Under-reporting of forensic findings: craniocervical emergency imaging in cases of survived hanging

Near-Hanging Injuries: Perspective for the Trauma and Emergency Surgeon

Introduction: Near-hanging injuries are a significant cause of morbidity and mortality worldwide. These injuries result in complex clinical presentations due to the combination of mechanical asphyxia and potential neck and cervical spine trauma. The primary objectives of this narrative review include assessing the incidence, sex distribution, pathophysiology, prognostic indicators, neurologic outcomes, and treatment strategies.Methods: Review performed using Medline in English from 1946 to 2023. Excluded: articles of accidental, sex-related, auto-asphyxiation, cancer-related, and pediatric near-hanging, review articles, and case reports.Results: 53 articles were first reviewed; 30 articles encompassing 4712 patients had complete demographic and neck injuries data. Sixteen articles reported the presence and absence of ligature markings in 1778 patients. Ligature markings were present in 1103 (73.5%). Median Age: 33 (29-38) 75.7% male distribution. Suicide attempt: 97.3%. Neck vascular injuries, aerodigestive, and neck bony injuries occurred in 83 (1.8%), 123 (2.6%), and 125 (2.7%), respectively. Cardiac arrest: 1195 (25.3%) and GCS<9-2125 (45%) were the major contributors to the mortality: 26.9%. Glasgow Outcome Score>3 or by a Cerebral Performance Category score of 1-2 was documented in 35.2% of patients. Hyperbaric oxygen treatment, hypothermia treatment, and targeted temperature management did not appear to be useful from the standpoint of survival in patients who suffered a cardiac arrest.Conclusions: Near-hanging as an attempt to suicide is more frequent in young male patients. The incidence of associated neck injuries is low; mortality is likely to occur in patients with cardiac arrest with an associated neurologic injury. There is insufficient evidence to support the use of hyperbaric oxygen treatment, hypothermia treatment, and targeted temperature management in patients who have suffered a cardiac arrest and severe neurologic injury after near-hanging.

[Strangulation]

CLINICAL PROBLEM

Detection of manual strangulation, choking and hanging, as well as the intensity of these actions, helps to clarify the course of events, to enforce the state's right to prosecute and ultimately to protect against further attacks. However, this is complicated by the scarcity of externally visible findings.

STANDARD PROCEDURE TO DATE

The forensic examination of the head and neck after strangulation is carried out by means of external inspection to detect injuries and congestion above the strangulation level. Lesions below the surface of the skin, in particular of the subcutaneous fat tissue, the muscles or the laryngeal structures, usually escape the external inspection.

FORENSIC RADIOLOGY AS AN IMPORTANT COMPONENT

Imaging techniques allow internal injuries to be recorded and objectified, which can be of considerable added value in the collection of evidence. Since criminal proceedings must meet the highest standards of security, high demands are placed on imaging and diagnosis.

ASSESSMENT

Imaging techniques are suitable for detecting and objectifying internal injuries after a person has survived strangulation. However, their excellent reconstruction and visualization capabilities also make them a valuable addition to postmortem examinations.

RECOMMENDATIONS FOR PRACTICE

After reported and survived strangulation, choking or hanging, magnetic resonance imaging (MRI) of the soft tissues of the neck should be performed as soon as possible, and if cerebral damage is suspected, the skull should also be examined. If the event was not survived, whole-body computed tomography (CT) is now standard practice at many forensic medicine institutes.

Longitudinal visibility of MRI findings in living victims of strangulation

Initial experiences with magnetic resonance imaging (MRI) of living strangulation victims demonstrated additional findings of internal injuries compared to the standard clinical forensic examination. However, existing studies on the use of MRI for this purpose mostly focused on the first 48 h after the incident. The aims of this study were (a) to evaluate the longitudinal visibility of MRI findings after violence against the neck by performing two MRI examinations within 12 days and a minimum of four days between both MRI scans and (b) to assess which MRI sequences were most helpful for the detection of injuries. Twenty strangulation victims participated in this study and underwent one (n = 8) or two (n = 12) MRI scans. The first MRI examination was conducted during the first five days, the second five to 12 days after the incident. Two blinded radiologists assessed the MRI data and looked for lesions in the structures of the neck. In total, 140 findings were reported in the 32 MRI examinations. Most of the findings were detected in the thyroid and the muscles of the neck. T2-weighted SPACE with fat suppression, T1-weighted TSE and T1-weighted MPRAGE were rated as the most helpful MRI sequences. Subjects who showed findings in the initial scan also demonstrated comparable results in the second scan, which was performed on average 8.4 days after the incident. Our results show that even up to 12 days after the incident, the criminal proceeding of strangulation cases may greatly profit from the information provided by an MRI examination of the neck in addition to the standard clinical forensic examination.