Subarachnoid Hemorrhage Confirmed by Magnetic Resonance Imaging in a Patient with Brain Death owing to Hypoxic Encephalopathy Following Suicide by Hanging.

Although true subarachnoid hemorrhage (SAH) is an atypical complication owing to suicide by hanging, pseudo-SAH can often develop because of hypoxic encephalopathy. Therefore, differentiating pseudo-SAH from true SAH using brain computed tomography (CT) is often challenging. In Japan, an individual's cause of brain death must be determined to be eligible for organ donation, regardless of whether true SAH is involved or not. Herein, we report a case of SAH confirmed by magnetic resonance imaging (MRI) in a patient with brain death owing to hypoxic encephalopathy following suicide by hanging. A 48-year-old man attempted suicide by hanging. Upon arrival at the hospital, he developed pulseless electrical activity with apnea. Although spontaneous circulation returned within a few minutes of his arrival, spontaneous breathing did not recover. The patient was in deep comatose state without response to pain stimulation, brainstem reflexes, or electrical activities on an electroencephalogram. Consequently, the patient met diagnostic criteria for clinical brain death based on the Japanese organ transplantation law. Brain CT revealed global hypoxic injury and high density in the basal cisterns and subarachnoid space. Brain MR T2*-weighted imaging revealed low intensity at the left Sylvian fissure underlying the hematoma. These findings indicated brain death owing to hypoxic encephalopathy following hanging, and incidental true SAH was confirmed by MRI. Donor surgery and organ transplantation were performed. Spontaneous SAH can often develop secondary to hanging, and brain MRI can effectively determine whether the cause of brain death involves true SAH.