CASE REPORT Delayed Left Anterior and Middle Cerebral Artery Hemorrhagic Infarctions After Attempted Strangulation A Case Report Prahlad K. Sethi, MD,* Nitin K. Sethi, MD,Þ Josh Torgovnick, MD,þ and Edward Arsura, MD§ Abstract: The 2 common carotid arteries bifurcate in the neck into the internal and external carotid arteries. The internal carotid artery enters the skull and further divides into the anterior and middle cerebral artery. During its short course in the neck, the carotid artery travels encased in the carotid sheath along with the vagus nerve and the internal jugular vein. During its course in the neck, the carotid artery is quite superficial, making it vulnerable to both penetrating and blunt traumatic injuries. We report here a case of a 40-year-old man who presented to the emergency department after sudden collapse and loss of consciousness a day after an attempted strangulation. Imaging revealed large hemorrhagic infarcts in the left anterior cerebral artery and middle cerebral artery territories as well as a smaller infarcts in the right anterior cerebral artery territory necessitating emergency decompressive hemicraniectomy. Our case report adds to the existing literature on nervous system injury due to strangulation. Physicians should be aware of the possibility of delayed presentation of neurological deficit after attempted strangulation. Key Words: strangulation, stroke, hemorrhagic infarctions (Am J Forensic Med Pathol 2012;33: 105Y106) artery territories as well as a smaller infarct in the right anterior cerebral artery territory with surrounding cytotoxic edema and midline shift (Fig. 1). Urgent decompressive hemicraniectomy was performed after which the patient was stabilized in the neurological intensive care unit (Fig. 1). An MR angiograph (MRA) of the brain and neck vessels showed normal vessels in the neck. The circle of Willis appeared to show normal communicating arterial connections, but the M2 segment of the left middle cerebral artery (MCA) had decreased branching, although no thrombus was visualized (Fig. 2). Carotid Doppler, 2-dimensional echocardiogram, and hypercoagulable workup were unrevealing. Despite all supportive measures, he died after 7 days of presentation because of sepsis and multiorgan failure. Taking the history of attempted strangulation into consideration, an autopsy was requested. The patient’s wife initially acceded to our request but, after consultation with extended family members, revoked it. She later admitted to us in private that it was fear of reprisal from her brother-in-law that made her deny our request for an autopsy. On the death certificate, the cause of death was listed as hemorrhagic cerebral infarction. CASE REPORT DISCUSSION A 40-year-old man was brought to the emergency department (ED) after he reportedly collapsed and lost consciousness while sitting in a shop. His wife denied any history of cerebrovascular and cardiovascular disease risk factors but, on further probing, volunteered a history of attempted strangulation approximately 24 hours previously. As per the wife, the patient got into an altercation with his brother. During the altercation, his brother held him by the neck, forcibly pinning him against the wall. While the asphyxia (attempted strangulation) was reported to last approximately a minute, it was so severe that his eyes turned red and he gasped for breath. After the attempted strangulation, he reportedly felt exhausted and went to bed. A day after the alleged strangulation attempt, he suddenly collapsed and lost consciousness while sitting in his shop. In the ED, the patient was in deep comatose and became decerebrate to painful stimulus. He had a dilated and fixed left pupil, and both eyes revealed stigmata of subconjunctival and retinal hemorrhages. Urgent noncontrast computed tomographic scan and magnetic resonance (MR) scan of the head revealed large hemorrhagic infarcts in the left middle and anterior cerebral The dictionary definition of strangulation is the act of suffocating someone by mechanical constriction of the neck structures. Domestic violence leading to strangulation is common and frequently underreported but can have dire consequences. Malek et al1 reported 3 cases of strangulation-induced bilateral dissection of the cervical carotid arteries. All 3 of their reported cases were young women who were victims of manual strangulation committed by their spouses. Their patients had delayed cerebral infarctions presenting between 3 months and as long as 1 year afterward. Angiography demonstrated evidence of focal mirror-image severe stenosis in the cervical internal carotid artery characteristic of healed chronic dissection. Thomas and Lowitt2 reported an interesting case of a 41-year-old woman who suddenly collapsed at home. When evaluated soon after in the ED, she was noted to be aphasic and had left hemiparesis. A computed tomographic scan was suggestive of an acute right MCA infarct, whereas an angiogram showed a filling defect above the bifurcation of the right internal carotid artery with abrupt termination and no filling of the right MCA consistent with an embolus. Their patient, too, had been a victim of spousal abuse, and 4 months before her clinical presentation, her ex-husband had attempted to strangulate her. Delayed postanoxic encephalopathy after strangulation has been reported, too. Hori et al3 reported a 13-year-old adolescent boy who was a victim of attempted strangulation by a burglar with resultant loss of consciousness for approximately 2 hours. When evaluated in the hospital 4 hours after the alleged assault, he was fully alert, and neurological examination remained normal through the sixth day after the assault. On the seventh day, however, he exhibited choreoathetosis of the arms and the trunk, and later, apathy, dysphagia, and dysarthria appeared. T2-weighted MR imaging revealed low-density and high-signal Manuscript received June 13, 2010; accepted July 14, 2010. From the *Department of Neurology, Sir Ganga Ram Hospital, New Delhi, India; †Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center; and Departments of ‡Neurology and §Medicine, Saint Vincent’s Hospital and Medical Centers, New York, NY. The authors report no conflicts of interest. Reprints: Nitin K. Sethi, MD, Comprehensive Epilepsy Center, New York-Presbyterian Hospital, Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065. E-mail: sethinitinmd@hotmail.com. Copyright * 2012 by Lippincott Williams & Wilkins ISSN: 0195-7910/12/3301Y0105 DOI: 10.1097/PAF.0b013e3182198672 Am J Forensic Med Pathol & Volume 33, Number 1, March 2012 www.amjforensicmedicine.com Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 105 Am J Forensic Med Pathol Sethi et al intensities in both deep gray nuclei. The authors hypothesized that the delayed onset of neurological deficits after strangulation were due to the biochemical alterations that followed anoxia in the basal ganglia nuclei. There was another interesting case report by Kiani and Simes4 who reported a 24-year-old man presenting after a fishing accident during which he was pulled underwater by a rope attached to a crayfish pot. When winched out of the water, he still had the rope wrapped around his neck. After initial resuscitation, he remained fully conscious for approximately 8 hours, after which he had a sudden and rapid decrease in sensorium. Carotid angiography revealed bilateral internal carotid artery thrombosis, which ultimately led to his demise. These case reports highlight the diverse mechanisms via which strangulation can result in central nervous system injury. These include traumatic dissection of the cervical carotid arteries with resultant stroke as in the 3 cases of Malek et al. Thomas and Lowitt and Kiani and Simes reported cases of traumatic strangulation that likely resulted in an injury to the carotid endothelium with resultant clot formation. In the case of Thomas and Lowitt, fragments of the clot further embolized with resultant stroke 4 months after the attempted strangulation. In the case reported by Hori et al, the mechanism of injury was likely a combination of mechanical obstruction of the airway, occlusion of the carotid arteries, and blocked venous return via the jugular vein. In our case, we hypothesize that the attempted strangulation resulted in injury to the carotid endothelial lining with resultant clot formation. Either this ‘‘new’’ clot or a preexisting thrombus further embolized into the intracranial circulation leading to bilateral hemorrhagic infarcts. Magnetic resonance angiography of the brain did show decreased branching of the M2 segment of the left MCA, although no thrombus was visualized and neck vessels were clear. & Volume 33, Number 1, March 2012 FIGURE 2. Magnetic resonance angiogram of the brain and neck vessels showing normal vessels in the neck with decreased branching of the M2 segment of the left MCA, although no thrombus is visualized. Our case report adds to the existing literature on nervous system injury due to strangulation. Although our case is not one of domestic violence, our literature review highlights that strangulation in the context of domestic violence frequently goes unreported and undetected in the emergency care setting. This may be due to a multitude of factors such as guilt, shame, and fear of reprisal. Strangulation is a relatively common mode of domestic violence, and physicians may play an important role in ascertaining its various causes and instituting appropriate interventions to help reduce its incidence while at the same time educating the public. The importance of seeking information of a forensic nature, although the patient may first present in a traditional clinical setting such as an ED, is emphasized. Lastly, physicians should be aware of the possibility of delayed presentation of neurological deficit after attempted strangulation. In some neurologically ‘‘intact’’ patients presenting to the ED after strangulation or history of neck trauma, a period of observation and computed tomographic scanning of the head and neck and Doppler sonography may be indicated. REFERENCES 1. Malek AM, Higashida RT, Halbach VV, et al. Patient presentation, angiographic features and treatment of strangulation-induced bilateral dissection of the cervical internal carotid artery. Report of three cases. J Neurosurg. 2000;92(3):481Y487. 2. Thomas P, Lowitt NR. A traumatic experience. N Engl J Med. 1995;333(5):307Y310. FIGURE 1. T1-weighted MR image showing large hemorrhagic infarcts in the left middle and anterior cerebral artery territories as well as a smaller infarct in the right anterior cerebral artery territory with surrounding cytotoxic edema and midline shift. Decompressive hemicraniectomy is also seen. 106 www.amjforensicmedicine.com 3. Hori A, Hirose G, Kataoka S, et al. Delayed postanoxic encephalopathy after strangulation. Serial neuroradiological and neurochemical studies. Arch Neurol. 1991;48(8):871Y874. 4. Kiani SH, Simes DC. Delayed bilateral internal carotid artery thrombosis following accidental strangulation. Br J Anaesth. 2000;84(4):521Y524. * 2012 Lippincott Williams & Wilkins Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.