apoptotic molecule active form. The c-FLIP plays as an inhibitor of apoptosis induced by a variety of agents, such as tumor necrosis factor (TNF), T cell receptor (TCR), TNF-related apoptosis inducing ligand (TRAIL), Fas and death receptor (DR). Increased expression of c-FLIP has been found in many human malignancies and shown to be involved in resistance to CD95/Fas and TRAIL receptor-induced apoptosis. We wanted to verify an investigative protocol using FLIP to make a differential diagnosis between skin sulcus with vitality or non-vital skin sulcus in hanged subjects and those undergoing simulated hanging (suspension of the victim after murder). The study group consisted of 21 cases who died from suicidal hanging. The control group consisted of traumatic or natural deaths, while a third group consisted of simulated hanging cases. The reactions to the Anti-FLIP Antibody (Abcam clone-8421) was scored for each section with a semi-quantitative method by means of microscopic observation carried out with confocal microscopy and three-dimensional reconstruction. The results obtained allow us to state that the skin reaction to the FLIP is extremely clear and precise, allowing a diagnosis of unequivocal vitality and a very objective differentiation with the post-mortal skin sulcus.

Vital reactions - An updated overview

The question whether an injury was sustained during life or not is one of the most important subjects in forensic medicine. Therefore, vital reactions have been a main research topic in forensic medicine for a long period and many renowned forensic pathologists have devoted important papers to this field. The research area ranges from macroscopically visible organ reactions, over tissue alterations (enzyme histochemistry, later on immunohistochemistry with a wide range of enzymes and other analytes, molecular pathology) to biochemical responses to injury. Especially in the field of immunohistochemistry and molecular pathology much progress has been achieved in the last years (e.g. heat-shock-proteins or positive aquaporine3-staining in mechanical skin trauma). Furthermore, 20 years after its implementation postmortem imaging also contributes to the detection and visualization of vital signs. The aim of the present review is to provide an update on forensically relevant vital signs/vital reactions. Systemic vital reactions especially of the circulatory and respiratory system as well as local vital reactions will be addressed. Vital reactions of different organ systems will be discussed in detail regarding pathogenesis and possible postmortem evolution. Current research on immunohistochemically detectable vital reactions (heat-shock-protein expression, aquaporine3-staining in mechanical trauma of the skin) will be addressed as well as biochemical vital reactions (agonochemical stress reaction, myoglobine in electrocution death, hypoxanthine as marker of hypoxia).

Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy - a systematic review

Several articles have described the use of postmortem computed tomography (CT) and postmortem magnetic resonance imaging (MRI) in forensic medicine. Although access to CT scanners and, particularly, access to MRI scanners, is still limited for several institutes, both modalities are being applied with increasing frequency in the forensic setting. Certainly, postmortem imaging can provide crucial information prior to autopsy, and this method has even been considered a replacement to autopsy in selected cases by some forensic institutes. However, the role of postmortem imaging has to be assessed individually according to various injury categories and causes of death. Therefore, this systematic review focuses on the role of postmortem CT and MRI in cases of hanging and ligature and manual strangulation. We assessed the most common and relevant findings on CT and MRI in cases of strangulation and compared the detectability of these findings among CT, MRI and autopsy. According to the available literature, mainly fractures of the hyoid bone or thyroid cartilage were investigated using postmortem CT. Compared to autopsy, CT demonstrated equivalent results concerning the detection of these fractures. A currently described "gas bubble sign" may even facilitate the detection of laryngeal fractures on CT. Regarding the detection of hemorrhages in the soft tissue of the neck, postmortem MRI is more suitable for the detection of this "vital sign" in strangulation. Compared to autopsy, postmortem MRI is almost equally accurate for the detection of hemorrhages in the neck. Another "vital sign", gas within the soft tissue in hanging, which is hardly detectable by conventional autopsy, can be clearly depicted by CT and MRI. The number of cases of manual and ligature strangulation that were investigated by means of postmortem CT and MRI is much smaller than the number of cases of hanging that were investigated by CT and MRI. Likewise, judicial hanging and the hangman's fracture on postmortem imaging were described in only a few cases. Based on the results of this systematic review, we discuss the additional value of CT and MRI in fatal strangulation compared to autopsy, and we reflect on where the literature is currently lacking.

Injury after non-judicial hanging

Hanging is an important and increasingly common method of suicide in developed countries. Little is known about the true human pathophysiological changes and injury patterns associated with hanging and near hanging. Cervical spine injury is commonly reported; however, there is a paucity of large data sets concerning this injury. This review article focuses on the incidence of cervical spine and associated neck injuries and their role in morbidity and mortality following non-judicial hanging. A total of 26 heterogeneous studies were identified examining injury after hanging or near hanging. In total, there were 2795 patients; 1530 (54.7%) with true hanging and 1265 (45.3%) with near hanging. Cervical spine injury was reported in a total of 58 (2.08%) patients. Injuries to the airway and vessels of the neck seem rare. This is somewhat lower than the current accepted incidence for cervical spine injury after hanging or blunt force trauma. The overall incidence of cervical spine injury after hanging is low. Spinal immobilisation should probably be instituted depending on the mechanism of the hanging. However, a patient presenting with signs of life to an emergency department is unlikely to have a severe cervical spine injury.