FINAL by: OSAC Program Office; Version 2, January 13, 2020 1 

OSAC RESEARCH NEEDS ASSESSMENT FORM

Title of research need: Indicators for Computer Tomography Angiography (CTA) Following Non-Fatal 

Strangulation

Describe

the need:

Insufficient data to support factors indicating neck Computer Tomography (CT) following 

non-fatal strangulation; considering risks, cost, and added trauma of CT-angiogram (CTA) 

after violence, data are needed to establish evidence-based criteria for CTA following nonfatal strangulation.

Keyword(s): strangulation, non-fatal strangulation, CTA, computed tomography, CT angiogram, 

domestic violence, intimate partner violence, sexual assault

Submitting subcommittee(s): Forensic Nursing Date Approved: 2/2/2023

Background Information:

1. Does this research need address a gap(s) in a current or planned standard? (ex.: Field identification system 

for on scene opioid detection and confirmation)

Yes - we would like to develop a standard regarding management of non-fatal strangulation within the 

context of medical forensic examinations. This research need will inform such a standard. 

2. Are you aware of any ongoing research that may address this research need that has not yet been published 

(e.g., research presented in conference proceedings, studies that you or a colleague have participated in but 

have yet to be published)?

Yes - Stellplug and colleagues (2022) examined data from 130 consecutive patients after non-fatal strangulation in a 

single sexual assault nurse examiner (SANE) program; a ratio of 1 to 23 patients receiving CTA had a positive finding 

and that patient had visible neck injuries. Zubieri and colleagues reviewed data from 142 consecutive patients with 

CTA following strangulation. CTA of the neck revealed 21 patients to have acute injuries (15.5%, 95% CI 9.5, 21.4) 

including 6 initially reported vascular injuries (4.2%, 95% CI 0.9, 7.5). Although neck pain (73, 51.4%), loss of 

consciousness (67, 47.2%), and headache (31, 21.8%) were frequently reported in the ROS, their predictive value of 

vascular injury was weak (4.1%, 4.5%, and 3.2%, respectively). On physical exam, redness/bruising of the neck (73, 

51.4%) and neck tenderness (47, 33.1%) were both the most common and had the highest prevalence (19.2% and 

12.8%, respectively), however, when selecting for vascular injuries alone were found to have low predictive yield 

(vascular injury 4.1% and 2.1%, respectively). The above statistics were based on the initial radiologist report and 

Emergency Department findings. After retrospective review, 3 Grade 1 BIFFL vascular injuries were identified (2.1%), 

with one false negative case (0.7%). Limitations of both studies include retrospective chart review with small 

samples. More data using large samples of both retrospective and prospective data are needed to identify evidencebased decision rules for CTA following non-fatal strangulation and systematically examine potential risks of more 

liberal CTA (e.g., radiation exposure, additional patient trauma, cost) and consequences of a more conservative 

approach (especially missed potentially fatal vascular events, failure to validate patient concerns). 
FINAL by: OSAC Program Office; Version 2, January 13, 2020 2 

3. Key bibliographic references relating to this research need: (ex.: Toll, L., Standifer, K. M., Massotte, D., eds. 

(2019). Current Topics in Opioid Research. Lausanne: Frontiers Media SA. doi: 10.3389/978-2-88963-180-3)

Clarot, F., Vaz, E., Papin, F., & Proust, B., (2005). Fatal and non-fatal bilateral delayed carotid artery 

dissection after manual strangulation. Forensic Science International, 149, 143-150. DOI: 

10.1016/j.forsciint.2004.06.009

McClane, G. E., Strack, G. B., & Hawley, D. (2001). A review of 300 attempted strangulation cases, part II: 

clinical evaluation of the surviving victim. Journal of Emergency Medicine, 21(3), 311-315

Patch, M., Dugan, S., Green, W., & Anderson, J.C. (2022). Emergency evaluation of nonfatal strangulation 

patients: A commentary on controversy and care priorities. Journal of Emergency Nursing, 48(3), 243-247.

https://doi.org/10.1016/j.jen.2022.03.003

Patch, M., Farag, Y., Anderson, T., Perrin, N., Kelen, G., & Campbell, J. (2021). United States ED visits by adult 

women of nonfatal intimate partner strangulation 2006 to 2014: Prevalence and associated characteristics. 

Journal of Emergency Nursing, 47(3), 437-448. https://doi.org/10.1016/j.jen.2021.01.008

Prosser, D. D., Grigsyby, T., & Pollock, J. M. (2018). Unilateral anoxic brain injury secondary to strangulation 

identified on conventional and arterial spin-labeled perfusion imaging. Radiology Case Reports, 13, 563-567. 

doi: 10.1016/j.radcr.2018.02.004

Shields, L.B., Corey, T.S., Weakley-Jones, B., & Stewart, D. (2010). Living victims of strangulation: a 10 year 

review of cases in a metropolitan community. The American Journal of Forensic Medicine and Pathology, 

31(4), 320-325.

Sorenson, S., Joshi, M., & Sivitz, E. (2014). A systematic review of the epidemiology of nonfatal strangulation, 

a human rights and health concern. American Journal of Public Health, 104, e54-e61. DOI: 

10.2105/AJPH.2014.302191

Stellpflug, S.J., Taymor, A.D., Dooley, A.E., Carlson, A.M., & LeFevere, R. C. (2022). Analysis of a consecutive 

retrospective cohort of strangulation victims evaluated by a sexual assault nurse examiner consult service. 

Journal of Emergency Nursing, 48(3), 257-265. https://doi.org/10.1016/j.jen/2022.01.001

Stellpflug, S.J., Weber, W., Dietrich, A., Springer, B., Polansky, R., Sachs, C., Hsu, A., McGuire, S., Gwinn, C., 

Strack, G., & Riviello, R. (2022b). Approach considerations for the management of strangulation in the 

emergency department. Journal of the American College of Emergency Physicians Open, 3(2), e12711.

https://doi.org/10.1002/emp2.12711

Zuberi, O., Dixon, T., Richardson, A., Gandhe, A., Hadi, M., & Joshi, J. (2019). CT angiograms of the neck in 

strangulation victims: Incidence of positive findings at a level one trauma center over a 7-year period. 

Emergency Radiology, 1-10. https://doi.org/10.1007/s10140-019-01690-3 
FINAL by: OSAC Program Office; Version 2, January 13, 2020 3 

4. Review the annual operational/research needs published by the National Institute of Justice (NIJ) at 

https://nij.ojp.gov/topics/articles/forensic-science-research-and-development-technology-working-groupoperational#latest? Is your research need identified by NIJ?

No.

5. In what ways would the research results improve current laboratory capabilities?

Not relevant to laboratory capabilities.

6. In what ways would the research results improve understanding of the scientific basis for the 

subcommittee(s)?

Controversy exists currently regarding use of CTA after non-fatal strangulation; research results would 

support evidence-based decision models for when to use CTA after non-fatal strangulation.

7. In what ways would the research results improve services to the criminal justice system?

Relevance to the criminal justice system is to prevent morbidity and mortality associated with violent 

strangulation and support prosecution of cases of non-fatal strangulation by validating potential lethality 

and identifying and documenting injuries that might be otherwise undetectable.

8. Status assessment (I, II, III, or IV):

II Major gap in 

current 

knowledge

Minor gap in 

current 

knowledge

No or limited

current research is 

being conducted I III

Existing current 

research is being 

conducted II IV

This research need has been identified by one or more subcommittees of OSAC and is being provided as an 

informational resource to the community.