Abstract
To summarize the published forensic pathology evidence base in deaths concluded to be the result of suicidal ligature strangulation, an uncommon entity. Four electronic bibliographic databases Medline Ovid, Embase, Scopus, HEINonline were screened for relevant literature. No date restrictions were applied. All English language case reports or case series were included. Articles were evaluated and key data extracted according to predefined criteria. A total of 1554 references eventually yielded 24 papers with 31 eligible case reports. The location of the deaths and background circumstances and history mirror broadly those of suicide generally. The range of ligature types was diverse. 19/31 cases reported one or more knots present. In the remaining 12 cases, the ligatures did not lend themselves to knots. In only one case were laryngeal fractures reported, but the available material does not justify confidence in that report given the significance of the finding. This systematic review has identified and synthesized the evidence from 31 case reports of suicidal ligature strangulation. A forensic pathologist faced with a possible case can locate it within the spectrum of reported cases and therefore identify its common and distinguishing features. Inherent difficulties for research in forensic pathology mean that case reports are an important source of learning and evidence for the discipline. Opportunities for improvement exist especially in harmonizing terminology and standardizing techniques generally, and in reports of suicidal ligature strangulation in particular.
Similar content being viewed by others
References
Casper JL. A handbook of the practice of forensic medicine : based upon personal experience: Vol II. Translated from the third edition of the original by George William Balfour. London: New Sydenham Society; 1862. pp. 219–20.
Maxeiner H, Bockholdt B. Homicidal and suicidal ligature strangulation-a comparison of the post-mortem findings. Forensic Sci Int. 2003;137:60–6.
El-Nageh MM, Cordner S, Linehan B, Wells D, McKelvie H. Ethical practice in laboratory medicine and forensic pathology. WHO Regional Publications. Eastern Mediterranean Series. WHO Regional Office for the Eastern Mediterranean. 1999. pp. 37–8.
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:1006–12.
Massaro L. Unusual suicide in Italy: criminological and medico-legal observations-a proposed definition of "atypical suicide" suitable for international application. J Forensic Sci. 2015;60:790–800.
Madea B, Schmidt P, Kernbach-Wighton G, Doberentz E. Strangulation-suicide at the wheel. Leg Med (Tokyo). 2015;17:512–6.
Zhao D, Ishikawa T, Quan L, Li DR, Michiue T, Maeda H. Suicidal vehicle-assisted ligature strangulation resulting in complete decapitation: an autopsy report and a review of the literature. Leg Med (Tokyo). 2008;10:310–5.
Barranco R, Caputo F, Bonsignore A, Fraternali Orcioni G, Ventura F. A rare vehicle-assisted ligature hanging: suicide at the wheel. Am J Forensic Med Pathol. 2018;39:69–72.
Abuhasna SD, Ebaid MA, Qadoom EDM, Rahman MU. Accidental asphyxiation by an Arabic headscarf. Anaesth Pain Int Care. 2013;17:91–3.
Das S, Patra AP, Shaha KK, Sukumar S, Chaudhari VA, Rahman NA. Occupational death due to bilateral carotid artery occlusion - a medico-legal case report. J Forensic Legal Med. 2015;32:30–3.
Asamura H, Ito M, Fukushima H. An unusual suicide case of the combination of asphyxia. Am J Forensic Med Pathol. 2009;30:215–6.
D'Ovidio C, Rosato E, Carnevale A. An unusual case of murder-suicide: the importance of studying knots. J Forensic Legal Med. 2017;45:17–20.
Nor FM, Das S. Planned complex suicide: self-strangulation and fall from height. J Forensic Legal Med. 2011;18:336–9.
Palmiere C, Risso E, van Hecke O, La Harpe R. Unplanned complex suicide by self-strangulation associated with multiple sharp force injuries: a case report. Med Sci Law. 2007;47:269–73.
Turillazzi E, D'Errico S, Neri M, Fineschi V. An unusual mechanical asphyxia in a homicide-suicide case by smothering and strangulation. Am J Forensic Med Pathol. 2006;27:166–8.
Claydon SM. Suicidal strangulation by ligature: three case reports. Med Sci Law. 1990;30:221–4.
Kennedy NM, Whittington RM, White AC. Suicide by self-strangulation whilst under observation. Med Sci Law. 1995;35:174–7.
Lambe A, Püschel K, Anders S. Extensive petechiae in attempted self-strangulation. J Forensic Sci. 2009;54:212–5.
Albuhairan F, Almutairi A, Al Eissa M, Naeem M, Almuneef M. Non-suicidal self-strangulation among adolescents in Saudi Arabia: case series of the choking game. J Forensic Legal Med. 2015;30:43–5.
Re L, Birkhoff JM, Sozzi M, Andrello L, Osculati AMM. The choking game: a deadly game. Analysis of two cases of "self-strangulation" in young boys and review of the literature. J Forensic Legal Med. 2015;30:29–33.
Sorokin V, Persechino F, de Roux SJ, Greenberg MJ. Suicidal ligature strangulation utilizing cable ties: a report of three cases. Forensic Sci Med Pathol. 2012;8:52–5.
Swain R, Bakshi MS, Dhaka S, Singh KK, Sikary AK. Self-strangulation turning into partial hanging for a suicide victim. J Forensic Sci. 2018;63:1309–11.
Duband S, Timoshenko AP, Morrison AL, Prades JM, Debout M, Peoc'h M. Ear bleeding: a sign not to be underestimated in cases of strangulation. Am J Forensic Med Pathol. 2009;30:175–6.
Scott KWM. A case of homicide followed by suicidal strangulation. Med Sci Law. 1992;32:47–50.
Elfawal MA. An unusual case of suicidal asphyxia. Forensic Sci Int. 1994;64:181–4.
Strack GB, McClane GE, Hawley D. A review of 300 attempted strangulation cases. Part I: criminal legal issues. J Emerg Med. 2001;21:303–9.
Lorin dela Grandmaison G, Fermanian C, Durigon M. Analysis of discrepancies between external body examination and forensic autopsy. Am J Forensic Med Pathol. 2008:40–2.
Polson C. Strangulation; manslaughter or murder. Med Leg J. 1957;25:101–8 discussion 8-10.
Sakelliadis EI, Vlachodimitropoulos DG, Goutas ND, Panousi PI, Logiopoulou AP, Delicha EM, et al. Forensic investigation of suicide cases in major Greek correctional facilities. J Forensic Legal Med. 2013;20:953–8.
Ubelaker DH. Hyoid fracture and strangulation. J Forensic Sci. 1992;37:1216–22.
Arif M. Ligature mark on the neck; how elucidative? Prof Med J. 2015;22:798–803.
Bockholdt B, Maxeiner H. Hemorrhages of the tongue in the postmortem diagnostics of strangulation. Forensic Sci Int. 2002;126:214–20.
Bohnert M, Faller-Marquardt M, Lutz S, Amberg R, Weisser HJ, Pollak S. Transfer of biological traces in cases of hanging and ligature strangulation. Forensic Sci Int. 2001;116:107–15.
Arun M, Kumar RG, Kumar GN, Chandrakanth HV, Nagesh KR, Menezes RG. Accidental strangulation by a hot belt: an occupational medico-legal case report. Med Leg J. 2013;81:132–4.
Cartwright AJ. Degrees of violence and blood spattering associated with manual and ligature strangulation: a retrospective study. Med Sci Law. 1995;35:294–302.
Fieguth A, Albrecht UV, Bertolini J, Kleemann WJ. Intracartilaginous haemorrhagic lesions in strangulation? Int J Legal Med. 2003;117:10–3.
Green MA. Morbid anatomical findings in strangulation. Forensic Sci. 1973;2:317–23.
Hlavaty L, Sung LM. Strangulation and its role in multiple causes of death. Am J Forensic Med Pathol. 2017;38:283–8.
Kempter M, Ross S, Spendlove D, Flach PM, Preiss U, Thali MJ, et al. Post-mortem imaging of laryngohyoid fractures in strangulation incidents: first results. Leg Med (Tokyo). 2009;11:267–71.
Erzinclioglu Z. Forensic entomology. Clin Med (Lond). 2003;3:74–6.
Živković V, Nikolić S. Petechial haemorrhages as a consequence of very short-term strangulation during suicidal fall from a height: case reconstruction. Med Sci Law. 2018;58:62–6.
Sauvageau A, Yesovitch R. Choking on toilet paper: an unusual case of suicide and a review of the literature on suicide by smothering, strangulation, and choking. Am J Forensic Med Pathol. 2006;27:173–4.
Adjutantis G, Coutselinis A, Dritsas C. Suicidal strangulation. Forensic Sci. 1974;3:283–4.
Maiese A, Gitto L, dell'Aquila M, Bolino G. When the hidden features become evident: the usefulness of PMCT in a strangulation-related death. Legal Med. 2014;16:364–6.
Kanchan T, Raghavendra Babu YP, Atreya A, Acharya J. Ligature mark on the face - forensic implications. Med Leg J. 2016;84:138–41.
Samberkar PN. Motor vehicle-assisted ligature strangulation causing complete decapitation: an autopsy report. Am J Forensic Med Pathol. 2012;33:86–7.
Subirana-Domènech M, Prunés-Galera E, Galdo-Ouro M. An uncommon suicide method: self-strangulation by vehicle-assisted ligature. Egyptian J Forensic Sci. 2014;4:21–4.
Watanabe-Suzuki K, Suzuki O, Kosugi I, Seno H, Ishii A. A curious autopsy case of a car crash in which self-strangulation and lung collapse were found: a case report. Med Sci Law. 2002;42:261–4.
Atilgan M. A case of suicidal ligature strangulation by using a tourniquet method. Am J Forensic Med Pathol. 2010;31:85–6.
Badiadka KK, Kanchan T, D'Souza DH, Subhash K, Vasu S. An unusual case of self-strangulation by ligature. J Forensic Legal Med. 2012;19:434–6.
Demirci S, Dogan KH, Erkol Z, Gunaydin G. Suicide by ligature strangulation: three case reports. Am J Forensic Med Pathol. 2009;30:369–72.
Di Nunno N, Costantinides F, Conticchio G, Mangiatordi S, Vimercati L, Di Nunno C. Self-strangulation: an uncommon but not unprecedented suicide method. Am J Forensic Med Pathol. 2002;23:260–3.
Frazer M, Rosenberg S. A case of suicidal ligature strangulation. Am J Forensic Med Pathol. 1983;4:351–4.
Furukawa S, Sakaguchi I, Morita S, Nakagawa T, Takaya A, Wingenfeld L, et al. Suicidal ligature strangulation without an auxiliary mechanism. Reports of two cases with a cotton rope or a T-shirt and staining results of the brains using anti HSP-70, CIRBP, RBM3, HIF1-α, SIRT 1 and p53 antibodies. Rom J Leg Med. 2013;21:9–14.
Kogan Y, Bloom T. Suicidal ligature strangulation with an elastic band. Am J Forensic Med Pathol. 1990;11:329–30.
Kumar P, Ahmed N, Rayamane N. Suicidal ligature strangulation without a knot - a case report. SAJ Forensic Sci. 2014;1:5.
Langlois NE, Byard RW. Cable tie suicide. Forensic Sci Med Pathol. 2017;13:110–2.
Lin Z, Kondo T, Sato Y, Ohtsuji M, Takayasu T, Ohshima T. An autopsy case of suicidal strangulation with four looped rubber bands. Nihon Hoigaku Zasshi. 1997;51:231–4.
Lo Pinto S, Tacchella T, Fossati F, Bonsignore A, Ventura F. Self-strangulation through a sphygmomanometer: an uncommon suicide. J Forensic Sci. 2017;62:528–30.
Marella GL, De Dominicis E, Arcudi G, Potenza S, Mauriello S, Milano F, et al. An unusual case of suicidal double ligature strangulation. Med Leg J. 2018;86:150–2.
McMaster AR, Ward EW, Dykeman A, Warman MD. Suicidal ligature strangulation: case report and review of the literature. J Forensic Sci. 2001;46:386–8.
Patel F. Undetected ligature self-strangulation: disadvantage at the scene of a decomposed body. J Clin Forensic Med. 1997;4:41–3.
Polson CJ. Strangulation - accident, suicide or homicide. J Forensic Sci Soc. 1961;1:79–83.
Pramanik P. An unusual method of suicidal ligature strangulation. J Forensic Sci. 2016;61:274–6.
Pramod Kumar GN, Arun M, Manjunatha B, Balaraj BM, Verghese AJ. Suicidal strangulation by plastic lock tie. J Forensic Legal Med. 2013;20:60–2.
Rupp JC. Suicidal garroting and manual self strangulation. J Forensic Sci. 1970;15:71–7.
Turkmen N, Eren B, Uyaniker ZD, Ergonen AT. An uncommon suicide method: self-strangulation. Med Arch. 2012;66:423–4.
Tzimas I, Bajanowski T, Pollak S, Trubner K, Thierauf A. Suicidal ligature strangulation using gymnastics bands. Int J Legal Med. 2014;128:313–6.
Zecevic D. Suicidal strangulation with a double-knotted noose. J Forensic Sci. 1982;27:963–7.
Zorro AR. Suicidal strangulation by double ligature: a case report. Med Sci Law. 2014;54:110–2.
Ashley CW. The Ashley book of knots. Edited and updated by Geoffrey Budworth. London: Faber and Faber; 1993.
Jones AW. The drunkest drinking driver in Sweden: blood alcohol concentration 0.545% w/v. J Stud Alcohol. 1999;60:400–6.
Kugelberg FC, Jones AW. Interpreting results of ethanol analysis in postmortem specimens: a review of the literature. Forensic Sci Int. 2007;165:10–29.
Berg S, Kampmann H. Unusual cases of self-strangulation. Arch Kriminol. 1992;190:9–16.
Bondarev A, Pascari A, Pädure P. A rare case of suicide by ligature strangulation. Rechtsmed. 2016;26:383.
Bonte W. Self strangulation by triple knotting of the strangling instrument. Kriminalistik. 1974;28:412–4.
Borquez Vera P, Reyes D, Vásquez E, JVP. L. Atypical Self-Induced Strangulation. Medicina Legal de Costa Rica Edición Virtual. 2018;35.
Dirnhofer R. Self strangulation? Arch Kriminol. 1976;158:80–6.
Doberentz E, Hagemeier L, Madea B. Cable tie used for suicidal ligature strangulation - a case report. Arch Kriminol. 2009;224:17–25.
Koops E, Brinkmann B. Suicidal strangulation by ligature. Z Rechtsmed. 1982;88:221–31.
Loriot JN, Eliakis E, Fully G, Breton J, Caroff J, Hadengue A, et al. Suicidal strangulation (apropos of 11 cases). Med Legale dommage corporel. 1971;4:385–97.
Madro R. Death by strangulation - suicide or homicide. Archiwum Medycyny Sadowej i Kryminologii. 1981;31:139–43.
Marziano A, Marziano E. A peculiar case of suicidal strangulation. Zacchia. 1987;60:309–13.
Rabl W, Markwalder C, Sigrist T. Study on self-strangulation: a forensic-criminalistic investigation. Arch Kriminol. 1992;189:1–8.
Radosavkić R, Vapa D, Pilija V. Homicide or suicide by strangulation-case report. Med Pregl. 2013;66:392–5.
Rothschild M, Maxeiner H. How extensive could be larynx injuries in suicidal strangulation? Arch Kriminol. 1992;189:129–39.
Wittig H, Grünewald S, Gerlach K, Dussy F, Scheurer E. Suicidal ligature strangulation using cable ties: case report and postmortem angiography results. Rechtsmed. 2017;27:433–7.
Acknowledgements
The authors acknowledge Janine Krochmal, Victorian Institute for Forensic Medicine (VIFM) Librarian, for the retrieval of full text articles.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
All authors declare they have no conflicts of interest.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
ESM 1
(DOCX 1.11 mb)
Rights and permissions
About this article
Cite this article
Cordner, S., Clay, F.J., Bassed, R. et al. Suicidal ligature strangulation: a systematic review of the published literature. Forensic Sci Med Pathol 16, 123–133 (2020). https://doi.org/10.1007/s12024-019-00187-2
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12024-019-00187-2