PAPER PATHOLOGY ⁄ BIOLOGY Petr Hejna, 1 M.D., Ph.D. Amussat’s Sign in Hanging—A Prospective Autopsy Study ABSTRACT: Amussat’s sign is typically a transverse laceration of the intimal layer of carotid arteries described in cases of hanging. Subtotal lac- eration of the carotid artery is not strictly specific for hanging and can be also caused by blunt neck trauma, extreme overstretching, or whiplash-inju- ries. In a prospective autopsy study of 178 cases of hanging, Amussat’s sign was found in 29 cases (a relative frequency of 16.1%). A statistically significant association between the occurrence of tears in the intimal layer of carotid arteries and the victims’ age was discovered in the cases studied (the frequency increased with age; p < 0.05). The occurrence of Amussat’s sign was independent of gender, weight, completeness of the victim’s body suspension, and position of the ligature knot on the neck. The study demonstrates the fact that the most probable cause of Amussat’s sign is a combination of direct compression of the artery by the rope and indirect stretching because of the gravitational drag produced by the weight of the body. KEYWORDS: forensic science, hanging, Amussat’s sign, cervical vessels, vital sign, autopsy Hanging is a form of ligature strangulation in which the force applied to the neck derives from the gravitational drag of the victim’s body weight. The most important signs in the diagnostics of hanging are internal neck injuries (1,2). Such vital findings are evidence of a premortem origin of hanging. Ligature marks them- selves are mainly a postmortem phenomenon (3). Injury to cervical vessels as a result of hanging is one such basic diagnostic sign. The best known is the so-called Amussat’s sign (4), i.e., transverse laceration in the intimal layer of the carotid artery (Fig. 1). Only rarely are these breaches oriented longitudinally. It is possible to have multiple tears (Fig. 2) and subintimal hematomas can be found around them. It must be emphasized that subtotal lacerations of the carotid artery are not specific for hanging only, but can also be caused by blunt neck trauma, extreme overstretching (5), or whiplash-injuries (6). In rare cases, intimal layer tears are combined with tears to the media or adventitia of the artery. Injuries to the intimal layer can even result in dissection of the medial layer of the carotid artery, with subsequent narrowing of its lumen (7,8). Such traumatic rup- ture in the artery wall can also be a morphological substrate for the potential formation of wall thrombosis and subsequent cerebral ischemia in surviving patients (1,9). Large subintimal hematomas (10) or intramural bleeding can also result in the narrowing of the arterial lumen. Injuries of a similar nature occur also in the area of the vertebral arteries, and with an even higher frequency than in carotid arteries (11), especially in judicial hanging (12). Neverthe- less, the carotid and vertebral arteries are not strictly comparable in mechanical terms. The objective of this paper is a descriptive analysis and statistical evaluation of injuries to the intimal layer of the carotid arteries and internal jugular veins in the hanging victims studied. The possibility of an association between the type of hanging, the completeness of the victim’s body suspension, the victim’s weight, gender, age, and the occurrence of Amussat’s sign in carotid arteries and internal jugular veins, respectively, was explored. Materials and Methods A prospective, consecutive, and continuous group of cases of hanging was set up from autopsies carried out at the Institute of Legal Medicine in Hradec KrµlovØ within the period of 2005–2007 (36 months in total). The entire group comprised suicide cases with the exception of one accident. In the given time period, a total of 2226 autopsies were carried out, of which there were 185 cases of hanging; 7 cases of hanging were excluded because of advanced putrefaction (severe devastation of neck organs by insects). In addi- tion to autopsy findings, all cases underwent full police investiga- tions with reviews of previous histories and circumstantial evidence. The point of the ligature knot was determined on the basis of the appearance of the ligature line, its course, depth and width, and the available anamnesis, including photodocumentation of the place where the body was found. A possible association between the occurrence of Amussat’s sign and the types of ligatures was not studied. For the identification and quantification of intimal tears in the carotid arteries and internal jugular veins in connection with the location of ligature knots, all cases were divided into four catego- ries according to the position of the knot on the neck (I–IV, Fig. 3). In cases of posterior hanging (I), the ligature knot was situ- ated in the posterior midline, the limit was the inner side of the mastoid process. In cases of anterior hanging (II), the ligature knot was situated in the anterior midline, the limit was the inner side of the sternocleidomastoid muscle. When the ligature knot was placed on the sides of the neck or head between mentioned limits (on the 1 Institute of Legal Medicine, Charles University in Prague, Simkova 870, 500 38 Hradec KrµlovØ, Czech Republic. Received 5 June 2009; and in revised form 29 Sept. 2009; accepted 31 Oct. 2009. J Forensic Sci, January 2011, Vol. 56, No. 1 doi: 10.1111/j.1556-4029.2010.01548.x Available online at: interscience.wiley.com 132 Ó 2010 American Academy of Forensic Sciences