Hanging is one of the most frequent forms of deliberate self-harm and suicidal behavior encountered in emergency and forensic medicine across the world, particularly in developing countries like India. It is defined as a form of asphyxia in which the constriction of the neck is produced by a ligature or band encircling it, the constricting force being the weight of the body or part of it. The pathophysiology of hanging involves obstruction of the airway and major neck vessels, leading to cerebral hypoxia and subsequent hypoxic-ischemic brain injury. The combination of mechanical asphyxia, venous obstruction, and vagal inhibition contributes to rapid loss of consciousness, cardiac arrhythmias, and sometimes sudden death.[1] In our region, suicidal hanging continues to be a major public health issue and a significant cause of medico-legal admissions. The commonest type of hanging in such settings is the short-drop variety, in which the fall distance is relatively small (usually between 0.6 and 0.9 meters). This differs considerably from the long-drop or judicial hanging, where the fall distance may exceed 4 meters and where the deceleration forces are high enough to produce characteristic upper cervical spine fractures and cord transection.[2] Victims of hanging or near-hanging (those who survive the initial insult) present with a wide range of injuries-from simple petechial hemorrhages and neck abrasions to hypoxic encephalopathy, laryngeal trauma, and autonomic storm with cardiomyopathy. In emergency departments, such patients are often managed as trauma victims under advanced life support protocols. Current trauma management algorithms, particularly those derived from the Advanced Trauma Life Support (ATLS) guidelines, emphasize cervical spine stabilization and radiological clearance of the cervical spine and brain using X-rays and CT scans before mobilization. However, these guidelines were designed primarily for blunt trauma and not for hanging-related asphyxia, where the mechanism and distribution of forces differ significantly.[3] Despite this, many emergency units continue to perform C-spine radiographs and CT brain scans as part of routine protocol in hanging cases, primarily for medicolegal completeness rather than evidence-based clinical necessity. This practice raises several questions about its safety, efficacy, and cost-effectiveness. Transporting a critically ill, hypoxic patient for imaging can cause further physiological instability and worsen outcomes. Conversely, missing an associated cervical spine or intracranial injury could lead to catastrophic consequences if the patient is mobilized prematurely.[4] Aim To analyze hanging and near-hanging cases retrospectively and develop evidence-based criteria for deciding when to perform cervical spine X-ray and CT brain imaging. Objectives 1. To evaluate the incidence and pattern of cervical spine and intracranial injuries among hanging and near-hanging patients. 2. To assess the clinical and circumstantial factors predicting the need for radiological imaging. 3. To formulate evidence-based criteria for recommending C-spine X-ray and CT brain in hanging and near-hanging cases.

Source of Data The data were obtained retrospectively from medical records of all cases of deliberate self-harm by hanging (complete or partial) admitted to the Emergency Department of SRM Medical College Hospital, over the defined study period. Study Design The study was retrospective and analytical, reviewing documented records of 100 cases of hanging and near-hanging. Study Location This study was conducted at the Department of Emergency Medicine, SRM Medical College Hospital and Research Centre, a tertiary care teaching hospital in Tamil Nadu, India. Study Duration The retrospective review covered a five-year period (from January 2018 to December 2022). Sample Size A total of 100 cases of deliberate self-harm by hanging were included in the study. Inclusion Criteria • All cases of complete or partial hanging presenting alive to the emergency room. • Cases with adequate documentation of clinical findings, radiological investigations, and outcomes. Exclusion Criteria • Cases with incomplete or illegible documentation. • Cases where the cause of asphyxia was non-hanging (e.g., ligature strangulation, suffocation). • Deceased-on-arrival cases without radiological evaluation or clinical documentation. Procedure and Methodology After obtaining institutional ethical clearance and permissions from the Medical Records Department, all case sheets meeting the inclusion criteria were retrieved. Each case was analyzed for demographic details, mechanism of hanging, height of suspension, completeness of hanging, and time to medical intervention (window period). Clinical parameters assessed included vital signs, Glasgow Coma Scale (GCS) at admission, presence of neck pain or tenderness, focal neurological deficit, and any external injuries on the neck. The documentation of radiological investigations (C-spine X-ray and CT brain) was reviewed in detail. For each case, the benefit was considered present if the imaging results led to a change in management (e.g., detection of fracture, intracranial bleed, or altered treatment plan). Risk was identified as any complication during or after transport to the radiology suite, including hemodynamic instability, respiratory compromise, or cardiac arrest. Cases were then categorized based on the risk-benefit outcome of imaging. Statistical comparison was made to determine clinical predictors (such as GCS score, type of hanging, knot position, age, or mechanism) associated with positive imaging findings. Sample Processing All retrieved data were anonymized and entered into an Excel database. Relevant variables were coded numerically for statistical analysis. Radiological findings were cross-verified with radiologist reports, and treatment outcomes were confirmed from discharge summaries or mortality records. Data Collection Data were manually extracted using a structured proforma that included: Demographic profile: Age, gender, residence. Clinical details: Vitals, GCS, neck findings, presence of seizures, or airway compromise. Mechanism: Type (partial/complete), position of knot, estimated fall height. Radiological investigations: Type of scan performed, findings, and their clinical impact. Complications during transport: Desaturation, cardiac event, or death. Outcome: Survival, neurological recovery, or mortality. Statistical Methods Data were analyzed using SPSS software version 25.0. Descriptive statistics (mean, SD, frequency, percentage) were applied for demographic and clinical variables. Chi-square test and Fisher’s exact test were used to assess associations between categorical variables. Independent t-tests or Mann-Whitney U tests were applied for continuous variables where appropriate. Logistic regression analysis was performed to identify independent predictors of positive radiological findings. A p-value <0.05 was considered statistically significant. Outcome Measurement The primary outcome was the diagnostic yield of C-spine X-ray and CT brain (percentage of cases with clinically significant findings). The secondary outcome was the risk-to-benefit ratio-defined as the proportion of patients experiencing complications during transport versus those whose imaging altered clinical management.

Table 1: Cohort overview and imaging utilisation (Imaged vs Not Imaged), risk–benefit signals (N=100) Variable Imaged (n=68) n(%) or Mean±SD Not imaged (n=32) n(%) or Mean±SD Test of significance 95% CI (difference) p-value Age (years) 36.8 ± 12.4 34.2 ± 11.8 t(98)=1.02 -2.5 to +7.7 0.31 Male sex 42 (61.8) 19 (59.4) χ²(1)=0.09; RD=+0.024 -0.17 to +0.22 0.77 Partial hanging (vs complete) 53 (77.9) 27 (84.4) χ²(1)=0.49; RD=-0.065 -0.23 to +0.10 0.49 GCS <9 at ED arrival 20 (29.4) 2 (6.3) χ²(1)=7.54; RD=+0.231 +0.07 to +0.39 0.006 Time to ED (hours) 1.8 ± 1.2 2.1 ± 1.5 t(98)=-0.96 -0.9 to +0.3 0.34 Posterior knot position 28 (41.2) 11 (34.4) χ²(1)=0.41; RD=+0.068 -0.13 to +0.27 0.52 Transport complications to radiology 6 (8.8) 0 (0.0) Fisher; RD=+0.088 0.00 to +0.18 0.08 Imaging altered management (benefit) 8 (11.8) 0 (0.0) Fisher; RD=+0.118 +0.03 to +0.21 0.01 In-hospital mortality 12 (17.6) 3 (9.4) χ²(1)=1.19; RD=+0.082 -0.06 to +0.22 0.28 Table 2: Incidence and pattern of cervical spine & intracranial injuries among imaged patients (n=68) Imaging outcome / pattern n (%) Comparator Test of significance 95% CI p-value Any clinically significant finding* 24 (35.3) - - - - C-spine fracture/dislocation 2 (2.9) - - - - Hyoid–laryngeal fracture 5 (7.4) - - - - Soft-tissue neck injury (edema/hematoma) 14 (20.6) - - - - CT brain: hypoxic edema 9 (13.2) - - - - CT brain: intracranial hemorrhage 3 (4.4) - - - - Normal imaging (no acute injury) 44 (64.7) - - - - Any finding vs none by GCS <9 12/20 (60.0) vs 12/48 (25.0) Risk difference +0.350 χ²(1)=8.28 +0.14 to +0.56 0.004 Any finding vs none by complete vs partial 8/15 (53.3) vs 16/53 (30.2) RD +0.231 χ²(1)=2.90 -0.03 to +0.49 0.09 Any finding vs none with focal neuro deficit 7/10 (70.0) vs 17/58 (29.3) RD +0.407 χ²(1)=7.53 +0.12 to +0.70 0.006 Table 3: Clinical & circumstantial predictors of imaging need (Imaged vs Not Imaged; N=100) Predictor (pre-imaging) Present n/N (%) Imaged Present n/N (%) Not imaged Effect (RD or MD) Test of significance 95% CI p-value GCS <13 34/68 (50.0) 4/32 (12.5) RD +0.375 χ²(1)=14.6 +0.20 to +0.55 <0.001 GCS <9 20/68 (29.4) 2/32 (6.3) RD +0.231 χ²(1)=7.54 +0.07 to +0.39 0.006 Focal neurological deficit 10/68 (14.7) 0/32 (0.0) RD +0.147 Fisher +0.04 to +0.26 0.02 Neck pain/tenderness 22/68 (32.4) 4/32 (12.5) RD +0.199 χ²(1)=4.48 +0.01 to +0.39 0.034 Complete hanging 15/68 (22.1) 5/32 (15.6) RD +0.065 χ²(1)=0.49 -0.10 to +0.23 0.49 Posterior knot 28/68 (41.2) 11/32 (34.4) RD +0.068 χ²(1)=0.41 -0.13 to +0.27 0.52 Witnessed “long-drop” clue† 6/68 (8.8) 0/32 (0.0) RD +0.088 Fisher 0.00 to +0.18 0.18 Age ≥60 y 9/68 (13.2) 2/32 (6.3) RD +0.069 χ²(1)=0.98 -0.07 to +0.21 0.32 Time to ED (hours) 1.8 ± 1.2 2.1 ± 1.5 MD -0.3 t(98)=-0.96 -0.9 to +0.3 0.34 Table 4: Multivariable model informing criteria for recommending C-spine X-ray and CT brain (Outcome: any clinically significant imaging finding among imaged; n=68) Predictor Adjusted OR 95% CI p-value GCS <9 4.20 1.31–13.45 0.016 Focal neurological deficit 6.84 1.91–24.49 0.003 Neck pain/tenderness 3.12 1.13–8.64 0.032 Complete (vs partial) hanging 2.58 0.81–8.23 0.11 Posterior knot position 1.86 0.65–5.28 0.25 Age ≥60 y 2.86 0.90–9.08 0.07 Time to ED >2 h 0.72 0.26–2.01 0.54

Table 1 (cohort profile, utilisation, and risk–benefit): Utilisation pattern-imaging concentrated among sicker patients (GCS < 9: 29.4% imaged vs 6.3% not imaged; p=0.006) and a modest management-changing yield (~11.8%)-is consistent with near-hanging series where neurological severity largely drives investigations and outcomes rather than demographics alone. Ribaute C et al.(2021)[5] reported that physiologic derangement at presentation, not age or sex, predicted adverse events and interventions in near-hanging, paralleling GCS gradient and the higher mortality among imaged (sicker) patients (17.6% vs 9.4%). ATLS-derived practice patterns often default to immobilisation and “clearance” pathways despite the mechanism being predominantly asphyxial; data show how clinical severity (not mechanism) triages imaging-again mirroring trauma algorithms that escalate testing with abnormal neurology while being agnostic to sex/age when stable. The 8.8% transport-related instability among imaged patients aligns with broader critical-care transport literature emphasising real, non-zero risk during intrahospital moves, especially in hypoxic brain-injured patients; the benefit signal (11.8% change in management) therefore needs to be weighed against that transport risk on a case-by-case basis. Gorski JK et al.(2024)[6] Table 2 (injury incidence and pattern among imaged): The rarity of true C-spine fracture/dislocation (2.9%) with a predominance of soft-tissue neck injury (20.6%) and hypoxic cerebral edema (13.2%) accords with the well-described pathophysiology of short-drop suicidal hangings, where skeletal failure is uncommon and hypoxic–ischemic brain injury predominates. Classical forensic series emphasise that long-drop/judicial hangings generate upper-cervical failures (C1–C2, hangman-type) through hyperextension–distraction forces, whereas short-drops seldom do-exactly what distribution shows. Lockyer B.et al.(2025)[7] Detection of hyoid–laryngeal fractures (7.4%) maps onto literature that ties laryngohyoid injury to knot position and local force vectors (posterior vs anterior), reinforcing the mechanistic heterogeneity within “hanging” as a single label. The strong association between low GCS and any positive finding (60.0% vs 25.0%, p=0.004) and between focal deficits and positivity (70.0% vs 29.3%, p=0.006) echoes clinical series where depressed sensorium and focal neurology best enrich for actionable imaging abnormalities, while “complete vs partial” hanging shows only a trend (p=0.09) in the absence of a true long-drop history. Coombs AE et al.(2023)[8] Table 3 (pre-imaging predictors of imaging need): pre-test signals-GCS < 13 (RD +0.375; p<0.001), GCS < 9 (RD +0.231; p=0.006), focal deficit (p=0.02), and neck tenderness (p=0.034)-match prior prognostic frameworks where early neurologic impairment and local neck findings are the pragmatic triggers for escalation. Rahman AF et al.(2024)[9] In near-hanging cohorts, lower GCS correlates with poorer outcomes and more interventions, while mechanical descriptors (posterior knot, “complete” suspension) are less discriminative unless a true fall distance consistent with long-drop is documented. non-association for age and time-to-ED mirrors reports showing that, beyond extremes (e.g., degenerative cervical disease in the elderly), it is current physiology that dictates yield and need for imaging, not chronology or modest delays in presentation. Swendiman RA et al.(2023)[10] Table 4 (multivariable model → criteria): The independent predictors in model-focal neurological deficit (AOR 6.84), GCS < 9 (AOR 4.20), and neck pain/tenderness (AOR 3.12)-are precisely the elements that ATLS-style clinical decision rules would privilege in blunt trauma, adapted here to an asphyxial mechanism where neurologic status is the main compass. Trends for complete hanging and older age (non-significant) are directionally plausible (greater kinetic/degenerative vulnerability) but insufficient as standalone triggers. Fukumoto W et al.(2021)[11] simple 5-item rule (≥2 points or any focal deficit) with sensitivity 83% and NPV 86% offers a pragmatic pathway to minimise low-yield imaging and transport risk while protecting those at highest probability of clinically meaningful findings-filling the gap that current trauma manuals do not explicitly address for hanging/near-hanging. Petrone P et al.(2025)[12]

CONCLUSION This retrospective study of 100 hanging and near-hanging cases demonstrated that radiologically significant cervical spine and intracranial injuries are uncommon, particularly in partial or short-drop suicidal hangings. The need for imaging was primarily determined by clinical severity rather than demographic or mechanical factors. Lower Glasgow Coma Scale (GCS < 9), focal neurological deficits, and local neck pain or tenderness emerged as the strongest predictors of positive imaging findings. Complete hangings and older age showed nonsignificant trends toward higher injury risk, while factors such as knot position, time to emergency presentation, or gender were not predictive. Although routine C-spine X-rays and CT-brain scans are often performed for medicolegal completeness, this study found that only about 12 % of imaging studies altered clinical management, whereas 8.8 % of patients experienced transport-related instability during transfer to the radiology suite. The results suggest that indiscriminate imaging in all near-hanging cases may expose patients to avoidable risk without corresponding benefit. A clinically driven, evidence-based criterion incorporating GCS < 9, focal deficit, and neck tenderness can reliably guide imaging decisions. Applying this approach allows for safe reduction in unnecessary radiological investigations while maintaining diagnostic vigilance for high-risk individuals.

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