Recently, a novel autopsy finding in deaths by hanging was reported - adventitial hemorrhages of the descending aorta at the junction with the posterior intercostal arteries. The suggested mechanism of appearance is the axial traction of the body on neck compression but also agonal convulsion-related repetitive spine hyperextension, leading to stretching and tearing of the adventitial blood vessels. So, they should appear in other deaths that share these agonal elements with hangings, such as epilepsy-related deaths, drownings, fatal electrocution or hypothermia. We report eight isolated, non-consecutive autopsy cases comprising epilepsy-related death (n = 1), electrocution (n = 1), drowning (n = 2), hypothermia (n = 1), and hanging (n = 2), where death involved exactly either agonal tonic-clonic seizures or other mechanical traction of the intercostal arteries, and severe thoracoabdominal trauma (n = 1), with mechanical latero-lateral traction of the intercostal arteries. In all eight cases, fresh adventitial hemorrhages were macroscopically visible as dark-red round to oval foci at the artery junctions and were confirmed by light microscopy. Histology revealed that, in addition to confluent adventitial hemorrhages, the microscopic subadventitial tear with fresh hemorrhage could be observed in some. The congested adventitial vasa vasorum in the proximity of these hemorrhages were observed on the histology samples, as well. This case series contributes to our understanding of adventitial hemorrhages at the junction of descending aorta with the posterior intercostal arteries, and provides insight into their morphology, with implications on the interpretation limitations but also hints to potential mechanism of their appearance, provided these prove to be intravital.

Hypothermic oxygenated machine perfusion (HOPE) is increasingly applied in donation after circulatory death (DCD) kidney transplantation to improve graft preservation, enable functional assessment, and reduce organ discard. In DCD settings characterized by prolonged mandatory agonal and warm ischemia phases, graft susceptibility to ischemia-reperfusion injury is amplified, rendering the preservation strategy particularly consequential. We describe a pragmatic technical workaround consisting of prolonged hypothermic perfusion of en bloc kidneys via aortic cannulation using a multiorgan perfusion system (VitaSmart Hypothermic Oxygenated Perfusion System, Bridge to Life Ltd., Northbrook, IL) operated under its standard renal perfusion settings. This approach allows continuous low-pressure perfusion, real-time monitoring, and the possibility of pharmacological intervention when renal-dedicated disposables are unavailable or when prolonged hypothermic preservation is required for logistical reasons. The technique was applied as a feasibility stress test in two DCD kidney grafts, which were perfused for 18 hours at controlled low pressure following an initial oxygenated flushing phase and maintained on continuous perfusion until implantation. The procedure proved technically stable and biologically informative, supporting its use as a rescue preservation strategy in selected DCD scenarios that require extended hypothermic oxygenated preservation and real-time graft assessment.

Fatal opioid intoxications provide a postmortem diagnostic challenge due to a lack of coherent autopsy findings and the potential of tolerance and individual variations to complicate the evaluation of toxicological results. This study investigates whether postmortem metabolomics could be used to discriminate between opioid intoxications, irrespective of the involved opioid, and hangings, and if the degree of respiratory failure in intoxications could be predicted. Data was acquired from toxicological screenings of femoral blood with high resolution mass spectrometry (HRMS) comprising 338 hangings and 287 opioid intoxications. Cases were divided into a training set and a validation set using a 3:1 ratio. An orthogonal partial least squares discriminant analysis (OPLS-DA) binary classification model was built using 269 features, with an R[2] = 0.474 and Q[2] = 0.377, and classification accuracy of 78.2%. A second model, aiming to classify the degree of respiratory failure did not perform successfully. Metabolite identification revealed differences in acylcarnitine, nicotinamide adenine dinucleotide (NAD) and monoamine metabolism. Analysis of misclassifications revealed a high proportion of misclassified opioid suicides and suggested a potential to differentiate between acute and delayed death in opioid intoxication. Further investigation with larger cohorts is needed to evaluate generalizability and explore opioid-related respiratory failure. However, the current study demonstrates that postmortem metabolomics can assist forensic pathologists in classification of cause of death, and potentially manner of death, in opioid related cases.

Donation after circulatory death has emerged worldwide as a safe and effective alternative pathway to increase the donor pool. However, organs undergo a variable period of warm ischemia during the agonal phase and the cardiac arrest before graft procurement, and the heart is particularly vulnerable to injury provoked by warm ischemia and subsequent reperfusion. Several reperfusion strategies are currently available for the recovery and assessment of heart function in these donors, with promising early and long-term results. Nevertheless, each technique implies specific financial, logistical and ethical challenges, translating into a heterogeneous landscape of protocols across European and non-European countries. Additionally, no randomized clinical trials have been published to assess the superiority of one technique over the other, and current clinical evidence is based on retrospective registry data and single-center observational studies.

Diatom testing is a key technique for forensic drowning diagnosis, yet species discordance between diatom taxa in victim tissues and water samples from the recovery site remains a major medico-legal challenge, often misattributed to technical errors or post-mortem contamination. This correspondence proposes an interdisciplinary interpretative hypothesis based on biological passive sampling theory from environmental science, hypothesizing three potential mechanisms driving this discordance: selective sampling by anatomical structures and diatom physical traits, time-integrated accumulation of diatoms during the agonal period of drowning versus snapshot water sampling, and chronic dietary diatom exposure forming a potential background signal. We cautiously distinguish natural biological discordance from artificial post-mortem contamination, and suggest reframing discordance from a methodological flaw to a potential source of actionable forensic information, provided that its interpretative boundaries are clearly defined. Evidence-based forensic interpretation guidelines for different discordance patterns and standardized practice recommendations for diatom testing are provided, including reporting organ-specific diatom profiles, evaluating tissue barrier integrity, and implementing strict blank controls. This framework is presented as a testable hypothesis consistent with recent systematic reviews on diatom test interpretation and provides a theoretical basis for the urgent standardization of forensic diatom testing, enhancing the scientific validity of drowning diagnosis and site inference in medico-legal practice.

Instantaneous rigor, historically referred to as cadaveric spasm, remains a controversial concept in forensic pathology with divergent interpretations. Despite skepticism regarding its status as a distinct entity, apparent immediate postmortem fixation-particularly of the hands-continues to be reported. We describe a witnessed suicidal railway fatality in a 38-year-old female who exhibited unusual limb postures suggestive of instantaneous rigor. Detailed scene reconstruction and autopsy revealed heterogeneous limb positioning: some postures were attributable to biomechanical support, whereas others, particularly involving the hands, were not readily explained by environmental factors, object retention, or conventional postmortem changes. These findings may be better interpreted as reflecting terminal neuromuscular activity during a brief agonal phase, followed by stabilization of the resulting posture by early rigor mortis. A comparable suicidal hanging case demonstrated similar hand postures, providing additional observational support for this proposed interpretation. Overall, these observations are consistent with a hypothesis that apparent instantaneous fixation may represent a continuum of terminal neuromuscular phenomena rather than a distinct postmortem entity. Careful correlation of scene findings with autopsy features remains essential when interpreting such unusual postmortem postures. Although these observations are hypothesis-generating, they highlight the importance of distinguishing terminal agonal neuromuscular activity from postures traditionally attributed to cadaveric spasm during medico-legal interpretation.

Brugada Syndrome (BrS) is a genetic condition that increases the risk of sudden cardiac death. Diagnosis relies on the presence of a type 1 Brugada electrocardiogram (ECG) pattern, which may be intermittent. In patients without symptoms or family history, the value of pharmacological provocation with sodium channel blockers (SCB) remains uncertain. The aim of this study was to evaluate the follow-up of patients with a positive ajmaline test who, according to current recommendations, would not have been eligible for undergoing the test. A retrospective study analyzed patients who underwent SCB provocation testing for suspected BrS based on ECG abnormalities, excluding those with prior cardiac arrest, syncope, nocturnal agonal respiration, or family history of BrS or sudden unexplained death. Patients with an induced type 1 Brugada pattern were further evaluated regarding spontaneous type 1 Brugada pattern, pathogenic or probably pathogenic genetic variants or, in the context of family screening, other family members with a Brugada pattern. Among 58 SCB provocation tests performed in patients with suspected Brugada pattern and no family history or relevant symptoms, 50% had a type 1 pattern in the treadmill exercise ECG, 36.7% had other family members with a BrS diagnosis, 23.3% had a spontaneous type 1 pattern in 12-lead ECG during follow-up, 20% had a type 1 pattern in 24-hour modified Holter and 13.3% had a positive genetic test for a pathogenic or probably pathogenic genetic variant. In conclusion, the current guidelines may be excessively restrictive regarding the diagnosis of BrS and, while leading to fewer false positives, may exclude patients with a true BrS diagnosis.

Refractory status epilepticus complicating hepatic encephalopathy poses unique palliative challenges as standard extubation protocols typically reduce or discontinue sedative infusions, risking immediate seizure recurrence and distress. We report a 53-year-old man with end-stage cirrhosis and hepatocellular carcinoma who developed hepatic encephalopathy and refractory status epilepticus precipitated by small bowel obstruction. Despite ammonia-lowering therapy and multiple antiseizure medications, seizures remained refractory. Electroencephalography confirmed status epilepticus despite escalating therapy. Given prohibitive surgical risk and poor prognosis, the multidisciplinary team and patient's family elected to withdraw life-sustaining treatments, requesting he not die with an endotracheal tube in place. He underwent palliative extubation while continuing propofol and midazolam infusions to suppress seizure activity and ensure comfort. He died peacefully without visible seizure activity. Although limited by a single patient, this case provides a practical example of a rarely described palliative strategy: continuing sedative infusions during palliative extubation to prevent agonal seizures in refractory status epilepticus.

We developed a physiologically grounded metric-the Delta Myocardial Stress Index (ΔMSI)-to estimate myocardial oxygen supply-demand imbalance during the donor agonal phase and evaluated its association with posttransplant graft dysfunction. We performed a retrospective single-center study of adult donation after circulatory death (DCD) heart transplants (February 2020-June 2025). High-resolution hemodynamic data from withdrawal to declaration of death (WTD) were analyzed. Delta Myocardial Stress Index, integrating myocardial oxygen supply-demand balance, was derived from available hemodynamic data. Associations between ΔMSI and severe primary graft dysfunction (PGD) were assessed. Among 191 cases (16 severe PGD events), ΔMSI trajectories were significantly elevated in donors who developed severe PGD (p < 0.001). Two distinct ΔMSI trajectory phenotypes were identified; high ΔMSI was independently associated with severe PGD (odds ratio [OR]: 2.49, p = 0.02) and 90 day mortality (OR: 4.58, p = 0.03). The association between WTD and PGD operated primarily through cumulative ΔMSI burden (p = 0.02), whereas WTD alone was not associated with PGD after accounting for ΔMSI (p = 0.25). Delta Myocardial Stress Index provides a noninvasive quantification of myocardial stress during DCD withdrawal. Myocardial stress, rather than agonal duration alone, was associated with severe PGD. These findings support a shift from time-based thresholds toward physiologic assessment of donor myocardial resilience.