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Death by asphyxia is defined as the prolonged and fatal deprivation of oxygen and/or blood to the brain and other vital organs. Strangulation, smothering, hanging, drowning, choking, suffocation and chemical asphyxia are considered the main modalities in which asphyxiation can occur. The study of injury patterns is crucial for assisting veterinary forensic experts in identifying the cause and manner of death with a higher degree of certainty. A retrospective study of necropsy cases identified using the keywords “asphyxia”, “anoxia”, “hypoxia”, “strangulation”, “hanging”, “choking”, “smothering” and “suffocation” was performed. A total of 33 dogs and 16 cats were included in the study. In 67 % of cases, asphyxiation was suspected from the circumstances in which the victim was found. Whereas strangulation was the most significant modality of asphyxiation in dogs (25/33, 76 %), smothering or airtight confinement were more prevalent in cats (6/16, 38 %). Some findings that are highly indicative of asphyxiation in humans were rare or even absent in our study cohort, such as external skin bruising and fracture or dislocation of the hyoid apparatus. Most lesions were confined to head and neck, including bilateral scleral reddening, meningeal congestion, circumferential laryngeal reddening, selective subcutaneous congestion and bruising within the superficial muscles and subcutaneous tissues, consistently accompanied by severe pulmonary congestion and oedema. Whereas no single lesion was considered pathognomonic; the combination of several lesions highly indicated asphyxiation. A significant association between some lesions, the modality of asphyxiation and victim’s species was also noted. •In 67 % of cases, asphyxiation was suspected from the circumstantial evidence.•Strangulation was the most significant modality of asphyxiation in dogs.•Smothering and confinement within an enclosed space were more prevalent in cats.•No single lesion was identified as pathognomonic of fatal asphyxiation.•A combination of several lesions was highly indicative of death by asphyxia.

The lack of pathognomonic findings to diagnose death by hanging is a well-known problem in forensic practice. This review examines the significance of signs that have been proposed over time as useful in forensic diagnosis, reporting the frequency of occurrence in the various published case histories. The analysis covered both internal and external signs, followed by an overview of potentially useful laboratory investigations. There is great variability in the frequency of occurrence of signs considered useful in forensic diagnosis. In addition, some of the signs that were considered historically valid must now be deemed not to be supported by sufficient scientific evidence as to their actual usefulness. There is a need for new case studies with overlapping methodologies and observed variables to enable effective and further comparisons. •Several signs have historically been associated with death by hanging.•No single sign is considered pathognomonic of death by hanging.•The diagnosis of hanging must result from a convergence of multiple elements.

Hyoid fractures are uncommon, but when they occur they are commonly the result of strangulation or hanging. Although there is a lack of available quantitative data, there is increasing evidence to suggest that strangulation is a relatively common feature of consensual sex play. This creates difficulty in clinical forensic medicine given the “rough sex” defence has previously been used successfully in cases of fatal intimate partner strangulation. We present a case where consensual and non-consensual strangulation has occurred in a woman who presents with a hyoid fracture. While manual strangulation was thought to be a more likely mechanism than consensual wearing of a sex-collar; ultimately the similar timeframes of the collar-wearing and the non-consensual manual strangulation meant that the accused was not convicted of this particular strangulation offense. This case highlights the importance of further research into consensual strangulation and the incidence of resultant injuries. It also demonstrates the importance of collecting a detailed forensic history and adequately documenting injuries in a contemporaneous matter.

The pathological mechanisms underlying the ligature mark in hanging involve the skin layers and an ischemic mechanism. The apoptotic process develops whenever ischemic mechanisms affect the dermal and epidermal layers. Effector caspase-3 appears to play a crucial role in both acute and chronic pressure-induced skin ischemia. The aim of this study is to identify the role of caspase-3 as a marker of supravitality in the diagnosis of premortem hanging. Skin samples from ligature marks in hanging cases were collected to investigate this apoptotic process. The caspase-3 levels in compressed skin were significantly higher compared to those found in healthy skin (p < 0.005). The apoptotic process in ischemic epidermal cells begins with stable mechanical stress, as seen in the hanging model. Caspase-3 expression seems to vary from minutes after the initial stress input. Caspase-3 activation is an ATP-dependent process and can only occur if the victim was alive before the pressure was applied. Caspase-3 is a reliable marker of supravitality in ligature marks in premortem hanging cases.

Autoerotic asphyxial deaths are a rare but recurring phenomenon, the most common modality of which involves neck compression. Autoerotic neck compression can involve any compression to the neck during individual sexual activity performed to heighten arousal. This retrospective study examines 72 such deaths occurring in Australia between 2000 and 2022. The study aims to provide detailed medico-legal interpretation of such deaths and recommendations for investigation within Australian contexts, and globally. Demographic analysis reveals a predominance of Caucasian males under 50 years of age, with diverse employment and health status. Pathological examination uncovers a spectrum of injuries, from superficial abrasions to rare skeletal and cartilaginous injuries, providing insights into the mechanics and characteristics of these fatalities. Contextual examination highlights sexual paraphernalia, evidence of genital stimulation, and isolation are consistent features in most autoerotic deaths within the sample. There was a wide variety of tool usage (ropes, belts, etc.), and geo-temporal features associated with autoerotic neck compression. The study provides comprehensive examination of the circumstances and characteristics of autoerotic neck compression which may assist in differentiation between suicidal and homicidal neck compression deaths such as hanging or ligature strangulation respectively. This study is an Australian first and is the first study of autoerotic asphyxial deaths to focus solely on deaths with a neck compression component. The study incorporates new variables and suggests ways these should be considered in future death investigations. The authors argue for delineation and subcategorization of autoerotic neck compression from other autoerotic asphyxial death due to their distinct injury characteristics and mechanism of injury. •The study uses a retrospective approach to death investigation.•Autoerotic Neck Compression Deaths primarily impact Caucasian men in Australia.•Findings within this article are consistent with global trends of autoerotic asphyxial deaths.•Unique contextual identifiers are present at most death scenes.

Uncertainty exists about what causes brain structure alterations associated with schizophrenia (SZ) and bipolar disorder (BD). Whether a history of asphyxia-related obstetric complication (ASP) - a common but harmful condition for neural tissue - contributes to variations in adult brain structure is unclear. We investigated ASP and its relationship to intracranial (ICV), global brain volumes and regional cortical and subcortical structures. A total of 311 patients on the SZ - BD spectrum and 218 healthy control (HC) participants underwent structural magnetic resonance imaging. They were evaluated for ASP using prospective information obtained from the Medical Birth Registry of Norway. In all groups, ASP was related to smaller ICV, total brain, white and gray matter volumes and total surface area, but not to cortical thickness. Smaller cortical surface areas were found across frontal, parietal, occipital, temporal and insular regions. Smaller hippocampal, amygdala, thalamus, caudate and putamen volumes were reported for all ASP subgroups. ASP effects did not survive ICV correction, except in the caudate, which remained significantly smaller in both patient ASP subgroups, but not in the HC. Since ASP was associated with smaller brain volumes in all groups, the genetic risk of developing a severe mental illness, alone, cannot easily explain the smaller ICV. Only the smaller caudate volumes of ASP patients specifically suggest that injury from ASP can be related to disease development. Our findings give support for the ICV as a marker of aberrant neurodevelopment and ASP in the etiology of brain development in BD and SZ.

Strangulation is a gendered and under-recognized form of violence often linked to intimate partner violence (IPV) and sexual assault, predominantly affecting women. Understanding injury patterns in non-fatal (NFS) and fatal strangulation (FS) is essential for diagnosis, prosecution, and prevention. This study examines injury patterns and forensic characteristics in NFS and FS cases in Sweden, contributing evidence to support clinical and forensic assessments. This retrospective study analyzed 617 NFS cases from 2022 and 139 FS cases from 2003–2022, sourced from the Swedish National Board of Forensic Medicine. Chi-square and Fisher’s Exact Test assessed associations between strangulation method and injury patterns. Manual strangulation predominated in NFS (96 %), while FS cases had a near-equal distribution of manual and ligature methods. Petechiae were much more common in FS (91 %) than in NFS (4 %), but no significant differences were observed in the occurrence of petechiae between the different types of strangulation. Fractures of neck structures were more frequent in older FS victims compared to younger. IPV was the primary context in both NFS (67 %) and FS (43 %) cases, with a majority of victims being female. Distinct injury patterns were observed in NFS and FS emphasizing the need for thorough forensic assessments. The findings underscore the importance of clinical vigilance and standardized documentation of injuries in suspected strangulation cases to support legal investigations and prevent future violence. •The majority of fatal and non-fatal strangulation victims are women.•Perpetrators of strangulation are predominantly male intimate partners.•Neither non-fatal nor fatal strangulation may leave any external visible injuries.•Fatal strangulation results in greater injuries compared to non-fatal strangulation.

The authors present a case involving a 37-year-old woman discovered in an operating freezer. Suicide hypothesis has been considered from the beginning. Due to the exceptional scene circumstances, a forensic autopsy was performed. Apart from some non-specific hypothermia and asphyxia signs, the autopsy revealed several skull fractures, prompting extensive anatomopathological and histological analyses. These analyses confirmed the fractures origin and determined whether they were ante-mortem or post-mortem, thus ruling out the possibility of a criminal act disguised as suicide. The authors also describe the challenges in determining the cause of death, particularly the issues related to the post-mortem diagnosis of lethal hypothermia and asphyxia. This case is the first in the literature to describe suicide by exposure to cold in a confined environment. It highlights the importance of close collaboration between forensic pathologists, histologists, toxicologists, and police investigators to answer judicial inquiries.

Postmortem lividity is a well-established external thanatological change, yet its internal manifestation remains underexplored, particularly in the lungs. This exploratory pilot study investigates the fixation dynamics of internal (pulmonary) lividity using postmortem computed tomography (PMCT), its association with external lividity, and its potential forensic implications. We retrospectively analyzed 50 medicolegal autopsy cases of hanging deaths where external lividity was present in any pattern other than the supine-only pattern. The right lung was divided into anterior and posterior segments, and Hounsfield Unit (HU) values of these segments were measured. Internal lividity patterns were scored using a novel HU-based ranking system. External lividity patterns were recorded from autopsy findings. Statistical analysis included paired t-tests, chi-square tests, and logistic regression. While 74 % of cases exhibited fixed external lividity in an inferior (“glove and stocking”) pattern, 78 % showed a posterior pulmonary lividity pattern on PMCT. Chi-square analysis failed to detect any statistically significant association between external and pulmonary lividity patterns (χ² = 0.26, p = 0.88). HU differences were greater in anteroposterior comparisons at the inferior lung level (mean Δ = 261.47 HU). The horizontal plane formation in posterior lung regions was significantly associated with complete fixation of external lividity (p = 0.020), though not with time in the supine position. Pulmonary lividity follows distinct fixation dynamics, independent of external lividity in hanging cases. Quantitative PMCT analysis offers a novel method for identifying pulmonary lividity patterns and provides preliminary evidence for hypothesizing its utility in detecting postmortem body manipulation. These findings highlight the importance of integrating internal lividity assessment into forensic imaging protocols for more accurate reconstructions of postmortem events. •PMCT analysis of 50 hanging deaths reveals lung lividity dynamics.•Pulmonary lividity patterns differ from external lividity.•Quantitative HU scoring identifies lividity patterns objectively.•Horizontal planes form in 46 % of cases, independent of external fixation.

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.