546 Journal ofNeurology, Neurosurgery, and Psychiatry 1991;54:546-548

SHORT REPORT J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.6.546 on 1 June 1991. Downloaded from The neuropsychological sequelae of attempted hanging

Alice A Medalia, Arnold E Merriam, John H Ehrenreich

Abstract by paranoid delusions, thought blocking and Only one report on the neuropsycho- suspiciousness. At that time he had a gross logical sequelae of attempted hanging impairment in recent memory. Psychological exists in the English language. Two cases testing carried out three weeks after the hang- of attempted hanging with subsequent ing found severe memory deficits on the recall isolated memory deficits are reported. portion of the Bender Gestalt Test, a measure Possible mechanisms for induction of of nonverbal memory. IQ testing revealed a this amnesia are discussed. In these two sharp drop in intelligence from the prehang- cases it is most likely that circulatory ing level (Performance IQ = 82; Verbal IQ = disturbance produced by the ligatures 80; Full Scale IQ = 80). A neurological caused ischaemic hippocampal damage, examination three months after the hanging which in turn led to amnesia. was unremarkable except for the memory impairment. Contrast CT was normal. Seven- Every year approximately 4000 people in the teen months after the hanging his psychosis United States commit suicide by hanging.' had remitted and mental status was remark- While no precise figures are available, it is safe able only for persistent memory deficits. to assume that additional thousands Neuropsychological testing performed two unsuccessfully attempt suicide by this years after the hanging when he was non- method. Nevertheless, relatively little is psychotic, revealed a return to his premorbid known about the neuropsychological sequelae intellectual level which was in the average of failed hanging. In the only English lan- range (Performance IQ = 104; Verbal IQ guage report on the subject,' attempted hang- = 93; Full Scale IQ = 97). His Performance ing was described as the cause of a persistent IQ was substantially higher than the pre- anterograde amnestic syndrome resembling hanging assessment which was performed that seen in Korsakoffs syndrome. We des- when he was psychotic. This was interpreted cribe two cases of attempted hanging with as compatible with the improvement in task subsequent anterograde memory deficits. performance that can be seen when psychosis remits. Language, somatosensory, visual- Case 1 spatial, constructional, abstracting and A 26 year old man with a history of polysub- grapho-motor abilities were intact. He did not http://jnnp.bmj.com/ stance abuse (which from the report did not show the expected right hand dominance on a include IV drug administration) had attemp- test of fine motor coordination; whether this ted suicide three times over the three years finding predates or is a consequence of the preceding our assessment of him. Information hanging cannot be determined. about the first two attempts, which occurred The one abnormal feature in his otherwise three days apart, is scant. First he slashed his unremarkable performance on neuropsy- throat and then he stabbed himself with a chological tests was his dense anterograde and Albert Einstein on September 26, 2021 by guest. Protected copyright. College of Medicine, fork. Apparently the wounds were superficial; retrograde amnesia. He did not recall the Bronx Municipal there was no substantial blood loss or ven- hanging incident, the subsequent admission to Hospital Center, New tilatory obstruction. Psychometric testing hospital or previous psychological assess- York ments. He remembered events in his life up to Department of seven weeks later revealed no signs of higher Psychiatry* cortical dysfunction and specifically no three years before the hanging, but did not A A Medalia memory impairment, although it did suggest recall the details of his life from that time Department of the presence of psychosis. His intelligence was forward. On formal testing he showed a Neurology found to be in the average range (Performance marked verbal and nonverbal memory deficit. A E Merriam* IQ = 94; Verbal IQ = 95; Full Scale IQ = He was unable to learn more than seven of a State University of list of 15 words after five trials and was very New York, College at 94). Old Westbury, New The third suicide attempt, a year later, was sensitive to proactive interference. Attentional York by hanging. The patient was cut down uncon- capacity was normal; his digit span was better Department of scious and incontinent of urine. Detailed than average. Scores on psychological tests are Psychology presented in the table. J H Ehrenreich information about the immediate medical con- Correspondence to: Alice sequences of this incident, including the Medalia, Bronx Municipal duration of unconsciousness before and sub- Case 2 Hospital Center Rm 1023, Pelham Parkway and sequent to discovery is not available. He was A 28 year old man with a history of polysub- Eastchester Road, Bronx, admitted to a general hospital for medical stance abuse had attempted to hang himself NY 10461 USA treatment and within a week was admitted to a three years before our assessment of him. He Received 30 May 1990 and in revised form 5 Ocrober 1990. psychiatric hospital for treatment of a was reported to have been anoxic for eight Accepted 5 October 1990 paranoid psychotic condition that was marked minutes before a tracheotomy was performed. The neuropsychological sequelae of attempted hanging 547

Table Scores on neuropsychological tests subsequent to induced obstruction of cervical blood flow J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.6.546 on 1 June 1991. Downloaded from attempted hanging and, to a lesser extent, cerebral anoxia result- Test Case I Case 2 ing from asphyxia due to mechanical airway obstruction. Reports of successful hanging in Full Scale IQ 97 77 individuals with tracheotomies at a level lower Performance IQ 104 79 Verbal IQ 93 78 than the ligature, suggest that asphyxia alone WMS Verbal Memory 68 56 does not play a lethal role,23 although upward WMS Visual Memory 88 50 WMS General Memory 69 < 50 displacement of the tongue and glottis are in WMS Attention/Concentration 106 96 some cases sufficient to occlude the airway. WMS Delayed Memory 61 50 Ravens Progressive Matrices 70%tile 10%tile The relative contributions to the morbidity Spreen Benton Token Test 70%tile 33%tile and mortality of interruptions to the anterior Block Design 95%tile 16%tile and posterior cerebral circulation induced by IQ = Wechsler Adult Intelligence Scale-Revised; hanging have not been well delineated. There WMS = Wechsler Memory Scale-Revised; Ravens Progressive Matrices is a test of visual-spatial and reasoning is evidence that flow ceases in both circula- skills; Spreen Benton Token Test is a language test; Block tions after a 16 kg pull on a noose, far less than Design from the IQ test is a test ofconstructional skills. is created when an individual's weight is truly suspended by the ligature.24 The survivor of He was comatose for several days afterwards an attempted hanging might therefore and remained in a general care hospital until theoretically suffer from the effects of cerebral his transfer to a psychiatric facility two mon- circulatory insufficiency and/or the effects of ths later because of intermittent agitation and asphyxiation. Additional mechanisms by persistent memory deficits. which near-hanging has the capacity to He was not maintained on psychotropic produce neurological defects in survivors are medication. Neurological examination three by mechanical interruption to flow in the years post-hanging was normal except for vertebral arteries as a result of extension, mild bradykinesia and tremor. CT and MRI rotation, and traction of the neck,5 by the done at that time were normal. Neuropsycho- instigation of arterial thromboses with result- logical testing indicated borderline normal ing cerebral infarction,5 and by the induction intelligence. Although this was entirely com- of a delayed post-anoxic encephalopathic syn- patible with his premorbid abilities as esti- drome.6 mated from educational and vocational his- In most cases the dual insults of arterial tory, a mild degree of generalised cognitive hypotension and arterial hypoxia coexist to impairment resulting from the hanging cannot some degree, hence the term "cardiopulmon- be excluded. Arithmetic, abstraction, visual- ary arrest". Anmesia is a well-recognised spatial perception, constructional praxis and sequel of cardiopulmonary arrest, and language were intact. Memory, however, was neuropathological correlation in such a case severely impaired. A retrograde memory suggests that the amnesia is mediated by deficit was evident in his amnesia for the bilateral hippocampal injury.7 Neuropatho- hanging and the events surrounding that time. logical findings in this case consisted of atro- There were significant verbal and nonverbal phy, neuronal loss, and glial proliferation. In anterograde memory deficits; retrieval was circumstances other than combined cardiac more impaired than storage. List learning was and pulmonary arrest a relatively pure http://jnnp.bmj.com/ limited to six of 15 words after five trials and hypotensive or hypoxic state may occur; per- he was very sensitive to proactive interference. haps the best examples are cardiac arrest while Memory for newly learned information de- intubated and ventilated during general anaes- clined significantly after a delay of 30 minutes. thesia (pure ischaemia) and carbon monoxide His attention and concentration were intact. poisoning without circulatory collapse (pure Results of IQ and memory testing are presen- hypoxia). Prominent amnestic syndromes

ted in the table. have been reported in both of these settings. on September 26, 2021 by guest. Protected copyright. While pure circulatory collapse8 can evoke a profound amnestic syndrome as an immediate Discussion sequel, carbon monoxide poisoning does so This report describes the second and third only after a latency of a month, as a manifesta- cases of amnesia secondary to attempted han- tion of the delayed encephalopathy character- ging that have been reported in the English istic of this disorder.9 The state of delayed language literature. Both cases are remarkable carbon monoxide encephalopathy with multi- for the severity of anterograde amnesia in the ple cognitive defects has also been reported to context of relative preservation of other cog- resolve, but for the presence of persistent nitive capacities. What was the mechanism by memory deficits.'0 which the amnesia was induced? As for the issue of vertebral artery Prominent amnestic syndromes have oc- insufficiency provoked by mechanical neck curred after hypoxia, after ischaemic insults twisting, extension, and traction, persistent due to mechanical posterior circulation inter- memory defects may be caused by posterior ference or posterior circulation thrombotic circulation insufficiency initiated by this events, and in the setting of delayed post- mechanism during vigorous chiropractic man- anoxic encephalopathy (see below). Each of ipulation.5 In this case, however, the patient these mechanisms may be set into motion by additionally suffered a bilateral homonymous attempted hanging. The two principal means hemianopia due to ischaemia of both occipital by which hanging induces brain damage are lobes. In a case of death induced by cervical cerebral ischaemia -resulting from ligature- manipulation, necropsy examination revealed 5485Medalia, Merriam., Ehrenreich

the presence of arterial thromboses presumed of the amnesia remains speculative. These J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.6.546 on 1 June 1991. Downloaded from to be secondary to vascular damage. The patients, however, did have temporally relative contributions of thrombotic and tem- limited retrograde amnesia and profound porary mechanical interruption to flow are anterograde amnesia, an amnestic profile often likely to be similar. seen with hippocampal lesions. One of the two patients we have presented exhibited no neurological findings other than 1 US Public Health Service: Vitalstatistics ofthe United States amnesia, while the other exhibited only mild 1984, vol II, pt A, 220. Hyattsville, Md: NCHS 1987. 2 Berlyne N, Strachan M. Neuropsychiatric sequelae of bradykinesia and tremor in addition to the attempted hanging. Brit JPsychiat 1968;114:411-21. memory defect. The onset of the neurological 3 Spitz WU. Asphyxia. In: Spitz WU, Fisher R, eds. Medicolegal investigation ofdeath. Springfield, I1: Charles and neuropsychological symptoms in both C Thomas, 1980:320-50. cases was simultaneous to the hanging 4 Gradwohl W. Hypoxia and asphyxia. In: Camps F, ed. Gradwohl's legal medicine. Chicago: Yearbook Publishing, episode, obviating the diagnosis of a delayed 1976:330-6. postanoxic syndrome. Neither patient 5 Krueger BR, Okazaki H. Vertebral-basilar distribution infarction following chiropractic cervical manipulation. required ventilatory assistance after rescue. Mayo Clin Proc 1980;55:322-32. This weight of evidence is that both cases of 6 Dooling EC, Richardson EP. Delayed encephalopathy after strangling. Arch Neurol 1976;33:196-9. amnesia occurred primarily on the basis of 7 Cummings JL, Tomiyasu U, Read S, Benson F. Amnesia circulatory interruption produced by the with hippocampal lesions after cardiopulmonary arrest. Neurology 1984;34:679-81. ligatures, rather than on the basis of ven- 8 McNeill DL, Tidmarsh D, Rastall ML. A case ofdysmnesic tilatory impairment. The circulatory distur- syndrome following cardiac-arrest. Brit J Psychiat 1965; 111:697-9. bance may have caused ischaemic hippocam- 9 Ajuriaguerra J, Daumezon G. Pseudosyndromes de Kor- pal damage which in turn led to amnesia. In sakoffconsecutifs a l'intoxication oxycarbonee. Paris Med 1937:189-93. the absence of radiological data confirming the 10 Choi I. Delayed neurologic sequelae in carbon monoxide presence of such lesions, the anatomical basis intoxication. Arch Neurol 1983;40:433-5. http://jnnp.bmj.com/ on September 26, 2021 by guest. Protected copyright.