Indicators of strangulation in medico-legal assessments: A scoping review

Abstract

This scoping review aims to synthesize the existing knowledge on third-party strangulation, both fatal and non-fatal, with an emphasis on identifying key physical and symptomatic indicators, their prevalence, and the critical point and circumstances surrounding such incidents. A total of 19 articles addressing homicidal fatal strangulation and 34 articles addressing non-fatal strangulation were retrieved. The majority of the strangulation victims studied were below 40 years of age, with a predominance of women. The findings from the reviewed studies highlight the complex and multifaceted nature of strangulation, both in consensual and non-consensual contexts. Strangulation events range from no injury to severe injuries and death. Objective findings are common but not universal, with their detection influenced by study design, victim selection, and the time between the assault and examination. Fatal cases without external injuries (up to 16 %) highlight the need for caution in assessing severity in nonfatal cases of alleged strangulation based solely on visible external signs. Most studies of non-fatal strangulation focus on victims of intimate partner violence or sexual assault and highlight that strangulation is a common feature of such violence. Emerging evidence suggests that repeated strangulation events has potential effects on brain function, though further research is needed. The exact critical threshold where strangulation becomes life-threatening is not possible to define and calls for a consensus approach in medico-legal assessments. These findings underline the importance of detailed medical records capturing subjective findings, along with high-quality photographic or radiographic documentation, combined with detailed police reports outlining the sequence of events, for medico-legal implications of such cases.