ORIGINAL ARTICLE
Petechial Hemorrhages in Suicide by Hanging
Possible Contributing Variables in Petechial Development
Jon Andreas Sundal, MD,* Bjørn Ove Mæhle, MD, PhD,*
Geir Egil Eide, MSc, PhD,†‡ and Inge Morild, MD, PhD*§
Abstract: Hemorrhagic petechiae in the conjunctiva and the skin have
been related to type of suspension and body height of the victims of hangings.
In 265 cases of hanging, we retrospectively examined whether petechiae relate
to type of suspension, body weight and height, body mass index (BMI), age,
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sex, type and thickness of the ligature, and blood alcohol content. The type
of suspension was divided into completely suspended, incompletely suspended,
and found with feet touching the ground. There was no significant difference in
the frequency of petechiae between the feet touching the ground and complete
suspension, and they were therefore considered as one group (complete suspen-
sions). Incomplete suspensions had more (58.7%) petechiae than the complete
suspension group (30.2%). Statistical analysis showed that incomplete suspen-
sion was significantly stronger related to the development of petechiae than
complete suspension. Body mass index was the only variable able to add infor-
mation to the type of suspension. In victims of incomplete hangings, high BMI
yielded 2.58 times higher probability of developing petechiae than low BMI.
These findings suggest that body size may contribute to the development of pe-
techiae in hangings.
Key Words: hanging, asphyxia, petechiae, suspension type, BMI
(Am J Forensic Med Pathol 2020;41: 90–96)
P etechial hemorrhages are pinpoint collections of blood in the
skin, sclera, or conjunctiva, varying in size from a one-tenth
to approximately 2 millimeters in diameter. Larger collections of
blood are called ecchymoses.1 Petechiae are present on the face
and in the eyes of victims after compression of the neck or chest
and have been used as an indicator of asphyxiation.
Tardieu2 was a pioneer when describing petechial hemor-
rhages as pathognomonic of death from strangulation. Petechiae
were also reported in the conjunctivae of Burke and Hare's victims,
who sold the corpses to Doctor Robert Knox for dissection in his
anatomy lectures.3 Prokop and Wabnitz found conjunctival pete-
chiae in both natural and unnatural deaths. In sudden cardiac deaths,
22 (4.3%) of 518 cases had petechiae, as did 61 (34%) of 177
hanging victims.4 Rao and Wetli5 found conjunctival petechiae
in 227 (4.5%) of 5000 consecutive autopsies. They were frequently
seen in deaths from cardiovascular diseases, accidents, homicides,
and suicides. The authors suggested that conjunctival petechiae
were most often the result of hypoxia coupled with an acute in-
crease in cephalic vascular pressure, possibly as a consequence of
“mechanical vascular obstruction or acute right heart failure.”5
Manuscript received November 13, 2019; accepted January 15, 2020.
From the *Gade Laboratory of Pathology, Department of Clinical Medicine,
University of Bergen, and †Department of Global Public Health and Primary
Care, University of Bergen; and ‡Centre for Clinical Research, and
§Department of Pathology, Haukeland University Hospital, Bergen, Norway.
The authors report no conflict of interest.
Reprints: Inge Morild, MD, PhD, Gade Laboratory of Pathology, Department of
Clinical Medicine, Jonas Lies vei 65, Haukeland University Hospital, 5021
Bergen, Norway. E-mail: inge.morild@uib.no.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0195-7910/20/4102–0090
DOI: 10.1097/PAF.0000000000000541
90 www.amjforensicmedicine.com
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Petechial hemorrhages are seen in approximately 25% of
hanging victims. They develop 10 to 20 seconds after complete
venous compression is exerted by a mechanical force on the
neck.1 Petechiae are seen more often in hangings with a part of
the body supported, that is, incomplete suspension, compared
with those hanging free, that is, complete suspension. The tradi-
tional theory is that the venous system is compressed while the ar-
terial system still persists in incomplete hangings. This increases
the venous pressure in the head and neck region, and the venules
may rupture. In hangings with complete suspension, the arteriae
are compressed as well, and the venous pressure remains low.6–8
Little notice has been given to hanging victims where the feet of
the deceased barely touch the ground. It is not obvious if these
cases should be registered as a complete or an incomplete type
of suspension.
Clement et al9 examined the frequency of petechiae in 206
deaths from hanging. They showed that type of suspension related
to the development of petechiae. In addition, body height was of
interest. It varied inversely with petechiae; bodies taller than
1.79 meters having fewer petechiae than bodies shorter than
1.60 meters. The victim's age, body mass index (BMI), body
height and weight, type of ligature, and cardiopulmonary resusci-
tation did not relate to petechiae.
Our aim was to analyze whether body height, body weight,
BMI, age, sex, position of the ligature, and type and thickness
of the ligature could add information to the type of suspension
to improve our understanding of why petechiae develop.
MATERIAL AND METHODS
All the data were retrieved through reports from medico-legal
autopsies performed at the Gade Laboratory of Pathology,
Haukeland University Hospital, Bergen, Norway, between 2007
and 2016. This laboratory serves a population of approximately
900,000, where nearly all suicides by hanging are autopsied
medico-legally. All autopsy cases of suicide by hanging during
this 10-year period were reviewed retrospectively. A total of 16
cases were excluded, because of either advanced decomposition
or other postmortem alterations, which could affect the evaluation
of conjunctival or palpebral petechiae, or because of scarcity of in-
formation. Deaths from ligature strangulations, manual strangula-
tions, and autoerotic asphyxiations were not included.
The presence or absence of petechiae (conjunctival and/or
palpebral) was registered. The type of suspension was categorized
as complete, contact, and incomplete suspension. Complete sus-
pension was defined as no contact between the body and the
ground, whereas incomplete suspension was present when the
ground supported a significant part of the body. We introduced a
third category called contact suspension, which occurred when
the feet barely touched the ground, as we were interested whether
this type of suspension yielded different results than the other 2
types. The type of hanging was either typical with the knot posi-
tioned in the occipital region or atypical with the knot positioned
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Am J Forensic Med Pathol • Volume 41, Number 2, June 2020 Petechial Hemorrhages in Suicide by Hanging

conjunctivae and palpebrae, 30 (25.9%) only in conjunctivae, and

TABLE 1. Sex-Specific Frequencies (%) of 265 Victims of Suicide 10 (8.6%) only in palpebrae (not shown). Incomplete suspension
by Hanging According to Presence of Petechiae, Type of
Suspension, Type of Ligature, Hanging Type, BAC, and Age, was frequent (47.5%), followed by complete suspension (38.9%),
Autopsied at Gade Laboratory of Pathology, Bergen, Norway and contact suspension (13.6%). Rope was the most common liga-
From 2007 to 2016 ture (59.1%). Men often used rope, whereas women tended to use
cord or textile (bed sheets, scarfs, towels, and other similar mate-
n (%) rials; P = 0.015). Nearly two-thirds of the victims had a typical
hanging and had no ethanol in their blood. We found more females
Variable Category Female Male Total in the youngest age group (10–19 years) and more males between
Petechiae Absent 36 (60.0) 113 (55.1) 149 (56.2) 20 and 49 years of age (P = 0.025). The median thickness of the lig-
Present 24 (40.0) 92 (44.9) 116 (43.8) ature was 1.0 cm, range 0.2 to 8 cm (not shown).
Suspension Complete 26 (43.3) 77 (37.6) 103 (38.9)
Contact 7 (11.7) 29 (14.1) 36 (13.6) Hemorrhagic Petechiae
Incomplete 27 (45.0) 99 (48.3) 126 (47.5) Victims of incomplete hanging (Table 2) had the highest fre-
Ligature* Rope 27 (45.0) 127 (62.0) 154 (58.1) quency of petechiae (58.7%), followed by the contact group
Cord 12 (20.0) 25 (12.2) 37 (14.0) (38.9%) and the complete group (27.2%). There was a highly
Strap 3 (5.0) 17 (8.3) 20 (7.5) significant relation between type of suspension and frequency of
petechiae (P < 0.001); deaths from incomplete hanging have
Belt 6 (10.0) 21 (10.2) 27 (10.2)
higher frequency of petechiae (63.8%) than contact (12.1%) and
Textile 12 (20.0) 15 (7.3) 27 (10.2)
complete (24.1%) hangings. We also compared the frequency of
Hanging Typical 36 (60.0) 131 (63.9) 167 (63.0) petechiae between the complete and contact groups and found
Atypical 24 (40.0) 74 (38.1) 98 (37.0) no significant difference (P = 0.188).
BAC, % 0 39 (65.0) 140 (68.3) 179 (67.6) Body weight, body height, and BMI did not relate significantly
0.001–0.049 4 (6.7) 13 (6.3) 17 (6.4) to frequency of petechiae (P ≥ 0.298). In addition, the frequency of
0.050–0.099 3(5.0) 11 (5.4) 14 (5.3) petechiae did not relate significantly (P ≥ 0.173) to BAC, type of
≥0.100 14 (23.3) 41 (20.0) 55 (20.8) hanging, type of ligature, ligature thickness, age, and sex
Age groups† 10–19 y 10 (16.7) 12 (5.9) 22 (8.3) (not shown).
20–49 y 32 (53.3) 131 (63.9) 163 (61.5)
50–89 y 18 (30.0) 62 (30.2) 80 (30.2) Regression Analyses
Total 60 (100) 205 (100) 265 (100) The logistic regression analyses (Table 3) confirmed that
2
type of suspension was strongly related to petechial hemorrhages
*χ test P = 0.015. and that BMI was the only variable able to add information to the
†χ2 test P = 0.025. type of suspension. After adjustment for BMI (multiple regression),
victims with incomplete suspension had 4.28 (95% CI = 2.40, 7.64,
in the left or right mastoid region or in front of the neck. The ma- P < 0.001) times higher risk of developing petechiae compared with
terial and the thickness of the ligature tool were registered together victims with complete suspension, after adjustment for BMI. The
with age, sex, body height, body weight, BMI, and blood alcohol probability of petechiae in the contact group was similar to that in
concentration (BAC). The BMI was calculated according to the the complete group.
formula BMI = weight/height.2 We used the 25% and 75% per-
centiles to group BMI (22.14, 27.41 kg/m2), body height (1.71,
1.84 m), body weight (67.0, 88.5 kg), and ligature thickness TABLE 2. Frequencies of Petechiae According to Type of
Suspension, BMI, Body Weight, and Body Height in 265 Victims
(0.8, 1.9 cm).
of Suicide by Hanging, Autopsied at Gade Laboratory of
We applied χ2 tests for comparing age, BMI, weight, and Pathology, Bergen, Norway From 2007 to 2016
height between groups with and without petechial hemorrhages.
The possible effects of type of suspension, BMI, body weight, Petechiae, n (%)
body height, BAC, type of hanging, type of ligature, age, and sex
on the presence of petechial hemorrhages were evaluated using sim- Variable Category Absent Present Total P*
ple and multiple logistic regression analysis. We report the results by Suspension Complete 75 (50.3) 28 (24.1) 103 (38.9) <0.001
the odds ratios (OR) with a 95% confidence interval (CI) and P values Contact 22 (14.8) 14 (12.1) 36 (13.6)
calculated by the likelihood ratio test using backward stepping. We
Incomplete 52 (34.9) 74 (63.8) 126 (47.5)
used a significance level of 0.05 with no adjustment for multiple
comparisons. We used the Statistical Package for the Social Sciences BMI, kg/m2 <22.02 43 (28.9) 24 (20.7) 67 (25.3) 0.298
(SPSS) 24 for all statistical analyses, except for the weighted meta- 22.02–27.36 69 (46.3) 62 (53.4) 131 (49.4)
analyses, for which we used the metan procedure of Stata software.10 >27.36 37 (24.8) 30 (25.9) 67 (25.3)
The study was approved by the regional ethical committee and by the Weight, kg <67 40 (26.8) 23 (19.8) 63 (23.8) 0.385
state prosecutor's office. 67–87 70 (47.0) 62 (53.4) 132 (49.8)
>87 39 (26.2) 31 (26.7) 70 (26.4)
RESULTS Height, cm <172 41 (27.5) 26 (22.4) 67 (25.3) 0.332
172–183 66 (44.3) 62 (53.4) 128 (48.3)
General Characteristics of the Study Population >183 42 (28.2) 28 (24.1) 70 (26.4)
A total of 265 victims (77.4% men) met the inclusion criteria, Total 149 (100) 116 (100) 265 (100)
of which 116 victims (43.8%) had petechial hemorrhages *P value from χ2 test.
(Table 1). In this group, 76 victims (65.5%) had petechiae in

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Sundal et al Am J Forensic Med Pathol • Volume 41, Number 2, June 2020

As single variables (simple regression), BMI, body weight,
and body height showed no significant relations to the frequency
of petechiae. However, tested simultaneously with type of suspen-
sion (multiple regression), BMI added information to the type of
suspension (P = 0.069). Medium and high BMI gave 2.14 and
1.86 times higher probability of petechiae compared with low
BMI, respectively. Using BMI as a continuous variable simulta-
neously with type of suspension, the probability of petechiae in-
creased an estimated 5% for each additional unit (kilogram per
square meter) of BMI (OR = 1.05, 95% CI = 0.99–1.12). This re-
lation did not, however, reach significance (P = 0.122). Body
weight and body height tested as category and continuous vari-
ables did not add information to the type of suspension.
To test whether the relation between BMI and petechiae is
different in victims of complete, contact, and incomplete hangings,
we tested the interaction between BMI and the 3 types of suspen-
sion by adding an interaction term. The interaction term with BMI
as category variable yielded a P value of 0.734, and as continuous
variable, it yielded a P value of 0.135. Although the interaction
was not significant, we tested the relation between BMI and pete-
chiae in each level of type of suspension. In the group with incom-
plete hangings, victims with high and medium BMI tended to
have higher risk of petechiae than victims with low BMI. This re-
lation was not present in the contact and complete groups
(P ≥ 0.382). In the incomplete group, medium and high BMI
had 2.58 (95% CI = 1.12–5.97) and 1.83 (95% CI = 0.70–4.79)
times higher risk of petechiae than low BMI (P = 0.084), respec-
tively. Using BMI as a continuous variable, the probability of pe-
techiae increased by an estimated 9% for each additional unit of
BMI (OR = 1.09, 95% CI = 1.00–1.18, P = 0.059).
DISCUSSION
This study confirms that victims of hangings with incom-
plete suspension have higher risk of hemorrhagic petechiae than
victims with complete suspension. Jointly analyzed with type of
suspension, higher BMI tended to increase the risk of petechiae.
The relation between BMI and risk of petechiae was present in
victims of hangings with incomplete suspension, whereas BMI
was not important in the groups with complete and contact sus-
pension. Body weight and body height showed no relation
to petechiae.
Type of Suspension in Relation to Petechiae
In previous studies (Table 4), the prevalence of petechiae in
the total material varies between 24% and 69%, the weighted av-
erage being 40.3% (95% CI = 38.3–42.3).8,9,11–23 This is consis-
tent with 43.8% (95% CI = 37.8–49.7) in the present study. The
meta-analysis of these studies, including the present one, yields
an updated weighted average of 40.3% and reveals that the varia-
tion of the prevalence between the studies was larger than ex-
pected by chance (P < 0.001).
Most previous studies show an increased risk of petechiae in
victims of incomplete hangings compared with complete hang-
ings, although the frequency of petechiae varies considerably.
We examined 9 studies (Table 5), which published the frequency
of petechiae in incomplete and complete hangings.9,12–15,17,19,21,22
The prevalence of complete suspension in these studies varied from
16.6% to 78.7%. A meta-analysis (Table 6) based on the studies in
Table 5 showed a 2.27-fold higher risk of petechiae with incomplete
suspension compared with complete (95% CI = 1.86–2.77).
These studies, as do our own findings, thus show a strong relation
between type of suspension and risk of hemorrhagic petechiae.
However, Suarez-Penaranda et al16 reported no difference in the
incidence of petechial development between complete and
incomplete suspensions.
To decide whether the suspension is complete or incomplete
can be challenging for the medical examiner. Kanchan et al24 ar-
gued that the frequency of true incomplete hangings could be
lower than what appears in the literature. They described 2 victims
initially hanging 15 to 30 cm above the floor. Approximately
3 hours later, the feet touched the floor in both cases. This change
was probably caused by pliability of the ligature and postmortem
stretching of the neck.24 These processes could thus explain why

TABLE 3. Results From Logistic Regression of Petechial Hemorrhages Associated With Type of Suspension, BMI, Body Height, and
Body Weight in 265 Victims From Suicidal Hanging, Autopsied at Gade Laboratory of Pathology, Bergen, Norway From 2007 to 2016

Simple Regression Multiple Regression

Variable Category OR 95% CI P* OR 95% CI P*
Suspension <0.001 <0.001
Complete 1.00 (reference) 1.00 (reference)
Contact 1.71 (0.77–3.79) 1.71 (0.77–3.83)
Incomplete 3.81 (2.18–6.68) 4.28 (2.40–7.64)
BMI, kg/m2 0.301 0.069
<22.02 1.00 (reference) 1.00 (reference)
22.02–27.36 1.61 (0.88–2.95) 2.14 (1.11–4.09)
>27.36 1.45 (0.73–2.91) 1.86 (0.89–3.90)
Height, cm 0.333
<1.72 1.00 (reference)
172–183 1.48 (0.81–2.70)
>183 1.05 (0.53–2.09)
Weight (kg) 0.388
<67 1.00 (reference)
67–87 1.54 (0.83–2.85)
>87 1.38 (0.69–2.78)
*P value from likelihood ratio test.

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Am J Forensic Med Pathol • Volume 41, Number 2, June 2020 Petechial Hemorrhages in Suicide by Hanging

TABLE 4. Results From a Meta-analysis of 15 Previous Studies and the Present One With EP and 95% CI

Number With
Study Year Victims Petechiae EP 95% CI % Weight
11
Luke 1967 106 73 0.689 (0.601–0.777) 5.13
Luke et al12 1985 61 29 0.475 (0.350–0.601) 2.53
James and Silcocks13 1992 84 27 0.321 (0.222–0.421) 3.99
Elfawal and Awad14 1994 61 18 0.295 (0.181–0.410) 3.03
Samarasekera and Cooke15 1996 233 113 0.485 (0.421–0.549) 9.65
DiMaio and DiMaio8 2001 83 21 0.253 (0.159–0.347) 4.54
Suarez-Penaranda et al16 2008 213 50 0.235 (0.178–0.292) 12.27
Sharma et al17 2008 66 28 0.424 (0.305–0.543) 2.80
Clement et al9 2011 206 94 0.456 (0.388–0.524) 8.59
Tse et al18 2012 100 26 0.260 (0.174–0.346) 5.38
Dean et al19 2012 229 83 0.362 (0.300–0.425) 10.25
Kurtulus et al20 2013 102 46 0.451 (0.354–0.548) 4.26
Ambade et al21 2015 127 33 0.260 (0.184–0.336) 6.83
Hlavaty et al22 2016 75 39 0.520 (0.407–0.633) 3.11
Ma et al23 2016 141 93 0.660 (0.581–0.738) 6.50
Present study 2019 265 116 0.438 (0.378–0.497) 11.14
Inverse-variance weighted pooled EP (w/ present study) 0.403 (0.383–0.423) 100.00
Heterogeneity χ2 = 173.30, df = 15, P < 0.001.
I2 (variation in EP attributable to heterogeneity) = 91.3%.
Test of EP = 0, z = 39.63, P < 0.001.
EP, estimated prevalence of petechiae.

victims of initially complete hangings could later be considered
victims of incomplete hangings.
In this study, we have introduced a third category for the type
of suspension variable, the contact group. It includes victims
hanging with their feet barely touching the ground. This was done
for 3 reasons. Firstly, police sometimes reported victims hanging
with their feet barely touching the ground, clearly without support
from the ground. Secondly, police photos sometimes show that a
body described as an incomplete hanging was in actual fact
merely touching the ground. Thirdly, reports such as Kanchan
et al's24 add uncertainty, leading us to define this contact group.
Our results show that the frequencies of petechiae were similar
in the contact and the complete suspension group.
Hypoxia and venous congestion have been considered im-
portant for the development of petechial hemorrhages. Rao and
Wetli5 suggested that conjunctival petechiae are most often the re-
sult of hypoxia in addition to an acute increase in cephalic vascular
pressure, and petechiae in natural deaths could be a result of in-
creased venous pressure after an acute right heart failure. Ely
et al25 argued that the development of conjunctival and facial pe-
techiae depends on the degree of venous obstruction and is unre-
lated to asphyxia or hypoxia. This view is supported by the
finding that a pure suicidal hypoxic death induced by a plastic
bag covering the head would not lead to formation of petechiae,
in comparison with cases when a co-existing ligature around the
neck is present.25 In addition, Saukko et al1 pointed out that in
many cases, death is so sudden that there is no time for hypoxia
to have a physiological effect.
Traditionally, higher venous pressure above the ligature has
been held responsible for the higher frequency of petechiae in

TABLE 5. Analysis of 9 Previous Studies Comparing the Presence of Petechiae in Hanging, and Frequency of Hemorrhagic Petechiae
According to Type of Suspension (Complete, Incomplete)9,12–15,17,19,21,22

Number; Total Complete Incomplete

Study (Complete, %) % Petechiae % Petechiae Statistics
12
Luke et al 56 (20–35.7) 25 61 P = 0.02
James and Silcocks13 75 (51–68.0) 22 46 P = 0.014
Elfawal and Awad14 61 (48–78.7) 21 62 Descriptive
Samarasekera and Cooke15 233 (97–41.6) 33 48 Descriptive
Sharma et al17 66 (45–68.2) 25 75 Descriptive
Clement et al9 170 (42–24.7) 28.6 50.0 P = 0.002, OR = 3.148
Dean et al19 229 (38–16.6) 15.79 40.31 Descriptive
Ambade et al21 127 (86–67.7) 17.4 43.9 Descriptive
Hlavaty et al22 75 (28–37.3) 4 81 Descriptive
Total number of victims and average % 1092 (455–41.7) 21.3 56.4
Present study 265 (137–52.9) 29.2 58.2 P < 0.001, OR = 3.88

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Sundal et al
TABLE 6. Relative Risks and 95% Confidence Interval (95% CI)
of Meta-analysis of 9 Studies Comparing the Presence of
Petechiae in Hanging With Complete Versus Incomplete
suspension9,12–15,17,19,21,22
Study Year RR (95% CI) % Weight
12
Luke et al 1985 2.44 (1.10–5.45) 6.36
James and Silcocks13 1992 2.13 (1.08–4.20) 6.96
Elfawal and Awad14 1994 2.95 (1.47–5.94) 4.22
Samarasekera and Cooke15 1996 1.45 (1.04–2.02) 36.95
Sharma et al17 2008 3.12 (1.77–5.49) 6.92
Clement et al9 2011 1.75 (1.05–2.91) 17.87
Dean et al19 2012 2.55 (1.20–5.43) 9.90
Ambade et al21 2015 2.52 (1.42–4.48) 9.58
Hlavaty et al22 2016 22.64 (3.23–155.92) 1.24
Mantel-Haenszel pooled 2.27 (1.86–2.77) 100.00
Heterogeneity χ2 = 15.43, df = 8, P = 0.051.
I2 (variation in RR attributable to heterogeneity) = 48.1%.
Test of RR = 1, z = 8.06, P < 0.001.
RR, relative risk.
victims of incomplete hangings compared with complete hang-
ings. In the former group, the veins are compressed while the
arteriae are still open. Complete suspension, on the contrary, leads
to compression of the blood supply to the head and venous return
at a much faster rate without an increased intravascular pressure
and less petechiae formation.8 The degree of the vessel compres-
sion depends on the internal vessel pressure and the external com-
pression force.26 Brouardel27 partially lifted a dead body by a
ligature and, after having removed the brain, showed that it takes
2 kg of pressure to occlude the jugular vein, 3.5 to 5 kg to occlude
carotid arteries, 15 kg to close the trachea, and 16 to 30 kg for the
occlusion of the vertebral arteries. In more recent experiments on
victims of hangings with atypical ligature position, the intra-
arterial pressure was estimated at 130 mm Hg. The external pres-
sure needed to close the carotid and vertebral arteries was 5.4 and
7.5 kg, respectively, with the ligature running at the level of the
mandible angle. Elsewhere on the neck, 35 kg was necessary to
close the vertebral artery.28 A venous pressure of at least 30 to
35 mm Hg was required for the formation of petechiae.29 It has
also been assumed that at least 10 seconds are required for the for-
mation of petechiae.30 However, an abrupt increase in venous
pressure in the head and neck region can cause immediate pete-
chiae formation in the conjunctivae, as seen during strong bouts
of coughing.31 The pressure needed to close arteries and veins
in the neck region is thus relatively low. We believe that this pres-
sure is reached in victims of both complete and incomplete hang-
ings. In our opinion, it is therefore difficult to explain the
difference in frequency of petechiae between these 2 groups based
on this traditional theory.
Body Mass Index and Body Weight in Relation
to Petechiae
In accordance with Clement et al,9 our data showed no simple
relation between BMI, body weight, and petechial hemorrhages. In
473 medico-legally examined deaths from different causes other
than strangulation, Maxeiner and Winklhofer32 found the highest
frequency in fire victims (31%), followed by deaths after intensive
care (24%), cardiac death (22%), and drowning and intoxication
(16% each). The frequency of petechiae in the conjunctivae and
eyelids tended to increase with BMI. This relation was significant
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Am J Forensic Med Pathol • Volume 41, Number 2, June 2020
in a subgroup of 181 deaths from cardiac diseases, even in a multi-
variate discriminate analysis.32
We found no significant association between body weight
and petechial development. However, using multiple logistic re-
gression with type of suspension included in the analysis, we
found that the risk of petechial hemorrhages tended to increase
with BMI. This was not found in the material analyzed by Clem-
ent et al.9 Interestingly, our analysis further showed that the rela-
tion between BMI and petechiae was present in the group of
incomplete hangings (P = 0.084), though not in the contact and
complete hanging groups. Victims with medium and high BMI
had 2.58 and 1.83 times higher risk of petechiae than those with
low BMI, respectively. According to the traditional theory, higher
BMI should add compressing force to the neck with higher risk of
both venous and arterial compression and lower frequency of pe-
techiae. In this study, the opposite is the case, with higher BMI
showing higher risk of petechiae in incomplete hangings, indicat-
ing that other mechanisms could be of interest. In the incomplete
group, the body is partly supported and the tension on the ligature
weaker than in the 2 other groups. This weaker tension, however,
could last longer before death compared with the contact and
complete groups. It is thus tempting to speculate whether both
the tension on the ligature and the time duration could be impor-
tant to understand the development of petechiae.
Body Height in Relation to Petechiae
In victims of hangings, Clement et al9 have shown that the
frequency of petechiae increases with shorter stature, even after
taking type of suspension into consideration. We have not been
able to confirm this relationship. They linked body height to con-
junctival, palpebral, gingival, and facial petechiae, whereas we
have focused on conjunctival and palpebral petechiae exclusively.
In this study, we have used 171 and 184 cm as cut points for body
height. We have also tested the relation between height and pete-
chiae using Clement's cut points (160 and 180 cm). These cut
points left only 7 victims (2.5%) in the shortest group, and still
body height showed no relation to petechiae.
Considering the localization of the petechiae, Clement et al9
also showed that longer stature leads to significantly less palpebral
petechiae (OR = 0.412, P = 0.01). Height was not important for
conjunctival and buccal petechiae. In this study, we also found a
relation between palpebral petechiae and body height, even after
adjustment for type of suspension. However, longer stature lead
to higher risk of palpebral petechiae (P = 0.028). Medium height
had 2.21 (95% CI = 1.11, 4.40) higher risk of palpebral petechiae
than short stature. The corresponding figures for victims with long
stature were OR = 1.05, 95% CI = 0.49, 2.46. Height was not im-
portant for conjunctival petechiae.
We have no explanation for the differences between the find-
ings of Clement et al9 and those in the present study. They could
partly result from differences in the material. They excluded 103
(33.3%) of 309 victims, whereas we excluded 16 (5.7%) of 281
cases. They were able to consider the importance of cardiopulmo-
nary resuscitation maneuvers, which had not been registered in
our database. Clement et al9 stated that the finding of petechiae
varying inversely with height could possibly be confounded by a
correlation with another hidden factor affecting the development
of petechiae. This may well be the case in our study. Clearly, a
study based on a larger number of victims of hanging is needed.
Ligature in Relation to Petechiae
The depth of the ligature mark varies with the material of the
ligature. A plastic clothes line would produce a narrow, deep mark
in the neck, whereas a soft cotton cloth would leave a broader and
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Am J Forensic Med Pathol • Volume 41, Number 2, June 2020
more superficial mark.14 A hard and narrow ligature would probably
obstruct the blood flow more effectively than a soft and a wide lig-
ature. We therefore examined whether the type of ligature could
be of interest for the development of petechiae. In agreement with
previous studies, we found no such association.9,13
Age in Relation to Petechiae
In 84 cases of hangings, James and Silcocks13 found no
association between age and petechial hemorrhages. In 181 deaths
from heart diseases, Maxeiner and Winklhofer32 found a significant
relation between age and frequency of petechiae; older persons hav-
ing petechiae less often. Clement et al9 reported that the frequency
of petechiae tended to decrease with age, the frequency being 61%,
44% and 40% in the age groups 0 to 19 years, 20 to 39 years, and
40 years and older, respectively. The trend did not reach statistical
significance.9 In our data, the frequency of petechiae was 45.5%,
40.9%, and 46.2% in the age groups 0 to 19 years, 20 to 49 years,
and 50 to 89 years, respectively. A relation between age and pete-
chiae has thus not been established.
Sex in Relation to Petechiae
Previous studies on hanging showed that the proportion of
males ranged from 71% to 92%, which is similar (78%) to this
study.9,13,16,20 In Norway, Puzo et al33 studied the incidence of sui-
cide by hanging for a 44-year period. Hanging accounted for
31.3% of suicides; 33.1% in males and 26.3% in females. The in-
cidence increased during the period. This trend was especially ev-
ident in women, with an increase of almost 3% per year.33 None of
these studies have shown a relation between petechiae and sex,
which is in accordance with the present study.
Type of Hanging in Relation to Petechiae
Kurtulus et al20 reported typical hanging with the ligature
knot located posteriorly in 54 (52.9%) of 102 cases. They reported
an association between type of hanging, typical hangings having
significantly less petechiae in the face and conjunctivae compared
with atypical hangings.20 The present study showed 62.9% of the
hangings to be typical. However, the type of hanging did not relate
to petechiae.
Blood Alcohol Concentration in Relation
to Petechiae
In previous studies on hanging, the frequency of cases with
alcohol in the blood varies, from 10.8% in North West London,
30% in Western Australia, and 32% in Sweden, which is similar
to our findings (32.8%).34–36 In 590 deaths from intoxication,
Flaagoy et al37 found 75 cases with petechiae either in the con-
junctivae, the eyelids, or in both. Cases with petechiae in both lo-
cations had alcohol in blood and urine/vitreous humor more often
than cases without petechiae.37 In 5000 consecutive autopsies,
Rao and Wetli5 reported no correlation between conjunctival pete-
chiae and the presence of alcohol or drugs. We found no relation
between alcohol in blood and urine and petechiae.
CONCLUSIONS
Despite the amount of research on victims of hangings, much
remains unknown. Petechial hemorrhages are seen in deaths from
natural and unnatural causes, and the factors contributing to their
development remain uncertain. Many studies report an increased
incidence of petechiae in hangings with incomplete suspension.
This is in accordance with the present study. However, in our
study, only 42.9% of the total hanging victims had developed
petechiae. The number of cases in the present material is large;
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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Petechial Hemorrhages in Suicide by Hanging
however, when stratifying the material according to type of sus-
pension, the smaller groups can add uncertainty to the results. Ev-
ery forensic pathologist has seen cases of incomplete hangings
where the circumstances should be classic and in adherence with
textbooks, but where even the smallest sign of petechial hemor-
rhages is absent. The pathophysiology of petechiae is still not
clear. Many factors such as arterial and venous blood pressure,
the effect of baroreceptor stimulation, the diameter and shape of
the neck, the exact position of the ligature, the length of the drop,
and, as in this study, the size of the body, and most likely other fac-
tors, could be of significance for the development of the petechiae.
In most studies on hanging, the number of cases and the registered
data are probably not large enough to provide a complete under-
standing of the whole hanging process. More research, probably
on prospective examined cases, is needed to enhance our under-
standing of the important phenomenon of petechial hemorrhages.
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