During the observational period, 5’448 patients with ischemic strokes or TIAs were admitted to our hospital and a SA preceded 5 of them (0.08%). We excluded a 6th patient with SA from benzodiazepine overdose who did not fulfill our definition of SFSA: towards the end of an ICU stay with multiple clinical complications and interventions, a subacute stroke of undermined timing was diagnosed following extubation after four weeks.
Of the included patients, four were male, and the median age was 52 years (Table 1). Initial stroke severity in our patients was a median of 3 (range 0–7); patients had few stroke risk factors and a history of psychiatric disorders.
Table 1
Characteristics of all reported AIS preceded by SA, and univariate comparison with a consecutive sample of 2’967 AIS from our stroke registry. Statistical comparison was done between all 12 reported cases (ours and the literature) and the control population from the acute stroke registry (ASTRAL).
Characteristics
|
Strokes related to suicide attempts in our center
|
Adding 7 reported cases in the literature
|
Control group (ASTRAL)
|
Odds ratio
|
CI
|
p-value
|
N
|
5
|
12
|
2’967
|
--
|
--
|
--
|
Female gender
|
1 (20%)
|
4 (33%)
|
1292 (43%)
|
0.39
|
0.08–1.44
|
0.14
|
Age, y, median (IQR)
|
52 (44–58)
|
58 (48–60)
|
73 (60–81)
|
0.95*
|
0.92–0.98
|
< 0.01
|
Admission NIHSS, median (IQR)
|
3 (0–5)
|
6 (2–31)1
|
6 (3–14)
|
1.00
|
0.99-1.0
|
0.93
|
Psychiatric comorbidity
|
5 (100%)
|
NA
|
368 (12%)
|
5.04*
|
1.25–18.56
|
0.01
|
Favorable outcome at 7 days
|
3 (60%)
|
5 (42%)
|
1617 (54%)
|
0.59
|
0.14–2.19
|
0.40
|
Favorable outcome at 3 months
|
4 (80%)
|
7 (58%)1
|
1803 (61%)
|
0.90
|
0.24–3.62
|
1.00
|
Mortality at 7 days
|
1 (20%)
|
3 (25%)
|
144 (5%)
|
6.53*
|
1.12–26.5
|
0.01
|
Mortality at 3 months
|
1 (20%)
|
3 (25%)
|
426 (14.4%)
|
1.98
|
0.34-8.0
|
0.40
|
NA = not available |
1 For the patients identified in the literature, the admission NIHSS and long term favorable outcome were estimated from the descriptions (see Online table) |
2 For this comparison, only data from our 5 reported patients were used because of missing data in the published cases. |
The mechanisms leading to stroke were variable and linked to the type of suicide attempt. Two suicide attempts were by hanging, two by hemorrhage (one venosection and the other arterial section – Hara-kiri) and one by attempted self-drowning in a lake. The self-drowning patient (patient #1) had embolus from insufficiently anticoagulated atrial fibrillation (AF) as the presumed stroke mechanism, occurring simultaneously with the SA. In the hanging attempts (patients #2 and #5), carotid dissection was the mechanism, whereas in the patients with extensive systemic hemorrhage (patients #3 and #4), several stroke mechanisms can be suspected: A) hypotension due to hypovolemia with borderzone mechanism, B) activation of the coagulation cascade (such as factor VII expression) from acute bleeding with systemic hypercoagulability, and/or C) hypothetic cardiac arrhythmia related to the acute blood loss activation of the coagulation cascade, leading to thromboembolic stroke.
We summarize below each patient’s SFSA and the circumstances, with more details provided in Table 2. The mechanisms leading to stroke were variable and linked to the type of suicide attempt.
Table 2
Description of our 5 patients with SFSA.
Patient number
|
#1
|
#2
|
#3
|
#4
|
#5
|
Age, sex
|
80y, F
|
52y, M
|
58y, M
|
44y, M
|
26y, M
|
Type of suicide attempt
|
Self-drowning in a lake; found comatose and hypothermic at 26.8°C
|
Found hanging by a rope from a tree, probably after a few minutes.
|
Venosection in the neck, both wrists and legs with a kitchen knife, then called for help
|
Hara-kiri -like self-stabbing with a kitchen knife, injuring left thoracic cage, pleura, pericardium, diaphragm, stomach walls, transverse colon, liver and section of gastroepiploic artery.
|
Found hanging from a balcony, found after 5 minutes
|
Stroke diagnosis and presumed mechanism
|
Right deep MCA embolic stroke. Patient with diagnosis of intermittent AF 5d earlier. Also episode of AF on admission
|
Right embolic MCA stroke from occlusive right ICA dissection
|
Multilevel posterior circulation strokes. Potential mechanisms: A) hypotension due to hypovolemia; B) systemic hypercoagulability from acute bleeding; C) cardiac arrhythmia related to acute blood loss
|
Right embolic posterior MCA, and left posterior junctional stroke. Presumed mechanism: see patient #3
|
Occlusive dissection of the left common and internal carotid artery
|
Initial neurologic deficit
|
Left brachio-crural hemiparesis.
|
Left-side SM HS and multimodal hemineglect; left lateral homonymous hemianopia; left asterognosis
|
Partial Wallenberg syndrome with cerebellar syndrome, dysarthria, right Horner syndrome, left corticospinal signs and discrete contra-lateral sensitive HS
|
Anhedonia, amnesia, and ideomotor apraxia
|
Likely epileptic seizure when found.
Slight asymmetry of contraction of the left soft palate
|
Psychiatric diagnosis, cerebrovascular risk factors, comorbidities
|
Left MCA TIA 5 days earlier with new onset intermittent AF; this diagnosis lead to acute adjustment disorder with probable anxiety and depression.
Hypertension, diabetes type II
|
MDD
Acute fracture of the thyroid cartilage
|
Recurrent MDD with psychotic features and not otherwise specified personality disorder. Suicide attempt with benzodiazepines 1.5m earlier. Non-specified personality disorder.
Type II diabetes IR. Smoking 90UPA. Mild hyper-homocysteinaemia
|
MDD with psychotic features.
Traumatic pericardic tamponade
Voluntary hospitalization in a psychiatric hospital 2 months before admission for insomnia and depression
|
Suspected bipolar disorder.
Cervical and supraglottic edema with involvement of the left recurrent laryngeal nerve and paralysis of dilator muscle of the left vocal cord
|
Imaging findings
|
CT 1d: Right subcortical frontal stroke.
MRI 6y: unchanged
|
Hyperacute CT: right MCA cortical swelling.
CT d1: right MCA cortico-subcortical effacement. CTA: occlusion on probable dissection right internal carotid
CT 3m: right MCA chronic stroke
|
Hyperacute CT, CTP and CTA: mild atherosclerosis.
CT d1: bilateral cerebellar (right > > left PICA), left PCA.
CT d3: same, and mass effect right PICA lesion
CT d20: mild hemorrhagic transformation right PICA and left PCA lesions.
(see Fig. 1)
|
CT 5d and MRI 6d: right posterior superficial MCA and left posterior borderzone lesions
MRa 6d: normal
(see Fig. 2)
|
Hyperacute CT: normal. CTA: occlusion left distal CCA. CTP normal.
CT d1: normal. CTA: partial recanalization: stenosing thrombi at origin of left internal and external carotid.
MRI d6: small left deep and superficial posterior borderzone lesions.
MRA 3m: irregular bifurcation of the left ICA
|
Complementary exams
|
ECG monitoring: intermittent AF
Cardiac US: normal except for bi-atrial dilatation; PFO not searched
|
None
|
ECG monitoring showed no arrhythmias.
Cardiac US: preserved left ventricular function without segmental dysfunction; negative PFO
|
Cardiac US: preserved left ventricular function without segmental dysfunction; negative PFO
|
None
|
NIHSS on admission, at 24h, 7d and 3m
|
3, 1, 0
|
7, 7, 0
|
5, 5, 2
|
0, 36, 36
|
0, 0, 0
|
Clinical outcome*: mRS at 7d, 3m and 12m
|
0, 0, 0
|
1, 0, 0
|
4, 2, 1
|
Completed suicide by defenestration 6d after stroke (mRS: 6, 6, 6)
|
0, 0, 0
|
MCA: Middle cerebral artery; ICA: Internal carotid artery; PCA: Posterior cerebral artery; PICA: Posterior inferior cerebellar artery; SM: sensorimotor; HS: Hemisyndrome; TIA: Transitory ischemic attack; AF: Atrial fibrillation; PFO: Patent foramen ovale; CT: Computed tomography; CTA: Computed tomography angiography; CTP: Computed tomography perfusion; MRI: Magnetic resonance imaging; MRA: Magnetic resonance angiography; ECG: Electrocardiogram; US: Ultrasound; NIHSS: National Institutes of Health Stroke Scale; mRS: Modified Rankin Scale. MDD: Major depressive Disorder |
*None were thrombolysed and each received acetylsalicylic acid 100 mg after stroke confirmation. Patient #1 (confirmed AF) and patient #5 received long-term and transitory oral anticoagulation, respectively. |
Patient #1: Self-drowning in a lake, found comatose and hypothermic at 26.8°C and Glasgow Coma Scale of 8, leading to intubation and not seeing a moderate left hemisyndrome. Diagnosis of right deep MCA embolic stroke made on the next day on CT, after extubation. The SA occurred following the diagnosis of a TIA due to new onset AF 5 days earlier. A vitamin-K antagonist had been started before the SA (INR = 1.1 on admission); therefore, the likely stroke mechanism was AF related to insufficient anticoagulation. There was no psychiatric diagnosis except for an adjustment disorder following the TIA.
Patient #2: Found hanging by a rope from a tree, probably after a few minutes; right embolic MCA stroke from right ICA dissection. Diagnosed with recurrent major depressive disorder (MDD).
Patient #3: Venosection in the neck, both wrists and legs with a kitchen knife and then called the daughter; multilevel posterior circulation strokes with the fall of hemoglobin from 155 to 109. In patients with extensive systemic hemorrhage (patients #3 and #4 below), several stroke mechanisms can be suspected: A) hypotension due to hypovolemia with borderzone mechanism, B) activation of the coagulation cascade (such as factor VII expression) from acute bleeding with systemic hypercoagulability, and/or C) hypothetic cardiac arrhythmia related to the acute blood loss activation of the coagulation cascade, leading to thromboembolic stroke. Figure 1 shows the neuroimaging for this patient. Patient diagnosed with recurrent MDD with psychotic features and not otherwise specified personality disorder.
Patient #4: Hara-kiri -like self-stabbing with a kitchen knife, with multiple thoracic and abdominal injuries, requiring multiple blood transfusions. Potential stroke mechanisms are as above (Fig. 2 for neuroimaging). Diagnosed with MDD with psychotic features, committed suicide 4 days after SA.
Patient #5: Found hanging from balcony after 5min; occlusive dissection of the left common and internal carotid artery. Patient with a suspected diagnosis of bipolar disorder.
None of the patients had anoxic encephalopathy clinically or on the subacute MRI performed in three patients. None were thrombolysed and each received acetylsalicylic acid 100 mg after stroke confirmation. Patient #1 (confirmed AF) and patient #5 received long-term and transitory oral anticoagulation, respectively.
The clinical outcome was globally positive, with mRS at 3 months of 0 in four patients, except patient #4 who committed an in-hospital suicide by defenestration on day 4, after having been transferred from the ICU to the visceral surgery floor. He had no major neurologic deficit at the time of his suicide. This patient was not formally evaluated by a psychiatrist but had a suspected bipolar disorder.
Psychiatric comorbidity included acute depressive episodes (n = 2, one after a recent TIA), recurrent depressive disorder (n = 2, one with a previous SA) and bipolar disorder (n = 1).
After reviewing the literature, 7 other cases were described from 1989 to 2014 (Table 3)(10–16). Similar to our case-series, SA methods were variable, leading to different types of strokes.
Table 3
Characteristics of all reported case-reports of SFSA in the literature.
|
Patient 1
|
Patient 2
|
Patient 3
|
Patient 4
|
Patient 5
|
Patient 6
|
Patient 7
|
Article/Author
|
H. Onishi et al. (1989)
|
K. Noguchi et al. (1992)
|
R. Hausmann et al. (1996)
|
Ikenga et al. (1996)
|
Garaci, F. G., et al. (2009)
|
Šupe, S., et al. (2013)
|
Yasushi Nishiyori et al. (2014)
|
Age, sex
|
84y, M
|
50y, F
|
58y, M
|
63y, M
|
37y, F
|
59y, M
|
64y, F
|
Type of suicide attempt
|
Hanging with a rope
|
Hanging with a rope
|
Hanging (after jumping the rope tears with 3m fall)
|
Hanging with a rope
|
Hanging
|
Hanging (found 2min after)
|
Ingestion of unknown dose of glyphosate surfactant herbicide
|
Stroke localization
|
Both anterior and left middle cerebral arteries
|
Right Common carotid artery
|
Massive bilateral carotid territory strokes (autopsy; not imaging)
|
Left ICA
|
Right thalamus and left cerebellum
|
Right MCA territory
|
Left hippocampus
|
Stroke diagnosis and presumed mechanism
|
Bilateral internal carotid artery dissection with embolic strokes
|
Dissection of the right CCA
|
Bilateral common carotid occlusion from carotid trauma (probably dissection)
|
Dissection of the left common carotid artery
|
Ischemic-arterial event
|
Artheriosclerotic (right ICA subocclusive stenosis and left ICA with 70% stenosis
|
Unclear origine;
hippocampal infarction leading to psychiatric symptoms before drug overdose?
Or, infarction occurred after the overdose, leading to ‘window period’ in which she was able to acknowledge?
No other toxic systemic manifestations of the drug were found.
|
Neurological deficit
|
Semicoma, right hemiparesis. Estimated NIHSS = 36
|
Loss of consciousness, strangulation on the neck, facial edema and multiple conjunctiva petechiae. Estimated NIHSS = 36
|
Initially no neurologic deficit. Fractures of the calcaneous bones on both sides. On day 4, acute hemiplegia. Estimated initial NIHSS = 36. Died a few hours later of central regulation failure. 7d mRS = 6.
|
Total aphasia, right hemiparesis and left ptosis. Estimated NIHSS = 30
|
Disturbed eye movement, delirium with memory and executive functions impairment. No other deficit. Estimated NIHSS = 5
|
On arrival: deeply somnolent, without any focal neurological deficits
25min later: left-sided hemiplegia NIHSS 14
|
Several hours after admission she manifested delirium, confusion, and severe anxiety; short-term memory loss was prominent (the patient forgot her suicide attempt). Estimated NIHSS = 2
|
Imaging findings
|
hCT: massive cerebral infarction of the territory of both anterior and left middle cerebral arteries
Cerebral angiography: linear shadow defect of the left extracranial internal carotid artery corresponding with the site of the ligature.
|
hCT(after 2 year): atrophic changes.
Angiography (after 2 year): approximately 80% stenosis of the right CCA.
|
No cerebral imaging
|
hCT: no abnormal finding
MRI(after 2 days): multiple infarctions in the left fronto-tenmpro-parietal and basal ganglia.
MR-angiography (after 2 days): severe stenosis at the cervical portion of ICA and occlusion of the left MCA.
|
hCT (ER): no acute lesion
CT (8d later): low density area in the right thalamus
MRI (8d later): hyperintense area on both T2-weighted and FLAIR images on the right thalamus and left cerebellum. DWI no area of diffusivity restriction. No cervical arterial dissection.
|
hCT (ER): no acute lesion
hCT (25min later): no acute lesion
hCT (24 hours after thrombolytic treatment) : acute ischemic right MCA territory
|
hCT: no acute lesion, only an old infarction in the bilateral basal ganglia.
MRI 9 days after admission: small high-intensity lesion in the dorsal part of the left hippocampal body on the DWI.
Memory tests demonstrated severe short-term recall deficits
|
Early outcome
|
He was treated conservatively and transferred to another institution after 1 month. Total aphasia and the right hemiparesis have remained. Estimated 7days mRS = 6
|
She gradually recovered except for her left upper limb weakness, with a diagnosis of left brachial plexus injury, Estimated 7d mRS = 3
|
Autopsie revealed: Submucosal haemorrhages of the epiglottis. Incomplete rupture of both common carotid arteries. Mixed post-traumatic thrombosis. Diffuse encephalomalacia, haemorrhagic alveolar and interstitial lung edema.
|
He was treated by thiamylal infusion and his aphasia and hemiparesis gradually recovered. Estimated 7d mRS = 5.
|
Estimated 7d mRS = 2
One month: slight anterograde memory deficits still present
|
Thrombolysed. Improvement after thrombolysis NIHSS 5. Estimated 7d mRS = 2
After 4 weeks: NIHSS score of 3 (mRS 1)
Six weeks after stroke, he was rehospitalized for
endovascular treatment.
|
She gradually became less confused over the course of a week. Estimated 7d mRS = 2. Follow-up memory test revealed partial improvement in some domains, with persistent memory impairments. No abnormalities were found on a follow-up brain scan.
|
MCA: Middle cerebral artery; ICA: Internal carotid artery; CCA: Common carotid artery; hCT: head Computed tomography; CTA: Computed tomography angiography; MRI: Magnetic resonance imaging; NIHSS: National Institutes of Health Stroke Scale; mRS: Modified Rankin Scale. |
Comparing all the 12 patients (including the five patients described here and seven published cases) to the control patients from ASTRAL in univariate analysis, we found the SFSA patients to be significantly younger with a higher incidence of psychiatric comorbidities. However, there was no clear difference in the sex distribution and initial NIHSS. Long-term functional outcome and mortality (3 months) were similar, but 7-day mortality was clearly higher in SFSA (25% vs 4.9%).