Ann Otol Rhinol Laryngol 108:1999 DIAGNOSTIC AND THERAPEUTIC MANAGEMENT OF BILATERAL CAROTID ARTERY OCCLUSION CAUSED BY NEAR-SUICIDAL HANGING WOLFGANG MAIER, MlLO FRADIS, M D MD HAIFA, ISRAEL FREIBURG, GERMANY SHELTON MALATSKEY, ANNETTE KREBS, MD MD FREIBURG, GERMANY HAIFA, ISRAEL In cases of attempted suicide by hanging, a combination of mechanisms causing local destruction of the pharynx, larynx, vessels, and spine, as well as neurologic complications, has to be considered. We present a case of hanging in which a deeply unconscious patient without any palpaple pulsation of the carotid arteries was referred to our otolaryngology department. Computed tomography and angiography showed parapharyngeal air, complete obstruction of both common carotid arteries, and a compensatory circulation through the vertebral arteries. Three hours after the trauma, surgical exploration with resection of the enrolled intima of both carotid arteries and repair of the pharynx was performed. The patient awoke with an infarct of the right hemisphere with incomplete left hemiparesis the next day, but symptoms slowly declined during the following months, and the patient learned swallowing again perfectly. We conclude from our experience that in near-hanged patients a prompt onset of adequate diagnostic and therapeutic measures is mandatory, as good neurologic and functional results may occur even in cases with coma and severe destruction of the carotid arteries and pharyngeal and laryngeal structures. Surgical repair of blunt carotid lesions is recommended and may be crucial for a good outcome. KEY WORDS — blunt carotid trauma, brain circulation, carotid artery, hanging, neck trauma, suicide. neurologic injuries were sustained. INTRODUCTION Hanging is the most common form of achieving death by suicide in Europe, and it is the third most frequent way of attempting suicide, following drug overdose and wrist-slashing.13 Almost half of suicides committed by men are by hanging.1-2 In the United States, firearm-related suicides are most common (and more frequent than in Canada, with its more restrictive firearm regulations), and hanging is the second most common method in the United States, followed by poisoning.4·5 From 1980 to 1992 in the United States, the proportion of suicide by hanging increased.4 CASE REPORT A 54-year-old man was admitted to the Freiburg University otolaryngology department after an attempted suicide by hanging. According to the relatives, the used rope broke, and the suicidal man fell and managed to crawl into the next room. The attending physician found the patient awake at first, but he rapidly became unconscious and had to be intubated. Then he was sent to the university hospital. On arrival, the patient was in a profound stuporous state. On his neck, there were circular marks made by the rope. The pulse could not be palpated over either carotid artery. Subcutaneous emphysema was found around the throat. A computed tomography (CT) scan of the brain showed no signs of intracerebral bleeding. Angiography of the carotid arteries revealed occlusion of both common carotid arteries in the middle third, just under the carotid bulb (Fig 1 A). Although the internal carotid arteries were not visualized, both anterior and posterior cerebral arteries and the left middle cerebral artery filled through the vertebral and basilar arteries and the circle of Willis (Fig IB). The right middle cerebral artery was not perfused. A Hanging can be classified as typical when the point of suspension is central over the occiput, and atypical when it is in any other position. In near-hanging cases, local injuries and neurologic complications do occur.6 The force necessary to cause obstruction of the arteries and the air passage is usually obtained by hanging in the typical position only.7 Hanging is considered to be complete if the whole body is suspended in the air, and incomplete if some part of the body touches the ground. We present a case of nearhanging in which vascular, pharyngolaryngeal, and From the Department of Otorhinolaryngology, University Hospital, Freiburg, Germany (Maier, Krebs), and the Department of Otolaryngology, Bnai Zion Medical Center, Haifa, Israel (Fradis, Malatskey). CORRESPONDENCE — Wolfgang Maier, MD, Dept of Otorhinolaryngology (HNO-Klinik), Universitätsklinik Freiburg, Killianstrasse 5, D79106 Freiburg, Germany. 189 Downloaded from aor.sagepub.com at INDIANA UNIV on May 10, 2015 190 Maier et al, Carotid Artery Occlusion by Hanging Fig 1. Angiography of head and neck arteries showed complete occlusion of both common carotid arteries. A) Right side shows contours of thrombus (arrows). On left side, dissection and occlusion were found, but no thrombus. These findings were confirmed intraoperatively. B) Anterior (a) and posterior (p) cerebral arteries and left middle (ml) cerebral artery filled well through vertebral (v) arteries, basilar (b) arteries, and circle of Willis (arrows). Right middle cerebral artery was not perfused in vertebral artery angiography. CT scan of the neck showed a fracture of the hyoid bone without displacement, and a suspected fracture of the upper margin of the thyroid cartilage. Subcutaneous emphysema and air pockets were present in the parapharyngeal, retropharyngeal, and paralaryngeal areas. The same night (3 hours after the attempted suicide), the patient underwent surgical exploration of Fig 2. Computed tomography scan of brain, 1 day after hanging, showing infarct of that region of right cerebral hemisphere that is perfused by right middle cerebral artery. the neck under general anesthesia. A vascular surgeon opened the carotid arteries by longitudinal incision after clamping the proximal and distal parts of the artery with vessel loops. On the right side, a thrombus was found and was extracted by a Fogarty catheter. Circulation was restored temporarily by insertion of an intraluminal shunt. A portion of the enrolled intima of the common carotid arteries was resected, and the intima was adapted to the arterial wall with U-shaped sutures. At the end of the operation, both carotid arteries were intact and had a good pulsation. In addition, a tear was found in the vallecula, between the epiglottis and the base of the tongue. The pharynx had been ruptured on both sides, between the lower poles of the tonsils and the pyriform sinuses, and only its posterior wall had intact mucosa. Both superior laryngeal nerves were intact, but extended by the trauma. The pharynx and the vallecula were sutured, and an epithelialized tracheostoma was created by otolaryngological surgeons. The patient was given low-dose heparin intravenously (10,000 IU/d), but when he awoke, he had a leftsided partial hemiparesis. Two days postoperatively, a CT scan showed an ischémie infarct in the region perfused by the right middle cerebral artery (Fig 2), and color flow Doppler sonography was performed. In this examination, we observed an obliteration of the left carotid artery, but the right side was well perfused. Thus, no therapeutic consequence resulted. Both vocal cords showed good mobility. When esophagography was performed with a water-soluble Downloaded from aor.sagepub.com at INDIANA UNIV on May 10, 2015 Maier et al, Carotid Artery Occlusion by Hanging 191 Dissection of the common carotid artery has been reported to occur as a result of hanging. ' ' In the reported case,11 the patient complained of attacks of numbness of the left upper extremity that increased 2 years after the hanging. Angiography was performed and demonstrated an 80% stenosis of the right common carotid artery. Histologie findings revealed dissection of the medial layer of the arterial wall. The symptoms disappeared after endarterectomy. The authors concluded that the stenosis was not due to arteriosclerosis, but rather, to dissection as a result of hanging. quired in comatose patients.8·14 In our case, the length of time of suspension could not be ascertained. Although the patient was conscious at first, he quickly became stuporous, and later, unconscious. Carotid pulses were not palpable. A free interval before the onset of unconsciousness is typical in cases of blunt carotid trauma, as dissection of the intimai layer and progressive thrombosis can follow a blunt carotid trauma with a latency period of up to 24 hours.15-17 Mooney and Bessen18 described a case of late onset of cerebral symptoms 2 weeks after blunt carotid trauma. Besides cerebral ischemia following common or internal carotid artery occlusion, cerebral embolization from a thrombus in the artery may also be causal for neurologic symptoms and may explain the latency of the onset of deficits.16 Intimai dissection can follow hyperextension or extreme flexion of the neck,19 and thus, also, hanging. Therefore, after neurologic examination, intensive observation, CT scan of the head and neck, and repeated color flow Doppler sonography20 are indicated in all patients who attempt suicide by hanging. If color flow Doppler sonography shows an intimai lesion, angiography and immediate surgery and reconstruction of the artery are indicated even if there is not yet a neurologic deficit.16 Mears and Leonard21 recommend angiography in all patients with neurologic symptoms, for cranial CT can be falsely negative. There is a common agreement that surgery is mandatory in patients with intimai lesions and no or only slight neurologic deficits, and in patients with progressive neurologic deterioration (stroke in evolution).16·20 Contraindications to surgical intervention are controversial. 16 · 17 · 19 - 22 In a follow-up of all patients with carotid trauma in North Carolina from 1987 to 1993, Ramadan et al20 describe a strikingly better outcome in those cases treated surgically as opposed to with conservative procedures. They recommend surgical treatment even in comatose patients. Brown et al22 recommend revascularization in comatose patients when ischemia has been present only a short period of time before surgery (as in the case reported here). Some authors decline to use surgery in cases with long dissections of the carotid artery up to the skull base,23 coma,16 or severe neurologic symptoms.24 They argue that those patients could sustain cerebral hemorrhage following revascularization.16 Hanging does not always result in death. Prompt release of the victim and aggressive resuscitation, even after prolonged periods of suspension and unconsciousness, increases the chance of survival.12 As stated by Bautz and Knottenbelt,13 initial care and resuscitation with intubation and ventilation are crucial. As unconsciousness, but not death, comes quickly after hanging, rapid diagnosis and therapy are re- In our case, quick surgical intervention revealed bilateral occlusion of the carotid arteries that had already been diagnosed angiographically and resulted in relatively minor impairment of the patient. The intima was adapted to the medial layer of the arterial wall and partially resected. The left-sided partial hemiparesis slowly improved without leaving longterm compromise. No cerebral hemorrhage resulted contrast medium 10 days postoperatively, the patient partially swallowed with aspiration, but this symptom improved slowly with intensive training. Neurologic deficits, too, slowly improved over the following months, leaving mild residual paresis of the forearm. Thus, due to prompt diagnostic measures and aggressive operative intervention, the patient survived with minimal functional deficit. DISCUSSION In suicidal hanging, the body usually does not fall from a high level. Therefore, the injuries rarely include dislocation or fracture of the cervical vertebrae. In a retrospective view of 35 cases of nearhanging, no cases of cervical spine fractures were found.8 Death by hanging is usually due to occlusion of the nerves and vessels of the neck, especially in cases of partial suspension.9 The mechanism of death in cases of complete suspension has been related to vagal stimulation by carotid sinus pressure, in addition to vascular and airway obstruction.9 Death has also been caused by hemorrhage and edema formation in the larynx with fracture of the hyoid bone or laryngeal cartilages. Fracture of the hyoid bone or laryngeal cartilage as occurred in our patient has been found in 36% of suicidal hangings. Fractures are related to increasing age, and are not found when a soft ligature is employed.10 In our patient, concurrent pharyngeal tears were diagnosed by direct endoscopy and immediately repaired. As hanging very often causes pharyngeal lesions,8 endoscopy under general anesthesia should be performed in all cases of near-hanging. Downloaded from aor.sagepub.com at INDIANA UNIV on May 10, 2015 192 Maier et al, Carotid Artery Occlusion by Hanging from revascularization. This outcome confirms that coma is not a contraindication to surgery when there is a short latency between trauma and surgical intervention.21 CONCLUSION Our case report shows that even in patients with unconsciousness accompanied by bilateral pulselessness and obstruction of the common carotid arter- ies, the compensatory circulation may be sufficient for a certain time to prevent permanent cerebral damage, given rapid diagnostic and therapeutic intervention. Thus, regardless of initial findings, rapid onset of diagnostic procedures and aggressive treatment of near-hanging victims should be initiated. As hanging may cause pharyngeal lesions, endoscopy under general anesthesia should be performed in all cases of near-hanging. REFERENCES 1. Etzersdorfer E, Fischer P, Sonneck G. Epidemiology of suicide in Austria 1980-1990. Wien Klin Wochenschr 1992;104: 594-9. 2. van Casteren V, van der Veken J, Tafforeau J, van Oyen H. Suicide and attempted suicide reported by general practitioners in Belgium, 1990-1991. Acta Psychiatr Scand 1993;87:4515. 3. Diekstra RFW, van Egmond M. Suicide and attempted suicide in general practice, 1979-1986. Acta Psychiatr Scand 1989;79:268-75. 4. Anonymous. Suicide among children, adolescents, and young adults — United States, 1980-1992. JAMA 1995;274: 451-2. 5. Sloan JH, Rivara FP, Reay DT, Ferris JA, Kellermann AL. Firearm regulations and rates of suicide. A comparison of two metropolitan areas. N Engl J Med 1990:322:369-73. 6. Bradshaw DA, Amundsen DE. Complications of suicidal hanging: a case report and brief review. Mil Med 1994; 159:7201. 7. Terazawa K, Akabane H, Nagao M, Wu B, Takatori T. An autopsy case of atypical hanging: were arteries and air passage obstructed? Jpn J Legal Med 1990;44:358-64. 8. van der Krol L, Wolfe R. The emergency department management of near-hanging victims. J Emerg Med 1994; 12: 285-92. 9. Elfawal MA, Awad OA. Deaths from hanging in the Eastern province of Saudi-Arabia. Med Sei Law 1994;34:307-12. 10. James R, Silcocks P. Suicidal hanging in Cardiff— a 15 year retrospective study. Forensic Sei Int 1992;56:167-75. 11. Noguchi K, Matsuoka Y, Hohda K, Katsuyama J, Nishimura S. A case of common carotid artery stenosis due to hanging. No Shinkei Geka 1992;20:1185-8. 12. Pradeep KG, Kanthaswamy V. Survival in hanging. Am J Forensic Med Pathol 1993;14:80-1. 13. Bautz P, Knottenbelt JD. Successful resuscitation from suicidal hanging: report of three cases. Injury 1994;25:111-2. 14. Brown VL, Espinosa J. Near-hanging injury: two case studies and an overview. J Emerg Nurs 1991;17:386-9. 15. Arseni C, Maretsis M, Dumitrescu L. Comments on the aetiology of indirect traumatic thrombosis of the internal carotid. Neurochirugia 1980;23:25-34. 16. Krajewski LP, Hertzer NR. Blunt carotid artery trauma. Report of two cases and review of the literature. Ann Surg 1980; 191:341-6. 17. Dauber A, Hoffmann K, Zenker H, Hufen V. Bilateral carotid artery stenosis following severe craniocervical trauma. Chirurg 1991;62:433-6. 18. Mooney RP, Bessen HA. Delayed hemiparesis following nonpenetrating carotid artery trauma. Am J Emerg Med 1988;6:341-5. 19. Fabian TC, George SM, Croce MA, Mangiante EC, Voeller GR, Kudsk KA. Carotid artery trauma: management based on mechanism of injury. J Trauma 1990;30:953-61. 20. Ramadan F, Rutledge R, Oiler D, Howell P, Baker C, Keagy B. Carotid artery trauma: a review of contemporary trauma center experiences. J Vase Surg 1995;21:46-56. 21. Mears GD, Leonard RB. Blunt carotid trauma: a case report. J Emerg Med 1988;6:281-4. 22. Brown MF, Graham JM, Feliciano DV, Mattox KL, Beall AC, De Bakey ME. Carotid artery injuries. Am J Surg 1982; 144: 748-53. 23. Richardson JD, Simpson C, Miller FB. Management of carotid artery trauma. Surgery 1988;104:673-80. 24. Davis JW, Holbrook TL, Hoyt DB, MacKersie RC, Field TO, Shackford SR. Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment. J Trauma 1990; 30:1514-7. Downloaded from aor.sagepub.com at INDIANA UNIV on May 10, 2015