Reflex spinal cord activity as a cause of a delay in the diagnosis of brain death

A 56 year old woman was admitted to our hospital following a fall in which she sustained an acute subdural haematoma. She failed to respond to treatment despite surgical intervention and active brain protection measures. During brain stem function testing on two occasions she demonstrated movement in the distribution of the accessory (XI) cranial nerve despite angiographically confirmed absence of a cerebral circulation. This delayed decision making and organ donation. We report this case in order to highlight this problem which may be encountered during brain stem function testing.