Frequency of spinal reflex movements in brain-dead patients

Spontaneous and reflex movements may occur in brain-dead patients. These movements originate from spinal cord neurons and do not preclude a brain-death diagnosis. In this study, we sought to determine the frequency and characteristics of motor movements in patients who fulfilled diagnostic criteria for brain death. Patients admitted to our department between January 2000 and March 2003 and diagnosed as brain-dead were prospectively evaluated in terms of spinal reflexes. Clinical brain death was diagnosed according to our national law. We also prefer to document the diagnosis of brain death with an EEG and/or TCD. Spinal reflex movements were observed in 18 out of 134 (13.4%) brain-dead patients during the study period. Lazarus sign, the most dramatic and complex movement seen in brain-dead patients, was observed a few times in two patients during an apnea test, an oculocephalic test, after a painful stimulus, and after removal of a ventilator. The other reflex movements observed in our brain-dead patients were finger and toe jerks, extension at arms and shoulders, and flexion of arms and feet. The occurrence of spinal reflexes in brain-dead patients may certainly delay decision making, such as starting a transplantation procedure, because of difficulties in convincing the family or even a physician taking part in the diagnosis of brain death. An awareness of spinal reflexes may prevent delays in and misinterpretations of the brain-death diagnosis.