Distinguishing antemortem from postmortem thermal injury remains one of the most challenging tasks in forensic pathology, particularly in cases involving rapid death, extensive charring, or advanced tissue degradation. Classical macroscopic and histological findings provide essential information but often lack sensitivity or specificity when considered in isolation. This review critically examines current evidence on burn vitality markers, with a primary focus on histological and immunohistochemical findings supported by human forensic studies, while contextualizing molecular and microRNA-based (miRNA-based) approaches as largely experimental and translational. Established indicators in forensic casework include erythrodiapedesis, fibrin deposition, inflammatory cell infiltration, and glycophorin-confirmed hemorrhage, together with selected immunohistochemical markers such as HSP70 (Heat Shock Protein 70) and aquaporin-3 (AQP3), which provide supportive evidence of tissue viability. In contrast, molecular biomarkers, such as cytokine gene expression, oxidative stress products, mitochondrial DNA (mtDNA) release, and miRNA signatures, offer mechanistic insight into early cellular responses to thermal injury but currently lack sufficient forensic validation in human autopsy-based studies to support routine medico-legal interpretation. The available evidence indicates that histological and selected immunohistochemical findings constitute the most reliable basis for burn vitality assessment, whereas molecular approaches should be interpreted cautiously as adjunctive and investigational. Diagnostic conclusions therefore rely on the integration of multiple independent findings, evaluated in relation to survival time, tissue preservation, and postmortem artifacts. Overall, this review emphasizes that burn vitality determination requires a cautious, multimodal, and context-driven approach, grounded in validated forensic evidence and supported, where appropriate, by complementary experimental data. Further progress in this field will depend on the systematic validation of emerging markers in human forensic autopsy cohorts.

This review proposes an integrative mechanistic model that brings together apoptosis, pyroptosis, ferroptosis, necroptosis, and necrosis within the broader context of heat-induced proteostasis disruption. Rather than depicting a strictly sequential or fully validated causal pathway, the model provides a conceptual framework through which interactions among cellular stress responses, endothelial dysfunction, heatstroke-induced coagulopathy (HIC), and multiple organ dysfunction syndrome (MODS) may be understood. Under extreme heat stress, widespread protein unfolding and chaperone saturation activate the unfolded protein response, disrupt endoplasmic (ER) calcium homeostasis, and couple through Ca²⁺-mediated injury to mitochondrial dysfunction and oxidative stress. These processes are reciprocally amplifying: reactive oxygen species (ROS) from failing mitochondria deepen proteostatic damage and potentiate necroptotic and ferroptotic signaling, while inflammation-driven immune activation further increases ROS production, closing a self-reinforcing cycle. The resulting engagement of multiple RCD pathways, apoptosis, pyroptosis, ferroptosis, and necroptosis, each with qualitatively distinct DAMP signatures, promotes inflammasome activation and a cytokine storm that destabilizes the endothelial glycocalyx, impairs barrier integrity, and triggers a pro-coagulant shift underlying HIC. We further examine biomarker candidates reflecting these mechanisms, evaluate emerging therapeutic strategies, ranging from HSP modulation and antioxidant therapy to endothelial-protective agents, mitophagy regulators, and nanomedicine, and outline the future role of multi-omics, machine learning, and regenerative approaches. By bringing together molecular, cellular, vascular, and systemic processes into a single cohesive model, this review proposes a conceptual foundation to guide diagnostic refinement, therapeutic innovation, and forensic interpretation in severe heat-related injury.