Forensic Science, Medicine and Pathology

, Volume 15, Issue 1, pp 84–92 | Cite as

Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy – a systematic review

  • Dominic GaschoEmail author
  • Jakob Heimer
  • Carlo Tappero
  • Sarah Schaerli


Several articles have described the use of postmortem computed tomography (CT) and postmortem magnetic resonance imaging (MRI) in forensic medicine. Although access to CT scanners and, particularly, access to MRI scanners, is still limited for several institutes, both modalities are being applied with increasing frequency in the forensic setting. Certainly, postmortem imaging can provide crucial information prior to autopsy, and this method has even been considered a replacement to autopsy in selected cases by some forensic institutes. However, the role of postmortem imaging has to be assessed individually according to various injury categories and causes of death. Therefore, this systematic review focuses on the role of postmortem CT and MRI in cases of hanging and ligature and manual strangulation. We assessed the most common and relevant findings on CT and MRI in cases of strangulation and compared the detectability of these findings among CT, MRI and autopsy. According to the available literature, mainly fractures of the hyoid bone or thyroid cartilage were investigated using postmortem CT. Compared to autopsy, CT demonstrated equivalent results concerning the detection of these fractures. A currently described “gas bubble sign” may even facilitate the detection of laryngeal fractures on CT. Regarding the detection of hemorrhages in the soft tissue of the neck, postmortem MRI is more suitable for the detection of this “vital sign” in strangulation. Compared to autopsy, postmortem MRI is almost equally accurate for the detection of hemorrhages in the neck. Another “vital sign”, gas within the soft tissue in hanging, which is hardly detectable by conventional autopsy, can be clearly depicted by CT and MRI. The number of cases of manual and ligature strangulation that were investigated by means of postmortem CT and MRI is much smaller than the number of cases of hanging that were investigated by CT and MRI. Likewise, judicial hanging and the hangman’s fracture on postmortem imaging were described in only a few cases. Based on the results of this systematic review, we discuss the additional value of CT and MRI in fatal strangulation compared to autopsy, and we reflect on where the literature is currently lacking.


Hanging Strangulation Postmortem CT Postmortem MRI Hyoid and thyroid fracture Vital reaction 


Compliance with ethical standards

Conflict of interest

The authors have no conflict of interest to report.

Ethical approval

Not required for this systematic review.

Informed consent

Not required for this systematic review.


  1. 1.
    DiMaio VJ, DiMaio D. Asphyxia. In: DiMaio VJ, DiMaio D, editors. Forensic pathology. 2nd ed. Boca Raton: CRC Press; 2001. p. 230–78.Google Scholar
  2. 2.
    Saukko P, Knight B. Fatal pressure on the neck. In: Saukko P, Knight B, editors. Knight’s forensic pathology. 4th ed. Boca Raton: CRC Press; 2015. p. 368–94.Google Scholar
  3. 3.
    Schulz F, Buschmann C, Braun C, Püschel K, Brinkmann B, Tsokos M. Haemorrhages into the back and auxiliary breathing muscles after death by hanging. Int J Legal Med. 2011;125:863.PubMedCrossRefGoogle Scholar
  4. 4.
    Bolliger SA, Thali MJ, Ross S, Buck U, Naether S, Vock P. Virtual autopsy using imaging: bridging radiologic and forensic sciences. A review of the Virtopsy and similar projects. Eur Radiol. 2007;18:273–82.PubMedCrossRefGoogle Scholar
  5. 5.
    Burke MP. Forensic pathology of fractures and mechanisms of injury: postmortem CT scanning. Boca Raton: CRC Press; 2016.Google Scholar
  6. 6.
    Gascho D, Schaerli S, Tuchtan-Torrents L, Thali MJ, Gorincour G. Use of postmortem computed tomography to detect bowel obstruction and its relationship to the cause of death. Am J Forensic Med Pathol. 2018;39:30.PubMedGoogle Scholar
  7. 7.
    Flach P, Gascho D, Ruder T, Franckenberg S, Ross S, Ebner L, et al. Postmortem and forensic magnetic resonance imaging. In: Saba L, editor. Imaging of the pelvis, musculoskeletal system, and special applications to CAD. Boca Raton: CRC Press; 2016.Google Scholar
  8. 8.
    Whiting PF, Rutjes AWS, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155:529–36.PubMedCrossRefGoogle Scholar
  9. 9.
    Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Yen K, Lövblad KO, Scheurer E, Ozdoba C, Thali MJ, Aghayev E, et al. Post-mortem forensic neuroimaging: correlation of MSCT and MRI findings with autopsy results. Forensic Sci Int. 2007;173:21–35.PubMedCrossRefGoogle Scholar
  11. 11.
    Garetier M, Deloire L, Dédouit F, Dumousset E, Saccardy C, Ben Salem D. Postmortem computed tomography findings in suicide victims. Diagn Interv Imaging. 2017;98:101–12.PubMedCrossRefGoogle Scholar
  12. 12.
    Graziani G, Tal S, Adelman A, Kugel C, Bdolah-Abram T, Krispin A. Usefulness of unenhanced post mortem computed tomography – findings in postmortem non-contrast computed tomography of the head, neck and spine compared to traditional medicolegal autopsy. J Forensic Legal Med. 2018;55:105–11.CrossRefGoogle Scholar
  13. 13.
    Paolo MD, Guidi B, Bruschini L, Vessio G, Domenici R, Ambrosino N. Unexpected delayed death after manual strangulation: need for careful examination in the emergency room. Monaldi Arch Chest Dis [Internet]. 2016;71. Available from: Accessed 14 Mar 2018.
  14. 14.
    Fais P, Giraudo C, Viero A, Miotto D, Bortolotti F, Tagliaro F, et al. Micro computed tomography features of laryngeal fractures in a case of fatal manual strangulation. Legal Med. 2016;18:85–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Kettner M, Potente S, Schulz B, Knauff P, Schmidt PH, Ramsthaler F. Analysis of laryngeal fractures in decomposed bodies using microfocus computed tomography (mfCT). Forensic Sci Med Pathol. 2014;10:607–12.PubMedCrossRefGoogle Scholar
  16. 16.
    Bolliger S, Thali M, Jackowski C, Aghayev E, Dirnhofer R, Sonnenschein M. Postmortem non-invasive virtual autopsy: death by hanging in a car. J Forensic Sci. 2005;50:JFS2004070–6.CrossRefGoogle Scholar
  17. 17.
    Aghayev E, Jackowski C, Sonnenschein M, Thali M, Yen K, Dirnhofer R. Virtopsy hemorrhage of the posterior cricoarytenoid muscle by blunt force to the neck in postmortem multislice computed tomography and magnetic resonance imaging. Am J Forensic Med Pathol. 2006;27:25.PubMedCrossRefGoogle Scholar
  18. 18.
    Viel G, Schröder AS, Püschel K, Braun C. Planned complex suicide by penetrating captive-bolt gunshot and hanging: case study and review of the literature. Forensic Sci Int. 2009;187:e7–11.PubMedCrossRefGoogle Scholar
  19. 19.
    Polacco M, D’Alessio P, Ausania F, Zobel B, Pascali VL, d’Aloja E, et al. Virtual autopsy in hanging. Am J Forensic Med Pathol. 2013;34:107.PubMedCrossRefGoogle Scholar
  20. 20.
    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.PubMedCrossRefGoogle Scholar
  21. 21.
    Sieswerda-Hoogendoorn T, Strik AS, Hilgersom NFJ, Soerdjbalie-Maikoe V, van Rijn RR. Pneumomediastinum and soft tissue emphysema in pediatric hanging. J Forensic Sci. 2014;59:559–63.PubMedCrossRefGoogle Scholar
  22. 22.
    Wallace SK, Cohen WA, Stern EJ, Reay DT. Judicial hanging: postmortem radiographic, CT, and MR imaging features with autopsy confirmation. Radiology. 1994;193:263–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Thali MJ, Yen K, Schweitzer W, Vock P, Boesch C, Ozdoba C, et al. Virtopsy, a new imaging horizon in forensic pathology: virtual autopsy by postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)--a feasibility study. J Forensic Sci. 2003;48:386–403.PubMedGoogle Scholar
  24. 24.
    Aghayev E, Yen K, Sonnenschein M, Jackowski C, Thali M, Vock P, et al. Pneumomediastinum and soft tissue emphysema of the neck in postmortem CT and MRI; a new vital sign in hanging? Forensic Sci Int. 2005;153:181–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Yen K, Thali MJ, Aghayev E, Jackowski C, Schweitzer W, Boesch C, et al. Strangulation signs: initial correlation of MRI, MSCT, and forensic neck findings. J Magn Reson Imaging. 2005;22:501–10.PubMedCrossRefGoogle Scholar
  26. 26.
    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. Legal Med. 2009;11:267–71.PubMedCrossRefGoogle Scholar
  27. 27.
    Duband S, Timoshenko AP, Mohammedi R, Prades J-M, Barral F-G, Debout M, et al. Study of endolaryngeal structures by videolaryngoscopy after hanging: a new approach to understanding the physiopathogenesis. Forensic Sci Int. 2009;192:48–52.PubMedCrossRefGoogle Scholar
  28. 28.
    Blanc-Louvry IL, Thureau S, Duval C, Papin-Lefebvre F, Thiebot J, Dacher JN, et al. Post-mortem computed tomography compared to forensic autopsy findings: a French experience. Eur Radiol. 2013;23:1829–35.PubMedCrossRefGoogle Scholar
  29. 29.
    Hayashi T, Hartwig S, Tsokos M, Oesterhelweg L. Postmortem multislice computed tomography (pmMSCT) imaging of hangman’s fracture. Forensic Sci Med Pathol. 2014;10:3–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Naimo P, O’Donnell C, Bassed R, Briggs C. The use of computed tomography in determining development, anomalies, and trauma of the hyoid bone. Forensic Sci Med Pathol. 2015;11:177–85.PubMedCrossRefGoogle Scholar
  31. 31.
    Schulze K, Ebert LC, Ruder TD, Fliss B, Poschmann SA, Gascho D, et al. The gas bubble sign—a reliable indicator of laryngeal fractures in hanging on post-mortem CT. Br J Radiol. 2018;20170479.Google Scholar
  32. 32.
    Decker LA, Hatch GM, Lathrop SL, Nolte KB. The role of postmortem computed tomography in the evaluation of strangulation deaths. J Forensic Sci. 2018:1401–5.Google Scholar
  33. 33.
    Elifritz J, Hatch GM, Kastenbaum H, Gerrard C, Lathrop SL, Nolte KB. 1.8. PMCT findings in hanging. J Forensic Radiol Imaging. 2014;2:97.CrossRefGoogle Scholar
  34. 34.
    Cormick C. Ned Kelly: under the microscope. CSIRO Publishing; 2014.Google Scholar
  35. 35.
    Menon KV, Taif S. Detailed description of anatomy of the fracture line in hangman’s injury: a retrospective observational study on motor vehicle accident victims. Br J Radiol. 2015;89:20150847.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Tracqui A, Fonmartin K, Géraut A, Pennera D, Doray S, Ludes B. Suicidal hanging resulting in complete decapitation: a case report. Int J Legal Med. 1998;112:55–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Zhu BL, Quan L, Ishida K, Oritani S, Taniguchi M, Fujita MQ, et al. Decapitation in suicidal hanging — a case report with a review of the literature. Legal Med. 2000;2:159–62.PubMedCrossRefGoogle Scholar
  38. 38.
    Dedouit F, Tournel G, Bécart A, Hédouin V, Gosset D. Suicidal hanging resulting in complete decapitation––forensic, radiological, and anthropological studies: a case report. J Forensic Sci. 2007;52:1190–3.PubMedCrossRefGoogle Scholar
  39. 39.
    Hejna P, Bohnert M. Decapitation in suicidal hanging – vital reaction patterns. J Forensic Sci. 2013;58:S270–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Khokhlov VD. Trauma to the hyoid bone and laryngeal cartilages in hanging: review of forensic research series since 1856. Legal Med. 2015;17:17–23.PubMedCrossRefGoogle Scholar
  41. 41.
    Feigin G. Frequency of neck organ fractures in hanging. Am J Forensic Med Pathol. 1999;20:128.PubMedCrossRefGoogle Scholar
  42. 42.
    Dunsby AM, Davison AM. Causes of laryngeal cartilage and hyoid bone fractures found at postmortem. Med Sci Law. 2011;51:109–13.PubMedCrossRefGoogle Scholar
  43. 43.
    Maxeiner H. Healed fractures of the larynx and lingual bone in forensic autopsy. Arch Kriminol. 1999;203:175–83.PubMedGoogle Scholar
  44. 44.
    Becker M, Leuchter I, Platon A, Becker CD, Dulguerov P, Varoquaux A. Imaging of laryngeal trauma. Eur J Radiol. 2014;83:142–54.PubMedCrossRefGoogle Scholar
  45. 45.
    Grabherr S, Heinemann A, Vogel H, Rutty G, Morgan B, Woźniak K, et al. Postmortem CT angiography compared with autopsy: a forensic multicenter study. Radiology. 2018;170559.Google Scholar
  46. 46.
    Gascho D, Thali MJ, Niemann T. Post-mortem computed tomography: technical principles and recommended parameter settings for high-resolution imaging. Med Sci Law. 2018;58:70–82.PubMedCrossRefGoogle Scholar
  47. 47.
    Maxeiner H. “Hidden” laryngeal injuries in homicidal strangulation: how to detect and interpret these findings. J Forensic Sci. 1998;43:784–91.PubMedCrossRefGoogle Scholar
  48. 48.
    Dirnhofer R, Jackowski C, Vock P, Potter K, Thali MJ. VIRTOPSY: minimally invasive, imaging-guided virtual autopsy. Radiographics. 2006;26:1305–33.PubMedCrossRefGoogle Scholar
  49. 49.
    Bush CH. The magnetic resonance imaging of musculoskeletal hemorrhage. Skelet Radiol. 2000;29:1–9.CrossRefGoogle Scholar
  50. 50.
    Haakma W, Froeling M, Pedersen M, Uhrenholt L, Douven P, Leemans A, et al. Post-mortem diffusion MRI of the cervical spine and its nerve roots. J Forensic Radiol Imaging. 2018;12:50–6.CrossRefGoogle Scholar
  51. 51.
    Blanc-Louvry IL, Papin F, Vaz E, Proust B. Cervical arterial injury after strangulation—different types of arterial lesions. J Forensic Sci. 2013;58:1640–3.PubMedCrossRefGoogle Scholar
  52. 52.
    Clarot F, Vaz E, Papin F, Proust B. Fatal and non-fatal bilateral delayed carotid artery dissection after manual strangulation. Forensic Sci Int. 2005;149:143–50.PubMedCrossRefGoogle Scholar
  53. 53.
    Higgins S, Parsons S, Woodford N, Lynch M, Briggs C, O’Donnell C. The effect of post-mortem computed tomography angiography (PMCTA) using water-soluble, iodine-based radiographic contrast on histological analysis of the liver, kidneys and left ventricle of the heart. Forensic Sci Med Pathol. 2017;13:317–27.PubMedCrossRefGoogle Scholar
  54. 54.
    Hussarek M, Wolf G. Subcutaneous emphysema of neck and larynx following attempted strangulation. Z Rechtsmed. 1971;68:41–4.PubMedCrossRefGoogle Scholar
  55. 55.
    Nikolić S, Živković V, Babić D, Juković F. Cervical soft tissue emphysema in hanging—a prospective autopsy study. J Forensic Sci. 57:132–5.Google Scholar
  56. 56.
    Bianco F, Floris R. Computed tomography abnormalities in hanging. Neuroradiology. 1987;29:297–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Ohkawa S, Yamadori A. CT in hanging. Neuroradiology. 1993;35:591.PubMedCrossRefGoogle Scholar
  58. 58.
    Matsuyama T, Okuchi K, Seki T, Higuchi T, Ito S, Makita D, et al. Magnetic resonance images in hanging. Resuscitation. 2006;69:343–5.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Forensic Medicine and Imaging, Institute of Forensic MedicineUniversity of ZurichZurichSwitzerland
  2. 2.Department of Diagnostic, Interventional and Pediatric Radiology, InselspitalBern University HospitalBernSwitzerland

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