Delayed and Hidden Injury After Non-Fatal Strangulation

In a review of 300 attempted-strangulation cases submitted for prosecution, most victims had no visible injury at all, or injuries too minor to photograph (Strack 2001). The absence of neck bruising or marks does not by itself establish that an assault did not occur or that the risk of injury was absent. Serious injury from strangulation can be internal, can appear on imaging even when the skin looks normal, and can be tied to specific symptoms rather than to anything visible.

For years, most of the medical literature on strangulation came from autopsy studies of fatal cases. Clinical knowledge about people who survive strangulation was comparatively thin, and a survivor-focused evaluation protocol was proposed to address that gap (McClane 2001).

More recent work has tried to quantify how often survivors have injuries that actually matter clinically. In a study of alert adults evaluated after non-fatal strangulation, identifiable injury was found in only 1.7% of patients, and clinically important injury in just 0.6% (Matusz 2020). The two clinically important injuries identified were cervical artery dissections, and neither patient had a neurologic deficit. Patients who did have a neck injury tended to show more than neck pain alone, such as a reduced level of consciousness or difficulty swallowing (Matusz 2020). The study excluded children under 16 and patients who were not alert and oriented, and its authors were careful to say their findings "suggest, but do not prove" that a selective approach to imaging is reasonable.

Imaging studies add another layer. MRI has revealed internal neck injury in strangulation cases with no external findings at all, particularly in chokehold-type assaults where the victim reported airway-compression symptoms such as breathing or swallowing difficulty (Heimer 2019). Whether an MRI finding showed up did not depend on how quickly the scan was done after the assault. A delayed scan could still show injury (Heimer 2019). In that same study, the incidence of carotid artery dissection and laryngeal fracture was low, and MRI findings did not help grade how severe the injury was.

Sexual assault research adds a related data point. Among women who reported non-fatal strangulation during a sexual assault, external physical signs of strangulation were absent in 49.4% of cases, and strangulation in this context was strongly associated with an intimate-partner assailant (Zilkens 2016).

Strangulation history also carries weight beyond the injury itself. Among women with a history of abuse, a prior episode of non-fatal strangulation was associated with roughly 6.7 times the odds of becoming an attempted-homicide victim (OR 6.70, 95% CI 3.91-11.49) and roughly 7.5 times the odds of becoming a completed-homicide victim (OR 7.48, 95% CI 4.53-12.35), compared to abused women without that history (Glass 2008). These are population-level associations relevant to risk assessment; they do not establish mechanism, intent, or outcome in any individual case.

What this does and does not mean

A normal-looking neck exam after a reported strangulation is common and expected. It is not, by itself, proof that the event did not occur or that the risk of injury was absent. At the same time, a low rate of identifiable injury in these studies should not be read as proof the event was harmless, and a positive imaging finding does not by itself indicate how severe the injury was. These adult cohorts do not establish rates of strangulation injury in children, and should not be extrapolated to pediatric cases.

In casework, this literature matters because strangulation allegations are often evaluated, and sometimes dismissed, based on what is visible at the time of exam. The data here support looking beyond visible marks, considering delayed imaging where clinically indicated, and weighing strangulation history in risk assessment. Any conclusion about severity or mechanism should still be tied to the actual findings in the record rather than assumed from the presence or absence of injury.

The studies cited below are indexed in PubMed; DOI links are provided.

References

1. Strack GB, McClane GE, Hawley D. A review of 300 attempted strangulation cases. Part I: criminal legal issues. J Emerg Med. 2001;21(3):303-309. doi:10.1016/s0736-4679(01)00399-7
2. McClane GE, Strack GB, Hawley D. A review of 300 attempted strangulation cases Part II: clinical evaluation of the surviving victim. J Emerg Med. 2001;21(3):311-315. doi:10.1016/s0736-4679(01)00400-0
3. Matusz EC, Schaffer JT, Bachmeier BA, Kirschner JM, Musey PI, Roumpf SK, Strachan CC, Hunter BR. Evaluation of nonfatal strangulation in alert adults. Ann Emerg Med. 2020;75(3):329-338. doi:10.1016/j.annemergmed.2019.07.018
4. Heimer J, Tappero C, Gascho D, Flach P, Ruder TD, Thali MJ, Franckenberg S. Value of 3T craniocervical magnetic resonance imaging following nonfatal strangulation. Eur Radiol. 2019;29(7):3458-3466. doi:10.1007/s00330-019-06033-x
5. Glass N, Laughon K, Campbell J, Block CR, Hanson G, Sharps PW, Taliaferro E. Non-fatal strangulation is an important risk factor for homicide of women. J Emerg Med. 2008;35(3):329-335. doi:10.1016/j.jemermed.2007.02.065
6. Zilkens RR, Phillips MA, Kelly MC, Mukhtar SA, Semmens JB, Smith DA. Non-fatal strangulation in sexual assault: a study of clinical and assault characteristics highlighting the role of intimate partner violence. J Forensic Leg Med. 2016;43:1-7. doi:10.1016/j.jflm.2016.06.005