Deaths in a head-down position: a case report and review of the literature

Deaths in a head-down position, mostly accidental events, are rare deaths in which a victim is found in an inverted body posture, with marked congestion of dependent body parts and no definite pathoanatomical cause of death. Such an exclusion diagnosis can only be put forward after elimination of other possible causes of death, following a scene investigation, medical record review, complete autopsy, and toxicological analysis. Particular attention should be taken not to confuse deaths by head-down position from the more usual positional asphyxia. We here report the case of an 82-year-old woman found stuck in the railings of the staircase leading to her house, her body freely suspended downward below the stairs. Death was finally attributed to a head-down position when correlating the autopsy findings with elements from the scene. Case reports of death by head-down position in the literature are reviewed. Furthermore, results from human experimental studies of head-down tilt are compiled. This systematic review allows an interesting insight into the physiopathology of those deaths, pointing more toward heart failure than to an asphyxial phenomenon per se.