Hemorrhagic Lividity of the Neck

Abstract

Postmortem hypostasis (livor mortis or lividity) is classically defined as the intravascular pooling of blood in gravitationally dependent parts of the body after death. However, intense lividity can be associated with small hemorrhages in the skin, so-called postmortem hypostatic hemorrhages (Tardieu spots). Postmortem hypostatic hemorrhages seem to contradict the usual understanding of lividity, since hemorrhage is by definition an extravascular phenomenon. Substantive medicolegal difficulties can arise if such hemorrhagic lividity develops in the necks of bodies that have ventral lividity due to prone position at the death scene. To study this phenomenon, we have developed a model for the controlled formation of hypostatic hemorrhages in human cadavers. In this model, extensive hypostatic hemorrhages or hemorrhagic lividity could be reproducibly but not universally induced in the soft tissues of the anterior neck and strap muscles. Histologic examination revealed hemorrhage that was microscopically indistinguishable from the acute hemorrhages observed in contusions. In addition, some larger areas of interstitially extravasated blood showed "buffy coat"-sedimentation separation of neutrophils that closely mimicked acute inflammation, further confounding the correct diagnosis. This research implies that hypostatic hemorrhages form after the progressive development of increasing gravitational hydrostatic pressure in an autolysing venous plexus. Thus, this phenomenon can mimic soft tissue injury ("pseudo-bruising") and the internal injuries related to strangulation. Caution must be exercised when diagnosing strangulation in bodies with anterior neck lividity.

Neck Hemorrhage

“…Three of 5 subjects had ventral neck hemorrhages after 48 hours and revealed the following gross examination findings: subject 1 had diffuse hemorrhages involving the right superficial soft tissues, left sternocleidomastoid, and strap musculature (right > left), subject 2 had diffuse bilateral hemorrhages of the sternocleidomastoids, and subject 3 had focal hemorrhage in the left sternohyoid muscle. 3 Given that the theory of how postmortem hypostatic hemorrhages are induced, congested venous plexuses combined with leaky vessels due to their loss of integrity from autolysis or decomposition, 3 one would posit that prone positioning would be more likely to result in diffuse, superficial hemorrhages in the anterior neck as a result of livor mortis. The basis of this theory is supported by the understanding of Prinsloo-Gordon hemorrhages, hemorrhages in the posterior pharyngeal wall, as a result of livor mortis plus a congested, leaky pharyngoesophageal venous plexus.…”

“…A total of 13 angiosomes have been identified in the head and neck. 3,11,12 Leakage from these vessels seems to be a more likely source due to the lack of structural integrity of smaller vessels when compared with larger ones. Another possibility is that these hemorrhages occur in perivascular and interstitial areas in which there is a lack of connective tissue that is well supported such as in the strap musculature's endomysium and perimysium.…”

“…2 One particular effect of livor mortis that presents a challenge is postmortem hypostatic hemorrhage; they are thought to be the result of the combined effects of livor mortis and vascular autolysis. 3 When discovered on autopsy, it may be challenging to distinguish postmortem hypostatic hemorrhages from true hemorrhages that may be secondary to medical interventions, trauma, or improper autopsy techniques.…”

“…These skills are used when evaluating the effects of livor mortis, also commonly referred to as lividity or hypostasis, which refers to the gravitational pooling and accumulation of blood in certain body parts 2 . One particular effect of livor mortis that presents a challenge is postmortem hypostatic hemorrhage; they are thought to be the result of the combined effects of livor mortis and vascular autolysis 3 . When discovered on autopsy, it may be challenging to distinguish postmortem hypostatic hemorrhages from true hemorrhages that may be secondary to medical interventions, trauma, or improper autopsy techniques.…”

Effects of postmortem positional changes on conjunctival petechiae

“…In contrast, the amount of petechiae obviously changed in bodies that had been discovered in the supine position <1.5 days, compared with >1.5 days postmortem (<12, 12–24 > 24–36 h: 38.5%, 21.4% and 17.2%, respectively). The assumed explanation for this finding is similar to the spread of postmortem lividity [ 10 ], in which the movement of blood in vessels becomes difficult due to gravity, and hemoglobin leaks through blood vessels along with liquid components due to hemolysis [ 11 , 12 ].…”