Case report

Medicine, Science and the Law

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Petechial haemorrhages as a ! The Author(s) 2017
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DOI: 10.1177/0025802417739163
strangulation during suicidal fall journals.sagepub.com/home/msl

from a height: Case reconstruction


Vladimir Zivkovi
c and Slobodan Nikoli
c

Abstract
We present the case of a 64-year-old woman who committed suicide by jumping from the open bedroom window of her
second-floor apartment. However, during a head-first fall, the victim’s head was caught perpendicularly between two
parallel metal strands of wire, used for drying laundry, on the first-floor window. This led to a 180 rotation of the body
around the lower part of the neck, bringing the victim’s body into the legs-first position. This chain of events also caused
short-term neck strangulation, for fractions of a second or a couple of seconds, which caused rupture of the peripheral
venules and apparent neck, facial and conjunctival haemorrhages, above the level of strangulation ligature – the metal
strands of wire. The presented case shows that even such incomplete, very short-term neck strangulation could raise
venous/capillary pressure sufficiently to cause petechial haemorrhages on the neck and face above the level of ligature.

Keywords
Petechiae, conjunctival haemorrhages, facial haemorrhages, strangulation, asphyxia

Introduction
Petechiae are pinpoint haemorrhages resulting from the
rupture of small vessels.1 Conjunctival and facial pete-
chiae, although non-specific findings, are considered
hallmarks of asphyxial deaths.2 Although commonly
present in cases of asphyxiation, petechial haemor-
rhages of the face, eyelids and conjunctivae are also
present in deaths due to other unnatural (e.g. electro-
cution, cranio-cerebral trauma, intoxication) or natural
(e.g. cardiac, central nervous system, infectious)
causes.3 They may also occur in situations of increased
intra-thoracic or intra-abdominal pressure, resulting in
inflow congestion and increased pressure to the veins
and capillaries of the head and neck region (e.g. epilep-
tic fit, asthma attack, sneezing, coughing, vomiting,
giving birth, Valsalva manoeuvre).1–7 These haemor-
rhages are commonly observed in neck strangulation,1
and they are commonly visible above the ligature
marks.7–9
There is no consensus concerning the time necessary
for the development of petechial haemorrhages in cases
of neck strangulation (hanging or manual or ligature
strangulation). According to some authors, the
required time is at least 10–20 seconds up to several
minutes of complete venous compression,10 while
others state that petechial haemorrhages may form
within seconds or milliseconds.3,11 Herein, we present
a case where the development of petechial skin and
conjunctival haemorrhages happened in a very short
time. This case emphasises that reconstruction of the
event is very important for the correct interpretation of
the injuries and their mechanism.
Case outline
A 64-year-old woman committed suicide by jumping
from the open bedroom window of her second-floor
apartment, from a height of about 6–7 m. She was
found lying on her right side (Figure 1(a)) on a concrete
surface. Since the victim was dead at the scene, no car-
diopulmonary resuscitation was performed. The victim
lived alone, and her apartment was secured with a
chain lock from the inside. Everything inside the apart-
ment was in order, and there was no disarray.
Institute of Forensic Medicine, University of Belgrade – School of
Medicine, Serbia
Corresponding author:
Slobodan Nikolic, Institute of Forensic Medicine, 31a Deligradska str.,
11000 Belgrade, Serbia.
Emails: bobanvladislav@yahoo.com; slobodan.nikolic@mfub.bg.ac.rs
2 Medicine, Science and the Law 0(0)
Figure 1. Police photos of the site. (a) Arrows point to the window from which the victim jumped, two metal holders with stretched
wire between them (for drying laundry) and the body of the deceased. (b) A closer aspect of the distorted holders with wire
stretched between them (arrows point to the intact and torn parts of the wire: the photo was taken through the window from which
the victim jumped).
The victim had no direct access to the roof from her
apartment. The examination of the bedroom revealed
partially elevated rolling shutters on the window from
which she jumped. The couch was standing right beside
this window. A kitchen knife with traces of blood was
found in the room on a small table. No suicide note
was found, and no prior suicide attempt was registered.
The victim had been suffering from depression. There
were no data about first-line relatives who committed
suicide. The police investigation revealed a torn metal
wire used for drying laundry on the window on the first
floor, exactly below the spot from where the victim
jumped (Figure 1(b)). The torn wire was stretched
between two metal holders, which were slightly dis-
torted. The police investigation of the scene excluded
homicide, assault or any other physical violence
inflicted by another person.
The deceased was 160 cm tall and weighed 62 kg.
The victim had an irregular scalp laceration in the
middle part of the parieto-occipital region, with sur-
rounding bruising, as well as an adjacent longitudinal
skull fracture (extending from the skull lambda,
through the sagittal suture, along the middle part of
the frontal bone and the left side of the anterior cranial
fossa) and a 0.7-cm-long laceration of the dural supe-
rior sagittal sinus, located on the periosteal part of the
dura. A subdural haematoma was absent, probably due
to the location of this laceration as well as the rapidity
of death. The victim suffered deep brain contusions on
the left basal ganglia, and only a few contusions were
present on the tip of the left frontal lobe. Other injuries,
both external and internal, which were consistent with
a fall from a height, included a fracture of the sternum
and multiple ribs, with corresponding pulmonary con-
tusions; burst fracture of the 10th thoracic vertebra;
fractures of the spinous processes of the first 10 thorac-
ic vertebrae with surrounding soft-tissue and muscle
contusions and haemorrhages; and skin contusions
and abrasions on the trunk, arms and legs. The autopsy
revealed injuries which implied that the victim fell legs
first, that is, the primary contact with the surface was
with her feet, not with her head.
However, some of the injuries fell out of this ‘fall
from a height’ pattern. First, multiple superficial par-
allel slash wounds, up to 4 cm in length, were found on
both wrists, indicating that this was the primary
planned method of suicide. Second, the external exam-
ination also revealed multiple petechial skin haemor-
rhages of the face and the anterior and lateral sides
of the neck (Figure 2), as well as conjunctivae
(Figure 3). On both lateral sides of the neck, two
almost symmetrical rectangular-shaped skin abrasions
were determined, implying ligature strangulation of the
neck (Figure 2). The examination of all soft and solid
neck structures prepared by the layers revealed bleed-
ing and soft-tissue contusions surrounding the lower
parts of both the sternocleidomastoid muscles and the
left carotid artery. An additional rectangular-
shaped abrasion was present on the lateral side of left
upper arm.
As a final note, there was no alcohol or drugs in the
blood sample taken from the femoral vein. The cause
of death was attributed to traumatic brain injury.
Discussion
Mechanical obstruction of venous return to the heart,
in the setting of continued arterial blood flow, causes
an increase in intravascular pressure that induces the
over-distention of the thin-walled peripheral venules,
and this can lead to rupture, as in mechanically
caused rhexis haemorrhages. The venules located in
areas that are low in connective tissue, such as the con-
junctiva and sclera, the skin of the upper eyelid, the
forehead, behind the ears and around the mouth, are
more prone to rupture.1 Other, multi-causal

Zivkovi
c and Nikolic
Figure 2. Right (a), anterior (b) and left (c) aspect of the neck. Petechial skin haemorrhages are visible on the neck and face. Arrows
point to a ligature mark – skin abrasions.
Figure 3. Petechial haemorrhages of the eyelids and conjunctivae of the right (a) and left (b) eye.
explanations include elevated intra-vessel pressure.
Mechanical factors seem to be crucial in the occurrence
of petechial haemorrhage, and although suggested by
some authors, hypoxia is most probably not a relevant
factor.2 As a result of a prone position and/or the head
lying lower than the rest of the body, petechiae may
also develop post-mortem.2,3 Neither retrospective nor
prospective investigations have shown any convincing
evidence that facial or conjunctival petechiae result
from cardiopulmonary resuscitation.4,5 In our pre-
sented case, no cardiopulmonary resuscitation was
performed.
As stated before, there is no consensus concerning
the time necessary for the development of petechial
haemorrhages in cases of neck compression. One of
the most commonly described situations where such
haemorrhages may form within seconds or milliseconds
is thoraco-abdominal compression or crush asphyxia
(also known as Perthes’ syndrome).12 In our presented
case, none of these mechanisms were related to petechi-
al haemorrhages: the police investigation did not reveal
attempted suicide by hanging, or homicidal strangula-
tion, while the autopsy did not reveal any defence
injuries.
The most probable scenario of the victim’s suicide,
having taken into account her age and physical consti-
tution, indicated that the only way she could have
jumped through the window was that she had climbed
3
onto the couch beside the window, squeezed through
the semi-open shutters and fallen head first (Figure 4
(a)). As some simulation studies have shown, in a head-
first fall from a 6 m height, it would be expected that
first the head and then the back of the shoulders hit the
ground, absorbing most of the impact energy from the
fall.13 However, in the presented case, during a head-
first fall, it seems that the victim’s head went perpen-
dicularly between two parallel metal strands of wire
(Figure 4(b)), with a gap of about 25–30 cm between
the wires being wide enough for the head to go
through, without being injured. The upper side of the
shoulders prevented the victim’s body from falling fur-
ther through the wires, and then gravity caused a 180
rotation of the body around the lower part of the neck,
bringing the victim’s body into the legs-first position
(Figure 4(c)). At that moment, the victim’s neck was
tightened between two strained and probably crossed
metal strands of wire, which left the symmetrical stran-
gulation marks (abrasions) on the lateral sides of the
neck and the rectangular-shaped abrasion on the later-
al side of the left upper arm. In this way, the metal
strands of wire used for drying laundry acted as a lig-
ature, causing short-term strangulation. After the wire
snapped under the weight of the victim’s body, the
victim fell (Figure 4(d)) on her left leg, and then suf-
fered injuries to the trunk, head and arms due to a
secondary impact.
4 Medicine, Science and the Law 0(0)

Figure 4. Graphic presentation of the most probable scenario of the event. (a) Victim squeezed through the semi-open shutters and
fell head first. (b) During the head-first fall, the victim’s head went perpendicularly between two parallel metal strands of wire, with the
junction of the neck and trunk being caught by these strands. (c) The neck and shoulders being caught in the wire led to a 180
rotation of the body around the lower part of the neck, bringing the victim’s body into the legs-first position and leaving the
symmetrical strangulation marks (abrasions) on the lateral sides of the neck. (d) After the wire snapped, the victim fell on her left leg
and then suffered injuries to the trunk, head and arms due to a secondary impact.

In the presented case, a short-term neck strangula-
tion – fractions of a second or a couple of seconds –
was sufficient to raise enough intravascular pressure to
cause rupture of the peripheral venules and apparent
neck, facial and conjunctival haemorrhages, above the
level of strangulation ligature – the metal strands of
wire. The examination of the scene, as well as the
skin and deep soft-tissue injuries to the victim’s neck,
revealed that this strangulation lasted for a very short
period but was strong enough to cause the petechial
head and neck haemorrhages.
Petechiae of the facial skin and conjunctivae are of
significant value in forensic medical diagnostics.
Knowledge of the possible differential diagnoses is
essential for the correct forensic interpretation. In the
presented case, both the police investigation of the
scene and the autopsy enabled the correct reconstruc-
tion of the suicidal fall from a height. A reconstruction
of the event revealed not only the underlying mecha-
nism of neck strangulation in this case, but also pointed
to the fact that even a very short-term (up to fractions
of a second or a couple of seconds), incomplete neck
strangulation could raise venous/capillary pressure suf-
ficiently to cause petechial haemorrhages on the neck
and face above the level of ligature.
Acknowledgements
This work was supported by the Ministry of Education and
Science of the Republic of Serbia as a part of the project ‘Age
related microarchitectural and mechanical bone properties:
Implications for increased fragility’, grant number 45005.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with
respect to the research, authorship and/or publication of this
article.

Zivkovi
c and Nikolic
Funding
The authors received no financial support for the research,
authorship and/or publication of this article.
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