What is the appropriate imaging work‑up for an adult who survived an attempted hanging?

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Last updated: February 21, 2026 • View editorial policy

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Imaging Following Attempted Hanging

For adults surviving attempted hanging, obtain non-contrast CT of the head and cervical spine as first-line imaging, reserving CT angiography (CTA) of the neck vessels for patients with severe neurological impairment (GCS <13), cardiac arrest, or specific high-risk clinical findings. 1, 2, 3, 4

Initial Clinical Assessment and Risk Stratification

The imaging workup should be guided by the patient's neurological status and specific clinical findings:

  • Patients with normal Glasgow Coma Scale (GCS = 15) and no focal neurological deficits have a very low incidence of significant injuries requiring intervention (approximately 2-10% will have any injury detected, and most require no treatment). 3, 4

  • Patients with abnormal GCS (<15) have a 55% incidence of associated injuries compared to 10.5% in those with normal GCS, making them the population that warrants comprehensive imaging. 4

  • Anoxic brain injury is the primary cause of morbidity and mortality, present in all patients who die after hanging and diagnosed clinically in approximately 36% of survivors. 4

First-Line Imaging: Non-Contrast CT Head and Cervical Spine

CT of the head and cervical spine without IV contrast should be performed as the initial imaging study for all patients meeting criteria for imaging:

  • Non-contrast head CT is the reference standard for rapid identification of surgically treatable lesions including subarachnoid hemorrhage (which occurs in hanging victims), cerebral edema, and mass effect. 5, 1, 6

  • CT cervical spine without contrast has 98-100% sensitivity for detecting clinically significant cervical spine injuries including fractures and subluxations. 2, 5

  • Common injuries identified include minimally displaced transverse process fractures, ligamentous injuries, and occasionally vertebral subluxations, though most do not require surgical intervention. 6, 3

When to Add CT Angiography of Neck Vessels

CTA of the supra-aortic and intracranial arteries should be reserved for high-risk patients, not performed routinely:

Indications for CTA:

  • Patients presenting in cardiac arrest or requiring ICU admission 7
  • GCS <13 or unexplained focal neurological deficits 1, 4
  • Cervical spine fracture identified on initial CT 1
  • Claude Bernard-Horner syndrome or other signs of vascular injury 1
  • Basilar skull fracture or significant soft-tissue neck injury 1

Evidence Against Routine CTA:

  • Only 2.5% of hanging victims have supra-aortic arterial dissection, and these occur exclusively in the most severely injured patients (those in cardiac arrest or requiring immediate ICU admission). 7

  • No vascular lesions were found in patients stable enough for emergency department discharge in a study of 162 hanging victims. 7

  • The yield is too low to justify routine use in neurologically intact patients, exposing them to unnecessary radiation and contrast. 7

Selective Imaging Based on Clinical Findings

For patients with GCS = 15, imaging can be further restricted based on specific examination findings:

Minimal Workup Criteria (GCS = 15 without high-risk features):

  • Patients with normal GCS, no cervical spine tenderness, and no dysphagia, dysphonia, stridor, or crepitus require minimal or no imaging. 3

  • The combination of cervical spine tenderness PLUS at least one significant examination finding (dysphagia, dysphonia, stridor, crepitus) is 100% sensitive and 79% specific for identifying underlying injury in neurologically normal patients. 3

When to Image Despite Normal GCS:

  • Cervical spine tenderness with dysphagia, dysphonia, stridor, or crepitus 3
  • Age ≥65 years (lower threshold for imaging due to reduced sensitivity of clinical criteria) 2
  • High-energy mechanism (fall from height during hanging attempt) 8

Role of MRI

MRI should be reserved for specific scenarios and is NOT first-line imaging:

  • MRI cervical spine is indicated when CT is negative but neurological deficits persist, as it detects soft-tissue and ligamentous injuries missed by CT. 5, 2

  • Brain MRI with T2 and susceptibility-weighted imaging (SWI) sequences should be obtained when initial CT is negative but neurological findings remain unexplained*, as it detects 30% more traumatic lesions than CT and is superior for identifying diffuse axonal injury. 1

  • MRI is complementary to CT, not a replacement, and should never delay initial CT imaging. 1, 2

Common Pitfalls and Critical Considerations

Avoid Over-Imaging:

  • Patients with normal neurological examination are receiving extensive unnecessary imaging in current practice, with studies showing 133 CT scans and 7 MRIs performed on 83 neurologically normal patients, identifying only 2 injuries requiring no intervention. 3

  • Whole-body CT is not indicated unless there are signs of additional trauma from the fall or struggle. 4

Cervical Collar Management:

  • Early removal of cervical collars should be considered after negative imaging, as prolonged immobilization can paradoxically worsen outcomes by increasing intracranial pressure and venous obstruction. 9, 5

  • Death in hanging is primarily from cerebral hypoxia and edema, not spinal injury, making aggressive cervical immobilization potentially harmful. 9

Maintain Hemodynamic Goals:

  • Systolic blood pressure should be maintained >110 mmHg during the diagnostic workup, as hypotension worsens neurological outcomes in traumatic brain injury. 1

Algorithmic Approach

Step 1: Assess GCS and perform focused neurological examination

Step 2: If GCS <13, cardiac arrest, or severe neurological impairment:

  • Non-contrast CT head
  • Non-contrast CT cervical spine
  • CTA neck vessels 1, 4, 7

Step 3: If GCS = 15 with cervical tenderness AND (dysphagia OR dysphonia OR stridor OR crepitus):

  • Non-contrast CT head
  • Non-contrast CT cervical spine 3

Step 4: If GCS = 15 without high-risk features:

  • Consider observation without imaging or limited imaging based on clinical judgment 3, 4

Step 5: Add MRI only if:

  • CT negative but persistent unexplained neurological deficits 1, 2

References

1
Guideline

Additional Diagnostic Imaging and Monitoring in Moderate‑to‑Severe Traumatic Brain Injury

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Imaging for Cervical Spine Pain After a Fall

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Research

A case for less workup in near hanging.

The journal of trauma and acute care surgery, 2016

5
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

8
Guideline

CT Scan Decision-Making After a Fall

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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