The ESRB has only ever given 2 games the AO rating solely for violence. One being a distasteful mass shooting simulator (Hatred), the other being an unreleased fighting game focusing on Fatalitites during the ESRB's infancy 20+ years ago (Thrill Kill).
So would I be safe in assuming that I can cram as many red pixels as I can into a 48x48 grid, so long as the violence isn't sexual in nature, and so long as it is not an attempt to inspire controversy?
I only ask because I'm a graphics artist and the idea of trying to gross people out in a pixelated horror game sounds like a fun challenge.
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Hey there and thanks for asking! When looking at Rule #14's mention of extreme violence, I would draw comparisons better with movies. You'd want to steer clear of graphical stuff like in the Saw/Hostel franchise, while completely over-the-top violence (like in Peter Jackson's Braindead/Dead Alive) maybe given more leeway.
Ultimately, though, you need to remember Rule #19. The judges have sole discretion to disqualify based on their interpretation of the rules. Therefore, if any of the four judges decide that your game breaks the extreme violence rule, then your will be disqualified. You wont be able to argue the semantics of Rule #14, even with what I've told you in the paragraph above.
In short: I recommend you steer clear of your gross-out idea, but if you feel that you can do it without crossing the line, go for it!