AJR 2002; 178:214
© American Roentgen Ray Society
Trauma Cases from Harborview Medical Center |
Radiologic Evaluation of Attempted Suicide by Hanging
Cricotracheal Separation and Common Carotid Artery Dissection
Ken F. Linnau1 and
Wendy A. Cohen
1
Both authors: Department of Radiology, Harborview Medical Center, 325 Ninth
Ave., Box 359728, Seattle, WA 98104-2499.
Received May 11, 2001;
accepted after revision May 11, 2001.
This is another in the continuing series on radiology in trauma cases from
the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Lee
B. Talner.
Address correspondence to F. A. Mann.
Introduction
A 33-year-old woman was comatose (Glasgow Coma Scale score of 3) after a
suicide attempt by hanging, and resuscitation was initiated. After emergent
tracheostomy for cricoid fracture—dislocation and cricotracheal
disruption, sequenced CT angiography of the neck
(Fig. 1A) and catheter
angiography of the carotid arteries (Fig.
1B) showed subintimal hematomas in both common carotid arteries.
Luminal diameter was narrowed by 60% on the right side and 30% on the left.
Emergent open reduction and internal fixation of the cricoid fracture and
repair of bilateral carotid dissections were performed. Despite an evolving
ischemic infarction in the right middle cerebral artery territory with
left-sided hemiplegia, the patient became increasingly responsive and was
discharged for rehabilitation.
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Fig. 1A. —33-year-old woman who attempted suicide by hanging. When
interpreting imaging studies in trauma cases, it is useful to apply mnemonic
developed for resuscitation: ABCD. Airway maintenance, Breathing, Circulation:
CT angiogram shows fracture—dislocation of cricoid cartilage and severe
obstruction of airway by soft-tissue swelling (arrowheads). Bilateral
common carotid artery dissections are depicted as crescentic nonenhancement of
abnormally round vessels (arrows). Patency of jugular veins and
vertebral arteries is shown (asterisks). Soft-tissue emphysema caused
by airway disruption is present.
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Fig. 1B. —33-year-old woman who attempted suicide by hanging. When
interpreting imaging studies in trauma cases, it is useful to apply mnemonic
developed for resuscitation: ABCD. Disability: Digital subtraction angiogram
of right common carotid artery shows subintimal dissection (arrow).
Downstream margin of subintimal hematoma shows irregularity toward bifurcation
(arrowhead), suggestive of clot and most likely source of emboli to
right middle cerebral artery.
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Asphyxia, venous occlusion, and arterial occlusion are believed to be the
major factors contributing to death in nonjudicial hanging
[1]. An organized approach such
as the AB-CDs of trauma resuscitation aids in diagnosis:
- Airway compromise in suicidal hanging may be caused by soft-tissue
hemorrhage, softtissue swelling, fracture of the laryngeal skeleton (thyroid
cartilage > hyoid bone > cricoid cartilage)
[2], airway disruption, and
occlusion by the ligature [3].
In suicide attempts by hanging, unlike in judicial hanging, the lower
magnitude of injuring forces to the neck rarely results in fractures of the
cervical spine and injuries of the spinal cord
[2]. Nevertheless, cervical
spine immobilization and protection is mandatory throughout resuscitation. A
near-hanging victim may present with stridor or severe hoarseness (Fig.
1A,1B)
[1].
- Breathing abnormalities may be the result of acute or delayed airway
obstruction (glottis edema) or autonomic reflex activity
[3]. Agonal or absent
respirations, absent heart beat, and a pH below 7.2 on arrival of patients at
the emergency department worsen prognosis
[1]. Pulmonary complications,
which include aspiration pneumonia, pulmonary edema, and adult respiratory
distress syndrome, cause most in-hospital deaths of near-hanging victims
[4].
- Circulatory collapse may result from mechanical stimulation of the carotid
sinus or pericarotid autonomous networks (reflex cardiac arrest). Brain
perfusion is diminished in all suicide attempts by hanging. Only 2 kg of
tension on a ligature around the neck is needed to block the jugular veins,
resulting in stagnant cerebral hypoxia
[5]. With loss of
consciousness, decreased muscle tone facilitates arterial obstruction and
intimal tears [1], which are
found at the level of the ligature in about 5% of autopsies of hanging victims
[5].
- Disability (severe to mild neurologic deficit) after suicide attempts by
hanging usually results from cerebral hypoxia. However, survivors often
recover fully and poor central nervous system function in the field (Glasgow
Coma Scale score of 3) may not presage poor outcomes
[3]. Therefore, aggressive
treatment in strangulation victims is warranted regardless of the initial
neurologic findings.
References
-
Iserson KV. Strangulation: a review of ligature, manual, and
postural neck compression injuries. Ann Emerg Med
1984;13:179
-185[Medline]
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Feigin G. Frequency of neck organ fractures in hanging.
Am J Forensic Med Pathol
1999;20:128
-130[Medline]
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Vander Krol L, Wolfe R. The emergency department management of
near-hanging victims. J Emerg Med
1994;12:285
-292[Medline]
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Kaki A, Crosby ET, Lui AC. Airway and respiratory management
following non-lethal hanging. Can J Anaesth
1997;44:445
-450[Abstract/Free Full Text]
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Polson CJ. Hanging. In: Polson CJ, Gee DJ, Knight B, eds.
The essentials of forensic medicine. Oxford: Pergamon,
1985: 357-388
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Introduction
References
