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Magnetic resonance images in hanging
Resuscitation (2006) 69, 343—345
CASE REPORT
Magnetic resonance images in hanging夽 Takeshi Matsuyama ∗, Kazuo Okuchi, Tadahiko Seki, Takafumi Higuchi, Shingo Ito, Daisuke Makita, Tomoo Watanabe, Yoshinori Murao Department of Critical Care and Emergency Medicine, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Japan Received 25 February 2005 ; received in revised form 1 August 2005; accepted 1 August 2005 KEYWORDS Hanging; Global cerebral ischaemia; Cardiopulmonary arrest; MRI
Summary Hanging is a devastating method of suicide and unfortunately is common in Japan. Although several CT findings of the head have been reported, there have not been any reports about magnetic resonance imaging (MRI) in hanging. We report here interesting MRI findings in a patient after hanging. A 39-year-old woman was transferred to our department after attempting suicide by hanging. Respiration had probably ceased for about three minutes but heart had not stopped when she was pulled down by her father. After her father performed cardiopulmonary resuscitation, she started to breathe immediately. She was treated conservatively in our intensive care unit for 14 days, her condition became stable. Ten days after admission, MRI demonstrated symmetrical hyperintensity on T1-weighted images and relative hyperintensity on T2 weighted images in bilateral lentiform nuclei and medial thalami. There have been several reports about characteristic MRI findings in the case of acute global cerebral ischaemia caused by severe hypoglycaemia or longstanding cardiopulmonary arrest. It was postulated that these specific findings reflected tissue degeneration, deposition of mineral substances, or lipid accumulation. These MRI findings suggest that severe acute global cerebral hypoperfusion also occurs in hanging in the same way as in long-standing cardiopulmonary arrest and that hanging has devastating sequelae. © 2005 Elsevier Ireland Ltd. All rights reserved.
Introduction
夽
A Spanish translated version of the summary and keywords of this article appears as Appendix in the online version at 10.1016/j.resuscitation.2005.08.003. ∗ Corresponding author. Tel.: +81 7442 23051; fax: +81 7442 90818. E-mail address: [email protected] (T. Matsuyama).
Hanging is a devastating method of suicide and unfortunately is common in Japan. Patients who have attempted to hang themselves are usually transferred to the emergency department and neuroradiological investigations such as cervical Xray or computed tomography (CT) are performed. Although several CT findings of the head have been reported,1—3 there have not been any reports about magnetic resonance imaging (MRI) in hanging. We
0300-9572/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2005.08.003
344
T. Matsuyama et al.
Figure 1 (A) T1-weighted image of MRI showing symmetrical hyperintensity in bilateral lentiform nuclei and medial thalami. (B) T2 weighted image of MRI showing hyperintensity in bilateral lentiform nuclei and medial thalami.
discuss here MRI findings in the head in a patient who attempted suicide this way.
Case report A 39-year-old woman was transferred to our department after attempting suicide by hanging. She hung herself using a thick string fixed to a windowsill. Her father found her and pulled her down to the floor. Respiration had probably ceased for about three minutes but the heart had not stopped from the account of her father. After her father performed cardiopulmonary resuscitation, she started to breathe spontaneously immediately. On admission, she was in coma with spontaneous regular respiration. Her pupils were equal and reacted sluggishly to light. A ligature mark was identified on the front side of the neck. Blood pressure was 128/76 mmHg. Heart rate was 120/min. Temperature was 36.7 ◦ C. The corneal reflex was present and doll’s eye test was positive. The patient was intubated because of the risk of an obstructed airway. Four hours after admission, computed tomography (CT) of the head disclosed normal findings. However, the patient developed generalized
convulsions, which were suppressed by serially intravenously administered diazepam. Eight hours after admission, the patient developed a decerebrate posture, hyperhydrosis on the upper body and Cheyne—Stokes respiration. CT disclosed diffuse brain swelling, many low-density spots in the cerebral cortex and relatively low-density spots in bilateral basal ganglia. Ten days after admission, MRI demonstrated symmetrical hyperintensity on T1-weighted images and hyperintensity on T2 weighted images in bilateral lentiform nuclei and medial thalami (Figure 1). She was treated conservatively in our intensive care unit for 14 days, her condition became stable, and was discharged to another hospital in a persistent vegetative state.
Discussion There have been several reports regarding specific CT changes in hanging1—3 Characteristic findings are symmetrical low-density spots in bilateral basal ganglia and thalami. In addition, lowdensity spots in the cerebral cortex and watershed zones are identified. These findings can be recognized in some hypoxic conditions such as carbon monoxide,4 cyanide5 and methanol intoxication,6
Magnetic resonance images in hanging hypoglycaemia,7 drowning8 and acute global cerebral ischemia.9 It is reported that the mechanism of these lesions may be based on the selective vulnerability of these regions. These regions have larger metabolic requirements than other regions in the cerebrum although there is poor vascularity because they are the boundary zone of cerebral perfusion and acute cerebral hypoxia can be easily precipitated in these regions.10,11 In hanging, there are several factors influencing cerebral ischaemia including autonomic hyperactivity leading to cardiac arrest, airway compromise by upward displacement of the tongue and epiglottis, jugular vein occlusion by mild compression, carotid artery occlusion by moderate compression and vertebral artery occlusion due to spine injuries.10 These combined factors can lead to acute global cerebral hypoxia more easily than other single conditions producing cerebral hypoperfusion, although cardiac arrest did not occur in this case. There have been several reports about characteristic MRI findings in the case of acute global cerebral ischaemia caused by severe hypoglycaemia or longstanding cardiopulmonary arrest.12,13 MRI revealed that hyperintensity on the T1-weighted image and hyperintensity on the T2-weighted image in basal ganglia and thalami at the chronic state corresponded with the CT findings. It was postulated that these specific findings reflected tissue degeneration, deposition of mineral substances, or lipid accumulation. In contrast, there have been no reports of MRI findings in patients who committed suicide by hanging. The reason is that they usually die, and few attempts to obtain further neuroradiological information are made other than cervical spine Xray and CT. In our case, the patient was resuscitated and survived, and thus MRI findings could be obtained. The MRI pattern of bilateral iso and hyperintensity (T1-image) and hyperintensity (T2images) in basal ganglia and thalami was recognized although respiration had stopped for a few minutes, suggesting that severe acute global cerebral hypoperfusion also occurs in hanging in the same way as in long-standing cardiopulmonary arrest and
345 that hanging may be accompanied by devastating sequelae.
Conclusions Bilateral iso and hyperintensity observed on the T1image and hyperintensity observed on the T2-image in basal ganglia and thalami are the characteristic MRI findings in hanging. It is confirmed that hanging produces several complications leading to severe global hypoxic insults.
References 1. Bianco F, Floris R. Computed tomography abnormalities in hanging. Neuroradiology 1987;29:297—8. 2. Brancatelli G, Sparacia G, Midiri M, Sarco C, Lagalla R. Brain damage in hanging: a new CT finding. Neuroradiology 2000;42:209—10. 3. Ohkawa S, Yamadori A. CT in hanging. Neuroradiology 1993;35:591. 4. Kim KS, Weinberg PE, Suh JH, Ho SU. Acute carbon monoxide poisoning: computed tomography of the brain. AJNR 1980;1:399—402. 5. Finelli PF. Case report: changes in the basal ganglia following cyanide poisoning. J Comput Assist Tomogr 1981;5:755—6. 6. Aquilonios SM, Bergstrom K, Enoksson P. Cerebral computed tomography in methanol intoxication. J Comput Assist Tomogr 1980;4:425—8. 7. Kaiser MC, Pettersson H, Harwood-Nash DC, Fitz CR, Chung S. Case report: computed tomography of the brain in severe hypoglycaemia. J Comput Assist Tomogr 1981;5:757—9. 8. Murray RR, Kapila A, Blanco E, Kagan-Hallet KS. Cerebral computed tomography in drowning victims. AJNR 1984;5:177—9. 9. Kjos BO, Brant-Zawadzki M, Young RG. Early CT findings of global central nervous system hyoperfusion. AJNR 1983;4:1043—8. 10. McHugh TP, Stout M. Near-hanging injury. Ann Emerg Med 1983;12:774—6. 11. Nemoto EM. Patjogenesis of cerebral ischemic anoxia. Crit Care Med 1978;6:203—14. 12. Fujioka M, Okuchi K, Hiramatsu K, Sakaki T, Miyamoto S, Iwasaki S. Specific changes in human brain following reperfusion after cardiac arrest. Stroke 1994;25:2091—5. 13. Fujioka M, Okuchi K, Hiramatsu K, Sakaki T, Sakaguchi S, Ishii Y. Specific changes in human brain after hypoglycemic injury. Stroke 1997;28:584—7.
CASE REPORT
Magnetic resonance images in hanging夽 Takeshi Matsuyama ∗, Kazuo Okuchi, Tadahiko Seki, Takafumi Higuchi, Shingo Ito, Daisuke Makita, Tomoo Watanabe, Yoshinori Murao Department of Critical Care and Emergency Medicine, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Japan Received 25 February 2005 ; received in revised form 1 August 2005; accepted 1 August 2005 KEYWORDS Hanging; Global cerebral ischaemia; Cardiopulmonary arrest; MRI
Summary Hanging is a devastating method of suicide and unfortunately is common in Japan. Although several CT findings of the head have been reported, there have not been any reports about magnetic resonance imaging (MRI) in hanging. We report here interesting MRI findings in a patient after hanging. A 39-year-old woman was transferred to our department after attempting suicide by hanging. Respiration had probably ceased for about three minutes but heart had not stopped when she was pulled down by her father. After her father performed cardiopulmonary resuscitation, she started to breathe immediately. She was treated conservatively in our intensive care unit for 14 days, her condition became stable. Ten days after admission, MRI demonstrated symmetrical hyperintensity on T1-weighted images and relative hyperintensity on T2 weighted images in bilateral lentiform nuclei and medial thalami. There have been several reports about characteristic MRI findings in the case of acute global cerebral ischaemia caused by severe hypoglycaemia or longstanding cardiopulmonary arrest. It was postulated that these specific findings reflected tissue degeneration, deposition of mineral substances, or lipid accumulation. These MRI findings suggest that severe acute global cerebral hypoperfusion also occurs in hanging in the same way as in long-standing cardiopulmonary arrest and that hanging has devastating sequelae. © 2005 Elsevier Ireland Ltd. All rights reserved.
Introduction
夽
A Spanish translated version of the summary and keywords of this article appears as Appendix in the online version at 10.1016/j.resuscitation.2005.08.003. ∗ Corresponding author. Tel.: +81 7442 23051; fax: +81 7442 90818. E-mail address: [email protected] (T. Matsuyama).
Hanging is a devastating method of suicide and unfortunately is common in Japan. Patients who have attempted to hang themselves are usually transferred to the emergency department and neuroradiological investigations such as cervical Xray or computed tomography (CT) are performed. Although several CT findings of the head have been reported,1—3 there have not been any reports about magnetic resonance imaging (MRI) in hanging. We
0300-9572/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2005.08.003
344
T. Matsuyama et al.
Figure 1 (A) T1-weighted image of MRI showing symmetrical hyperintensity in bilateral lentiform nuclei and medial thalami. (B) T2 weighted image of MRI showing hyperintensity in bilateral lentiform nuclei and medial thalami.
discuss here MRI findings in the head in a patient who attempted suicide this way.
Case report A 39-year-old woman was transferred to our department after attempting suicide by hanging. She hung herself using a thick string fixed to a windowsill. Her father found her and pulled her down to the floor. Respiration had probably ceased for about three minutes but the heart had not stopped from the account of her father. After her father performed cardiopulmonary resuscitation, she started to breathe spontaneously immediately. On admission, she was in coma with spontaneous regular respiration. Her pupils were equal and reacted sluggishly to light. A ligature mark was identified on the front side of the neck. Blood pressure was 128/76 mmHg. Heart rate was 120/min. Temperature was 36.7 ◦ C. The corneal reflex was present and doll’s eye test was positive. The patient was intubated because of the risk of an obstructed airway. Four hours after admission, computed tomography (CT) of the head disclosed normal findings. However, the patient developed generalized
convulsions, which were suppressed by serially intravenously administered diazepam. Eight hours after admission, the patient developed a decerebrate posture, hyperhydrosis on the upper body and Cheyne—Stokes respiration. CT disclosed diffuse brain swelling, many low-density spots in the cerebral cortex and relatively low-density spots in bilateral basal ganglia. Ten days after admission, MRI demonstrated symmetrical hyperintensity on T1-weighted images and hyperintensity on T2 weighted images in bilateral lentiform nuclei and medial thalami (Figure 1). She was treated conservatively in our intensive care unit for 14 days, her condition became stable, and was discharged to another hospital in a persistent vegetative state.
Discussion There have been several reports regarding specific CT changes in hanging1—3 Characteristic findings are symmetrical low-density spots in bilateral basal ganglia and thalami. In addition, lowdensity spots in the cerebral cortex and watershed zones are identified. These findings can be recognized in some hypoxic conditions such as carbon monoxide,4 cyanide5 and methanol intoxication,6
Magnetic resonance images in hanging hypoglycaemia,7 drowning8 and acute global cerebral ischemia.9 It is reported that the mechanism of these lesions may be based on the selective vulnerability of these regions. These regions have larger metabolic requirements than other regions in the cerebrum although there is poor vascularity because they are the boundary zone of cerebral perfusion and acute cerebral hypoxia can be easily precipitated in these regions.10,11 In hanging, there are several factors influencing cerebral ischaemia including autonomic hyperactivity leading to cardiac arrest, airway compromise by upward displacement of the tongue and epiglottis, jugular vein occlusion by mild compression, carotid artery occlusion by moderate compression and vertebral artery occlusion due to spine injuries.10 These combined factors can lead to acute global cerebral hypoxia more easily than other single conditions producing cerebral hypoperfusion, although cardiac arrest did not occur in this case. There have been several reports about characteristic MRI findings in the case of acute global cerebral ischaemia caused by severe hypoglycaemia or longstanding cardiopulmonary arrest.12,13 MRI revealed that hyperintensity on the T1-weighted image and hyperintensity on the T2-weighted image in basal ganglia and thalami at the chronic state corresponded with the CT findings. It was postulated that these specific findings reflected tissue degeneration, deposition of mineral substances, or lipid accumulation. In contrast, there have been no reports of MRI findings in patients who committed suicide by hanging. The reason is that they usually die, and few attempts to obtain further neuroradiological information are made other than cervical spine Xray and CT. In our case, the patient was resuscitated and survived, and thus MRI findings could be obtained. The MRI pattern of bilateral iso and hyperintensity (T1-image) and hyperintensity (T2images) in basal ganglia and thalami was recognized although respiration had stopped for a few minutes, suggesting that severe acute global cerebral hypoperfusion also occurs in hanging in the same way as in long-standing cardiopulmonary arrest and
345 that hanging may be accompanied by devastating sequelae.
Conclusions Bilateral iso and hyperintensity observed on the T1image and hyperintensity observed on the T2-image in basal ganglia and thalami are the characteristic MRI findings in hanging. It is confirmed that hanging produces several complications leading to severe global hypoxic insults.
References 1. Bianco F, Floris R. Computed tomography abnormalities in hanging. Neuroradiology 1987;29:297—8. 2. Brancatelli G, Sparacia G, Midiri M, Sarco C, Lagalla R. Brain damage in hanging: a new CT finding. Neuroradiology 2000;42:209—10. 3. Ohkawa S, Yamadori A. CT in hanging. Neuroradiology 1993;35:591. 4. Kim KS, Weinberg PE, Suh JH, Ho SU. Acute carbon monoxide poisoning: computed tomography of the brain. AJNR 1980;1:399—402. 5. Finelli PF. Case report: changes in the basal ganglia following cyanide poisoning. J Comput Assist Tomogr 1981;5:755—6. 6. Aquilonios SM, Bergstrom K, Enoksson P. Cerebral computed tomography in methanol intoxication. J Comput Assist Tomogr 1980;4:425—8. 7. Kaiser MC, Pettersson H, Harwood-Nash DC, Fitz CR, Chung S. Case report: computed tomography of the brain in severe hypoglycaemia. J Comput Assist Tomogr 1981;5:757—9. 8. Murray RR, Kapila A, Blanco E, Kagan-Hallet KS. Cerebral computed tomography in drowning victims. AJNR 1984;5:177—9. 9. Kjos BO, Brant-Zawadzki M, Young RG. Early CT findings of global central nervous system hyoperfusion. AJNR 1983;4:1043—8. 10. McHugh TP, Stout M. Near-hanging injury. Ann Emerg Med 1983;12:774—6. 11. Nemoto EM. Patjogenesis of cerebral ischemic anoxia. Crit Care Med 1978;6:203—14. 12. Fujioka M, Okuchi K, Hiramatsu K, Sakaki T, Miyamoto S, Iwasaki S. Specific changes in human brain following reperfusion after cardiac arrest. Stroke 1994;25:2091—5. 13. Fujioka M, Okuchi K, Hiramatsu K, Sakaki T, Sakaguchi S, Ishii Y. Specific changes in human brain after hypoglycemic injury. Stroke 1997;28:584—7.