Autopsy Findings in Pressure over Neck Deaths: A Cross-Sectional Autopsy Study from Western India

Abstract Background In some violent asphyxial deaths, fatal ligature-related neck compression is established at autopsy, but the available findings do not permit confident classification as hanging or ligature strangulation. Pressure over Neck (PoN) may be used as a cautious pathological description in such cases. Objectives To document demographic, scene, external and internal neck findings in deaths classified as PoN and compare them with confirmed hanging and non-hanging neck-compression deaths. Methods A cross-sectional observational autopsy study was conducted at a tertiary care government medical college hospital in Western India, from January 2023 to March 2024. Of 2,405 consecutive medicolegal autopsies, 203 (8.4%) were violent asphyxial deaths. Twenty-three deaths were classified as PoN because fatal ligature-related neck compression was established but the available findings did not permit confident classification as hanging or ligature strangulation. Hanging (n = 147), ligature strangulation (n = 15) and throttling (n = 8) served as comparators. All cases underwent standardized external examination and layered internal neck dissection using the Prinsloo–Gordon bloodless technique. Fisher's exact test was used for selected categorical comparisons. Results PoN accounted for 11.3% of violent asphyxial deaths. Males represented 52.2% of PoN cases versus 95.2% in hanging. Open or non-residential scenes occurred in 56.5% of PoN cases versus 10.9% of hanging and none of the non-hanging neck-compression cases. No ligature was present in situ in PoN. A ligature mark was present in 91.3%; direction was oblique in 60.9% and transverse in 39.1%. The mark was at the laryngeal prominence in 78.3%. Peri-ligature abrasions/ecchymoses occurred in 47.8%. Subcutaneous bruising/haemorrhage was present in 30.4%. Hyoid, thyroid and cricoid fractures were absent in all PoN cases. Laryngo-tracheal congestion was present in all PoN cases. Conclusions PoN should be understood as a cautious pathological description rather than a newly defined biological mechanism. It permits documentation of established fatal ligature-related neck compression without forcing the findings into hanging or strangulation when the evidence does not support such a specific classification. Manner of death remains a separate determination based on integrated autopsy, scene and investigative evidence.