Complex suicide by drowning and stabbing: first italian case reported in literature.

Background: "Complex suicide" refers to suicides in which more than one suicide method is applied. The victim can either plan different and simultaneous ways of death, to prevent any failures, or change the method because the first one fails or turns out to be too painful. Case report: A Middle-age-man was found dead inside a car, in a field, near the seaside. Clothes were intact, wet, and smeared with mud and gravel. His shirt had dried whitish biological material on the thoracic area, referable to oedema fluid, his trousers were down to his ankles exposing external genitalia. Inside the car, a kitchen-serrated blade knife and scissors were found, both smeared with dried blood material. Cadaveric inspection showed: multiple superficial stab/cut injuries; nasal cavities leaking aqueous-like fluid; triangular and linear stab lesions all over the body; hesitation marks on both latero-cervical regions and both wrists; no defensive injuries referrable to third parties; maceration over both palmar and plantar surfaces. Autopsy showed: hemorrhagic infiltration for thoracic muscles; expanded and heavily congested lungs. Conclusions: This is the first Italian case, and one of the few cases reported in major literature (third case worldwide), of unplanned complex suicide achieved through stabbing and drowning by a man with no psychiatric or substances abuse history. Therefore, analyzing any evidence to distinguish this kind of sudden/unnatural death from accidental or homicidal ones is mandatory. Such cases require a flawless approach to judicial inspection, autopsy, and toxicological exams. Moreover, a multidisciplinary perspective including psychiatric criminological investigation is needed.

An unusual case of homicide-suicide: overkilling by stabbing and suicide by hanging.

Background: This case presents a detailed forensic examination of a unique femicide case followed by the perpetrator's suicide. Case report: On a Sunday afternoon, a 52 year old man killed his 43 year old partner in their home with eleven stab wounds. A few minutes later, he committed suicide by suspending himself to a tree in their home garden by means of a rope. This unique case is interesting because of the combination of methods used for both homicide and suicide, as well as the relationship dynamics between the victim and perpetrator. The perpetrator committed homicide by stabbing and then hanged himself. Conclusion: The case adds valuable knowledge to Forensic Medicine, advocating for increased awareness and preventive measures against domestic and gender-based violence. This report provides an in-depth analysis of a homicide-suicide incident, focusing on a unique case of homicide-suicide. It serves to highlight the global crisis of femicide. The case is situated within the context of gender- based violence, illustrating how such acts are deeply rooted in societal norms. It highlights patterns of intimate partner violence, where emotional factors play a significant role. Forensic analysis uncovered the overkill nature of the homicide, indicating excessive injuries beyond what was necessary for death, reflecting the psychological turmoil of the perpetrator. It emphasizes the importance of identifying signs of potential violence in domestic settings and implementing interventions for mental health support and the prevention of genderbased violence.

[Vertebral artery dissection during traumatic injury of the cervical spine, two case reports]. / Nyaki gerinc traumás sérülése során jelentkezo arteria vertebralis dissectio, két esetbemutatás.

If severe cervical spinal cord injury or severe cervical vertebral fracture, subluxation or luxation is confirmed, 20-40% of the cases have vertebral artery dissection or occlusion. These can be asymptomatic, but can cause additional neurological damage in addition to cervical myelon and cervical nerve root symptoms. Vertebral artery dissection can be caused by direct injuries, stab wounds or gunshot wounds. Indirect vertebral artery dissection can occur at the same time as subluxation, luxation, or complex fractures of the cervical vertebra. CTA is the examination procedure of choice. In many cases, digital subtaction angiography examination and, if necessary, neurointerventional treatment must precede open neurosurgery. In our report, in the first patient, complete luxation of the C.VI vertebra caused unilateral vertebral artery 2-segment dissection-occlusion, while in our second patient, a stab injury caused direct vertebral artery compression and dissection. The occlusion of the vertebral artery did not cause neurological symptoms in any of the cases. In both of our cases, parent vessel occlusion was performed at the level of the vertebral artery injury before the neurosurgical operation.

Hidden Inferior Vena Cava Injury: A Case of Missed Diagnosis after Preoperative CT and Laparotomy.

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

Homicidal or suicidal death? Evidence-based approach to assessing cause of death in a peculiar forensic case.

Background: In recent years, the improvement of common standards of forensic practice has received attention to promote an unambiguous and better-quality forensic investigation method. Although most hanging deaths are attributed to suicides, cases occasionally occur due to accidents or homicides. From an investigative point of view, hanging deaths are usually straightforward, but unusual circumstances may raise suspicions of crime. This includes complex suicides, which are rare events pursued by victims with two or more different fatal methods and can be classified as planned or unplanned, depends on whether the methods are applied simultaneously or sequentially. The multiplicity of injuries detected can often lead to misinterpretations, thus making a multidisciplinary approach extremely important. Case Report: A 44-year-old man, after requesting law enforcement, has been instead found inside a garden of an uninhabited property located a few kilometers away from his own property, suspended from a beam with wire; the wire created a noose at the back of his head, his hands were placed at his neck, and stab wounds were found. Conclusions: The crime scene investigation, interview of relatives, autopsy, histological and toxicological examinations, and GAP led to the determination that the death was suicide. This comprehensive approach emphasizes the importance of meticulous investigation and analysis to reach accurate conclusions in forensic cases.

Lethal injuries in single stabs to the trunk - A study on homicides and suicides in Sweden.

INTRODUCTION: Homicides using knives or other sharp objects are the most common type of homicide in Europe, and the second most common type of homicide worldwide. In contrast, suicides using sharp objects are rarer, constituting only a few per cent of all suicides in western countries. We investigated single stab injuries to the trunk in both homicides and suicides to assess differences in extent of injuries and in medical care, which could be of value for trauma management, public health and forensic assessment. METHODS: We identified all cases in Sweden between 2010 and 2021 that died of a single stab to the trunk, in either a homicide (n = 94) or a suicide (n = 45), and that were the subject of a forensic autopsy. We obtained data on demographics, hospital care and injured structures. To assess the severity of injuries, we applied AIS (Abbreviated Injury Score) and NISS (New Injury Severity Score). The inter-rater reliability of NISS between two raters was evaluated with intra-class correlation (ICC), with 95 % confidence intervals (CI). The data was analysed using Fisher's exact test, Mann-Whitney U test and logistic regression models. RESULTS: The inter-rater reliability between the two NISS raters showed an ICC of 0.87 (95 % CI 0.68-0.95). We observed a larger variation of injuries in suicides, with a higher proportion of both unsurvivable (NISS 75) and minor injuries (NISS ≤ 8) (66.7 % and 8.9 % respectively) compared to in homicides (46.8 % and 0 % respectively). We observed a larger proportion of injuries to the heart in suicides (68.9% vs. 46.8 %, p = 0.018). In homicides, injuries involving vessels (52.1% vs. 13.3 %, p < 0.001) and hospital care (56.4 % vs. 8.9 %, p < 0.001) were significantly more common compared to suicides. DISCUSSION AND CONCLUSION: Causation (self-inflicted or assaults) seems to be associated with characteristics of injury and the likelihood of receiving hospital care. These findings could potentially be valuable for trauma management and forensic assessment of manner of death, however, determining the mortality of the injuries would require a comparison group comprising injured survivors.

Atypical suicide by single incising cut to the throat without hesitation marks: Case report and review of the literature.

Several studies have been performed to recognize the main features in homicide and suicide sharp wound-related death, revealing that a single cutting wound to the neck is an infrequent event in suicide cases, and several hesitation marks near the fatal injury are usually present. We report a case of an atypical self-inflicted cutthroat injury without tentative marks involving a 79-year-old female. The weapon used, a kitchen knife, was found at the crime scene. The wound had clean margins, and no other incisions were found. Scene circumstances, namely the absence of signs of a break-in, the victim found on the bed, the knife located near the body, the vital wound in an accessible site, and the absence of defense injuries, collectively support a likely suicide. A literature review was also performed to compare forensic data of the case presented with the other 6 cases reported regarding atypical suicide characterized by a single incising cut to the throat without hesitation marks. Given the few cases reported and the lack of gross descriptions and histopathological data available in the literature, additional knowledge of such a case may help forensic pathologists in the identification of suicidal events when a single neck injury is observed. In this frame, suicide by a unique single incising cut to the throat without hesitation marks near the lethal injury may be observed as an atypical presentation, and the crime scene investigation, together with additional background information of the deceased, aid in the identification of the manner of the death.

Intracranial graft of bioresorbable polymer scaffolds loaded with human Dental Pulp Stem Cells in stab wound murine injury model.

The prevalence of central nervous system (CNS) dysfunction as a result of disease or trauma remains a clinically unsolved problem which is raising increased awareness in our aging society. Human Dental Pulp Stem Cells (hDPSCs) are excellent candidates to be used in tissue engineering and regenerative therapies of the CNS due to their neural differentiation ability and lack of tumorigenicity. Accordingly, they have been successfully used in animal models of spinal cord injury, stroke and peripheral neuropathies. The ideal therapy in brain injury should combine strategies aiming to protect the damaged lesion and, at the same time, accelerate brain tissue regeneration, thus promoting fast recovery while minimizing side or long-term effects. The use of bioresorbable nanopatterned poly(lactide-co-ɛ-caprolactone) (PLCL) polymeric scaffolds as hDPCSs carriers can represent an advantage for tissue regeneration. In this chapter, we describe the surgical procedures to implant functionalized bioresorbable scaffolds loaded with hDPSCs to improve the brain lesion microenvironment in an intracranial stab wound injury model severing the rostral migratory stream (RMS) that connects the brain subventricular zone (SVZ) and the olfactory bulb in nude mice. Additionally, we also describe the technical steps after animal sacrifice for histological tissue observation and characterization.

Self-inflicted very-low-velocity penetrating head injury: A CARE-compliant case report.

RATIONALE: Low-velocity penetrating head injury (PHI) is rare, comprising 0.2% to 0.4% of head traumas, but can be devastating and is associated with significant morbidity and mortality. No previous case of very-low-velocity PHI due to self-inflicted stabbing with a gimlet has been reported. PATIENT CONCERNS: A 62-year-old man was admitted to the hospital with bleeding head and abdominal wounds after stabbing his abdomen with a gimlet, and then hammering the same gimlet into his forehead and removing the gimlet himself. DIAGNOSES: Upon examination at admission, stab wounds were present on the forehead and the right upper quadrant. Computed tomography (CT) of the head revealed a bone defect in the left frontal bone and showed the intracranial path of the gimlet surrounded by mild hemorrhage and pneumocephalus. Magnetic resonance imaging (MRI) confirmed a small amount of hemorrhage with pneumocephalus but no vascular injury. INTERVENTIONS: Conservative treatment without surgery. OUTCOMES: Follow-up MRI on hospital day 58 showed no abscess or traumatic intracranial aneurysm. The patient achieved full recovery of motor and mental functions with conservative treatment and was discharged on hospital day 69. LESSONS: Very-low-velocity PHI might be successfully treated with conservative treatment.

Needle Decompression Complicated by Cardiac Injury in a Prehospital Environment.

Needle decompression is a mainstay intervention for tension pneumothorax in trauma medicine. It is used in combat and prehospital medicine when definitive measures are often not available or ideal. It can temporarily relieve increased intrathoracic pressure and treat a collapsed lung or great vessel obstruction. However, when done incorrectly, it can result in underlying visceral organ and vessel trauma. This is a case of an adult male who presented to the emergency department after sustaining multiple stab wounds during an altercation. On arrival, the patient had a 14-gauge angiocatheter inserted at the 4th intercostal space (ICS), left of the parasternal line traversing the right ventricle and interventricular septum and terminating in the left ventricle. The case emphasizes the importance of understanding the landmarks of performing needle decompression in increasing the procedure's efficacy and reducing iatrogenic complications.

Spatial relationships among offender, knife, and victim during slashing attacks: implications for crime scene reconstruction.

BACKGROUND: The offender-victim spatial relationship is crucial in reconstructing a crime scene. The study aims to evaluate the spatial relationship of performing slashing attacks on a dummy using a Chinese kitchen knife, and thus to establish a scientific basis for crime scene reconstruction. METHODS: Twenty-four participants (12 males and 12 females) slashed a dummy's neck or chest using a kitchen knife, and the kinematic data were obtained using a three-dimensional motion capture system. The spatial relationships among offender, knife, and victim during slashing attacks were analyzed. RESULTS: Slashing distance and occupancy area are significantly influenced by gender (all P < 0.05), with males having higher values than females. Body parts significantly influence bevel angle, offender and victim azimuth angles, slashing distance, relative slashing distance, and occupancy area (all P < 0.01), with slashing the chest resulting in larger values than slashing the neck. CONCLUSION: Gender and body position significantly influence the spatial relationships of slashing action. Our data indicate that males stand farther away and occupy a larger area during slashing attacks. When the chest is slashed, the wound orientation is more diagonal, the offender's standing position and slashing distance are farther, and the occupancy area is larger compared to the neck. The findings could help identify the spatial relationships among offender, knife, and victim, providing a scientific basis for criminal investigations and court trials.

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds.

INTRODUCTION: This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso. METHODS: Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020. RESULTS: A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study. CONCLUSIONS: Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

[Air Embolism of the Left Ventricle due to Pulmonary Stab Wound].

A man in his 50s was stabbed deeply in the back with a knife and brought to the emergency room. He was found to have a significant left hemopneumothorax. He was planned to undergo hemostatic surgery under general anesthesia. However, shortly after the change in a right lateral decubitus position, he experienced ventricular fibrillation. Hemostasis of the intercostal artery injury, the source of bleeding, and suture of the injured visceral pleura were performed under extracorporeal membrance oxgenation( ECMO). Although sinus rhythm was resumed, when positive pressure ventilation was applied to the left lung for an air leak test, ST elevation on the electrocardiogram and loss of arterial pressure occurred. A transesophageal echo revealed air accumulation in the left ventricle. It was determined that air had entered the damaged pulmonary vein from the injured bronchi due to the stab wound, leading to left ventricular puncture decompression and lower left lower lobectomy. Subsequently, his circulatory status stabilized, and ECMO was weaned off. He recovered without postoperative neurological deficits postoperatively. The mortality rate for chest trauma with systemic air embolism is very high. In cases of deep lung stab wounds, there is a possibility of systemic air embolism, so treatment should consider control of airway and vascular disruption during surgery.

The role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune inflammation index in predicting the necessity for surgery and therapeutic surgery in patients with anterior abdominal stab wounds.

BACKGROUND: In this diagnostic accuracy study, we examined the effectiveness of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune inflammation index (SII) in predicting the need for surgical intervention in patients with anterior abdominal stab wounds (AASW) who exhibit unclear findings on physical examination yet remain hemodynamically stable. METHODS: Over a 7-year period, patients with AASW were retrospectively analyzed. Patients were divided into two groups as surgical (SG) and nonsurgical group (nSG). The SG were also divided into two groups as therapeutic surgery (TS) group and the non-therapeutic surgery (nTS) group. The groups were compared in terms of NLR, PLR values and SII scores. RESULTS: In a retrospective analysis of 199 patients with AASW, NLR, PLR and SII obtained during clinical follow-up of patients with AASW in whom the necessity for immediate surgery was unclear significantly predicted therapeutic surgery (p < 0.001 for all). These parameters did not show a significant difference in predicting the need for surgery at the admission. NLR showed an AUC of 0.971 and performed significantly better than PLR and SII (AUC = 0.874 and 0.902, respectively) in predicting TS. The optimal cut-off value for NLR was 3.33, with a sensitivity of 98.2%, a specificity of 90%, and a negative likelihood ratio of 0.02. Time from admission to surgery was significantly shorter in the TS group (p = 0.001). CONCLUSION: NLR, PLR and SII values may be useful in predicting therapeutic surgery during clinical follow-up in AASW patients with unclear physical examination findings and in whom immediate surgical decisions cannot be made.

Shared inflammatory glial cell signature after stab wound injury, revealed by spatial, temporal, and cell-type-specific profiling of the murine cerebral cortex.

Traumatic brain injury leads to a highly orchestrated immune- and glial cell response partially responsible for long-lasting disability and the development of secondary neurodegenerative diseases. A holistic understanding of the mechanisms controlling the responses of specific cell types and their crosstalk is required to develop an efficient strategy for better regeneration. Here, we combine spatial and single-cell transcriptomics to chart the transcriptomic signature of the injured male murine cerebral cortex, and identify specific states of different glial cells contributing to this signature. Interestingly, distinct glial cells share a large fraction of injury-regulated genes, including inflammatory programs downstream of the innate immune-associated pathways Cxcr3 and Tlr1/2. Systemic manipulation of these pathways decreases the reactivity state of glial cells associated with poor regeneration. The functional relevance of the discovered shared signature of glial cells highlights the importance of our resource enabling comprehensive analysis of early events after brain injury.