yes, I will go ahead as it is a spinal cord reflex
this movement could be observed within the first 24 hours after the declaration of brain death and might be days after. these spinal reflexes are present in brain death if the ischemic lesion is above C1–C4 due to interruption of the supraspinal inhibition
reference:
Conci F, Procaccio F, Arosio M, Boselli L. Viscero-somatic and viscero-visceral reflexes in brain death. J Neurol Neurosurg Psychiatry 1986;49:695–698.
Samay Jain1 and MD. Brain Death-Associated Reflexes and Automatisms. Neurocrit Care. 2005;3:122–6.
ahmed saleeh
2 years ago
How do you explain this event?
Spinal cord reflex
Will you go ahead?
Yes, i shall proceed, as brain stem death is confirmed
Theepa Mariamutu
2 years ago
Reflexes of spinal origin may be present and should not be confused against the diagnosis of brain death. Leg movements after stimulation considered as spinal reflexes
Spinal reflexes includethe stretch reflex, the Golgi tendon reflex, the crossed extensor reflex, and the withdrawal reflex.
The increase in intracranial pressure (ICP) that accompanies brain death spares the rostral portion beyond the second cervical spine and does not compromise blood supply to this area.
This could be the explanation for complex motor movements at the spinal cord level even after diagnosing brain death.
Clinical testing for brain death
Coma: Absence of response to noxious stimulus except for spinally mediated reflexes.
Absent brain stem reflexes (a formal evaluation of the brain stem reflexes is undertaken when the patient has had fixed dilated pupils and absent cranial nerve reflexes for more than 4 h).
Apnea test: The aim of this test is to check for the integrity of the brain stem respiratory Centre at high levels of blood carbon dioxide.
Will you go ahead?
Yes I will proceed the transplantation
Last edited 2 years ago by Theepa Mariamutu
Tahani Ashmaig
2 years ago
▪︎How do you explain this event?
This is one of the spinal reflexex
Note: 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 [1].
▪︎Will you go ahead? Yes.
____________
Ref:
L Döşemeci et al. Frequency of spinal reflex movements in brain-dead patients.Transplant Proc. 2004.
Mu'taz Saleh
2 years ago
How do you explain this event?
This spinal reflex
Will you go ahead?
yes
Hinda Hassan
2 years ago
Spontaneous and reflex movements may be found in patients with brain death (BD). Saposnik et al prospectively evaluated their frequency using a standardized protocol. Among 38 patients who fulfilled criteria for BD, the authors found 15 (39%) with spontaneous or reflex movements. The most common movement was finger jerks. Undulating toe flexion sign, triple flexion response, Lazarus sign, pronation-extension reflex, and facial myokymia also were seen. These movements may be more common than reported and do not preclude the diagnosis of BD. Saposnik G, Bueri JA, Mauriño J, Saizar R, Garretto NS. Spontaneous and reflex movements in brain death. Neurology. 2000 Jan 11;54(1):221-3. doi: 10.1212/wnl.54.1.221. PMID: 10636153.
Alyaa Ali
2 years ago
1.this is a spontaneous and reflex movement originates from spinal cord neuron ( spinal reflex) and does not preclude a brain death diagnosis.
2.yes
Döşemeci L, Cengiz M, Yilmaz M, Ramazanoĝlu A. Frequency of spinal reflex movements in brain-dead patients. Transplant Proc. 2004 Jan-Feb;36(1):17-9.
Last edited 2 years ago by Alyaa Ali
Nazik Mahmoud
2 years ago
This is a spinal reflex so will proceed for donor Nephrectomy and Kidny transplant
Hamdy Hegazy
2 years ago
How do you explain this event? This a spinal cord reflex. Will you go ahead? I will proceed.
Nasrin Esfandiar
2 years ago
Q1: This movement could be considered as spinal reflexes which may be present in brain-dead patients. Q2: Will you go ahead? Yes, I will proceed for the transplantation. Han SG, Kim GM, Lee KH, Chung CS, Jung KY. Reflex movements in patients with brain death: a prospective study in a tertiary medical center. J Korean Med Sci. 2006 Jun;21(3):588-90.
Heba Wagdy
2 years ago
It is a movement due to spinal cord reflex, may occur with brain stem death, we can go ahead with retrieval.
Ahmed Abd El Razek
2 years ago
This event can be explained by the presence of spinal reflexes which can exist even after brain stem death for some time. Other movements may be found as undulating toe, increased deep tendon reflexes, plantar responses, Lazarus sign, flexion-withdrawal reflex, facial myokymia, neck-arm flexion, finger jerks and fasciculations.
No contraindication for proceeding for organ retrieval; after proper explanation for the relatives.It should be born in mind that brain death can be determined in the presence of spinal reflexes.
Neurological consultation may be beneficial for further decision approval.
Beckmann Y, Çiftçi Y, Incesu TK, Seçil Y, Akhan G. Spinal reflexes in brain death. Acta Neurol Belg. 2014 Dec;114(4):303-6. doi: 10.1007/s13760-014-0284-0. Epub 2014 Mar 7. PMID: 24604683.
Ramy Elshahat
2 years ago
How do you explain this event? Criteria for clinical confirmation of brain stem death 1. Absent respiratory drive: Apnea test: no response to hypercapnia (PaCO2 above 6.5 Kapa Confirmed by ABG) and should be repeated twice by two different doctors. 2. Loss of brain stem function: · Absent pupillary reflexes · Absent corneal reflexes · Absent cranial motor function · Absent gag reflexes · Absent vestibuli-ocular reflex. Leg movements after stimulation are considered spinal reflexes which occur in up to 75% of brain-dead patients, such as the pronation-extension reflex, abdominal reflex, and flexion reflex and can be evoked by painful or tactile stimuli. Will you go ahead? Yes, I will precede the transplantation after counseling the family and reconfirming the diagnosis by a senior expert neurologist. Reference: 1) Kumar L. Brain death and care of the organ donor. J Anaesthesiol Clin Pharmacol. 2016 Apr-Jun;32(2):146-52. doi: 10.4103/0970-9185.168266. PMID: 27275040; PMCID: PMC4874065. 2) Busl KM, Greer DM. Pitfalls in the diagnosis of brain death. Neurocrit Care. 2009;11(2):276-87. doi: 10.1007/s12028-009-9231-y. Epub 2009 May 15. PMID: 19444652
rindhabibgmail-com
2 years ago
This is a spinal reflex , I will proceed.
Balaji Kirushnan
2 years ago
This is a spinal reflex and it is not a criteria for brain stem death…spinal reflexes can be present in cases of brain stem death and there presence is not a criteria for rejecting this donor
yes i will go ahead
Wee Leng Gan
2 years ago
This is spinal reflex.
Yes I will go ahead with DBD donation.
Reference 1) Quality Standards Subcommittee of the American Academy of Neurology (1995) Practice parameters for determining brain death in adults. Neurology 45:1012–1014.
2 ) Saposnik G, Maurino J, Saizar R et al (2005) Spontaneous and reflex movements in 107 patients with brain death. Am J Med 118:311–314
amiri elaf
2 years ago
# How do you explain this event?
*Spontaneous and reflex movements may occur in brain-dead patients. These movements originate from spinal cord neurons.1
*Many of this reflex movements have been reported in patients with brain death, in the form of plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks. So as these reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death.2
# Will you go ahead?
*Yes, I will go a head because it is a normal phenomenon and the awareness of these movements may prevent delays in brain-dead diagnosis and misinterpretations. Also we need to explain this to donor’s family properly, by the senior most clinician in ITU.
1.L Döşemeci et al. Transplant Proc. 2004 Jan-Feb. 2.Reflex Movements in Patients with Brain Death: A Prospective Study in A Tertiary Medical Center Suk-Geun Han, Gyeong-Moon Kim, Kwang Ho Lee, Chin-Sang Chung, and Ki-Young Jung
2006 Jun; 21(3): 588–590.
Published online 2006 Jun 21.
Mugahid Elamin
2 years ago
A variety of reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks).Because the aforementioned reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death.
Will you go ahead?
Yes. I will proceed as this is a local reflexive phenomenon at the spinal cord level.
Abhijit Patil
2 years ago
Brain death is the state of irreversible loss of brain function due to organic brain lesions. The essential criteria for establishing brain death include complete unresponsiveness, permanent apnea, and an absence of brainstem reflexes.
A variety of reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks.
Because the aforementioned reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death
So, this spinal reflex can be explained to the relatives, and we can proceed with organ retrieval.
Wijdicks EF. The diagnosis of brain death. N Engl J Med. 2001;344:1215–1221.
Saposnik G, Maurino J, Bueri J. Movements in brain death. Eur J Neurol. 2001;8:209–213
Han SG, Kim GM, Lee KH, Chung CS, Jung KY. Reflex movements in patients with brain death: a prospective study in a tertiary medical center. J Korean Med Sci. 2006 Jun;21(3):588-90. doi: 10.3346/jkms.2006.21.3.588. PMID: 16778413; PMCID: PMC2729975.
Amit Sharma
2 years ago
How do you explain this event?
This is spinal reflex – complex motor movement at the spinal cord level. It is due to sparing of rostral portion of spinal cord beyond C2 by the increased intracranial pressure, leading to non-compromised blood supply to the area (1). A combination of mechanical stimuli and hypoxia may be the trigger for these reflexes (2).
Will you go ahead?
Yes. I will proceed as this is a local reflexive phenomenon at the spinal cord level. This phenomenon should be explained to the family members
Reference:
1) Kumar L. Brain death and care of the organ donor. J Anaesthesiol Clin Pharmacol. 2016 Apr-Jun;32(2):146-52. doi: 10.4103/0970-9185.168266. PMID: 27275040; PMCID: PMC4874065.
2) Busl KM, Greer DM. Pitfalls in the diagnosis of brain death. Neurocrit Care. 2009;11(2):276-87. doi: 10.1007/s12028-009-9231-y. Epub 2009 May 15. PMID: 19444652.
AMAL Anan
2 years ago
– The potential DBD donor confirmed his brain stem death but moved his legs in response to trivial stimulus
How do you explain this event?.
-there are specific condition which required to confirm brain stem death deep coma dependant on ventilator or inversible damage of brain
– the criteria to confirm brain death which must be done by a clinicians with relevant experience where one must be a consultant and the other one is registrated with GMC for at least 5years provided that the clinicians are not a member of transplant team are:
– absent respiratory drive.
– absent brain stem reflex.
Will you go ahead?
Yes, I will proceed INSHALLAH.
References:
Prof: Ahmed Halawa lectures deceased donor transplantation.
Dalia Ali
2 years ago
How do you explain this event?
Conditions required to perform brain stem death test
Deep coma relaying entirely on ventilator (apnoeic coma)
Irreversible brain damage compatible with the diagnosis of brain stem death
Criteria for clinical confirmation of brain stem death
1– Absent respiratory drive
No response to hypercapnia (PaCO2 above 6.5 Kpa
2- Absent brain stem reflexes ( no brain stem function)
Absent pupillary reflexes
Absent corneal reflexes
Absent cranial motor function
Absent gag reflexes
Absent vestibulo-ocular reflex.
Apnea test should be repeated (done twice by two different doctors) after unspecified length of time
Leg movements after stimulation considered as spinal reflexes
Spinal reflexes include the stretch reflex, the Golgi tendon reflex, the crossed extensor reflex, and the withdrawal reflex.
In brain-dead patients, spinal reflexes may be present. Absent spinal reflexes is not an indication of brain stem death as spinal reflexes originate from the spinal cord rather than higher centres.
Will you go ahead?
Yes I will precede the transplantation
Reference
Lecture of Deceased Donor Transplantation
By
Ahmed Halawa
Consultant Transplant Surgeon
Associate Professor, University of Liverpool – UK
Up to date 2022
AHMED Aref
2 years ago
Movements originating from the spinal cord (spinal reflexes) or peripheral nerve may occur after the declaration of brain death (1). These are common (33 to 75 %) and may be triggered by tactile stimuli or occur spontaneously (2). Examples of such movements include:
●Subtle, semi-rhythmic movements of facial nerve-innervated muscles can arise from the denervated facial nerve.
●Finger flexor movements.
●Triple flexion response with flexion at the hip, knee, and ankle upon foot stimulation (e.g., testing for a Babinski sign).
●Tonic neck reflexes. Passive neck displacements, especially flexion, may be accompanied by complex truncal and extremity movements, including adduction at the shoulders, flexion at the elbows, supination or pronation at the wrists, flexion of the trunk (“sitting up” type movements), neck-abdominal muscle contraction or head turning to one side. These might be pretty dramatic, often called a “Lazarus sign.”
●Other truncal movements, including asymmetric posturing of the trunk and preservation of superficial and deep abdominal reflexes.
● Pronation extension reflex of the upper limb.
●Alternating flexion-extension of the toes with a passive displacement of the foot (undulating toe sign), or flexion of the toes after foot percussion, or a Babinski sign.
●Occasional fasciculations of the trunk and extremity muscles.
These movements do not preclude the loss of higher centre functions nor the diagnosis of brain death (2).
References:
1) Wijdicks EF, Varelas PN, Gronseth GS, et al. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74(23):1911.
A variety of reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks . Because the aforementioned reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death.
will you go a head?
Yes, as these movements are from spinal reflexes and does not exclude brain death.
Reference:
J Korean Med Sci 2006; 21: 588-90 ISSN 1011-8934
abosaeed mohamed
2 years ago
– Many brain-dead patients have spontaneous movements such as jerking of fingers or bending of toes that can be disturbing to family members and health care professionals and even cause them to question the brain-death diagnosis. These movements occur in 39 percent of brain-dead patients ( according to a study published in the January 11 issue of Neurology, the scientific journal of the American Academy of Neurology )
& as per BTS guidelines , death can be diagnosed when
1. Asystole has occurred, and
2. Brain function has been lost, and
3. The possibility of spontaneous return of cardiac function has passed, providing that
4. There will be no subsequent intervention that restores cerebral perfusion whilst the brain remains responsive to such restoration.
So , based on this scenario , death was confirmed & the retrieval team should be aware of that & I will go ahead without any delay .
Zahid Nabi
2 years ago
Reflex movements have been reported in up to 75% of brain dead patients. A variety of reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks ( Because the aforementioned reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death.The frequency of spinal reflex movements is not rare and the awareness of these movements may prevent delays in brain-dead diagnosis and misinterpretations. I will go ahead.
Refernce
Reflex Movements in Patients with Brain Death: A Prospective Study in A Tertiary Medical CenterSuk-Geun Han, Gyeong-Moon Kim, […], and Ki-Young Jung
Sahar elkharraz
2 years ago
variety of reflex movements have been reported in 75% in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks. Because the aforementioned reflexes are spinal reflex and presence of this reflex movements does not preclude the diagnosis of brain death.
Q2: Yes i will go ahead
Mohammed Sobair
2 years ago
How do you explain this event
Reflex movements have been reported to occur in up to 75% of brain-dead patients(1).
reflex movements such as the pronation-extension reflex, abdominal reflex, flexion
reflex, the Lazarus sign, and periodic leg movements are reported.
Will you go ahead?
yes .
References :
1- Suk-Geun Han etal Reflex Movements in Patients with Brain Death:
Spontaneous and reflex movements such as moving limbs may occur in brain-dead patients. These movements originate from spinal cord neurons (LMN) and do not preclude a brain-death diagnosis. They are considered spinal reflexes. These reflexes may create difficulties to convince a family or even a physician unfamiliar with brain death that the patient is indeed dead despite these movements.
Increase Awareness of these reflexes will decrease the time from declaring brain death to organ procurement which is often longer than expected. And analyzing these factors that delay organ procurement may help to prevent damage to organs from marginal and unstable donors and aid in preparation for recipient operation.
In the current scenario ,I will proceed for organ retrieval and considered the case as DBD donor.
Abdullah hindawy
2 years ago
How do you explain this event?
it is asinal cord reflux dont main that brain stem is working however i have to acertain that brain death protocol and diagnosis is done well
Mahmud Islam
2 years ago
Brain death is based on 3 criteria:
*persistent coma (confirmed with pain stimulus without response, eye-opening), no limb movement, no verbal response etc
*absence of brainstem reflexes (no corneal reflex, no gag reflex, no reflex on tracheal suctioning etc)
*apnea or lack of spontaneous breathing (Apnea test is done in eligible cases with evaluation of respirations and increase in CO2 pressure ..); if not eligible radiographic tests like radionuclide studies or contrast CT/MRI) to evaluate blood perfusion
Reference:
(Walter K. Brain Death. JAMA. 2020;324(11):1116. doi:10.1001/jama.2020.15898)
***** After confirmation, the patient is taken to the operating room.
Leg response is probably spinal reflex. So after confirmation of brain death; the retrieval team is expected to proceed
Manal Malik
2 years ago
The three essential findings in brain death are coma, absence of brainstem reflexes, and apnoea.
Performance of a complete neurological examination. Components of a complete neurological examination are: i. Examination of the patient- absence of spontaneous movement, decerebrate or decorticate posturing, seizures, shivering, response to verbal stimuli, and response to noxious stimuli administered through a cranial nerve path way. During the examination spinal reflexes may be present. So in this case the movement related to spinal reflexes so proceed in transplantation
References
1- Guidelines for the determination of death: Report of the medical consultants on the diagnosis of death to the President’s commission for the study of ethical problems in medicine and biomedical and behavioral research. JAMA 1981;246:2184-6.
2- The Quality Standards Subcommittee of the American Academy of Neurology. Practice parameters: Determining brain death in adults. Neurology 1995;45:1012-4.
Ahmed Fouad Omar
2 years ago
How do you explain this event?
o Brain death is loss of function of the entire cerebrum and brain stem functions
o Brain death include complete unresponsiveness, permanent apnea, and an absence of brainstem reflexes
o Some reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks and the knee jerk reflex movement observed in this patient. These are spinal reflexes, there existence does not preclude the diagnosis of brain death.
o Reflex movements have been reported to occur in up to 75% of brain-dead patient and the awareness of these movements may prevent delays in brain-dead diagnosis and misinterpretations.
Will you go ahead?
yes , I will go ahead as these reflex movement originating from the spinal cord doesn’t exclude brain stem death.
References:
Suk-Geun Han et al. Reflex Movements in Patients with Brain Death: A Prospective Study in A Tertiary Medical Center. J Korean Med Sci 2006; 21: 588-90
MICHAEL Farag
2 years ago
Brain death is the state of irreversible loss of brain function due to organic brain lesions. Although there are minor variations among the criteria that are used to define brain death, the essential criteria for establishing brain death include complete unresponsiveness, permanent apnea, and an absence of brainstem reflexes. A variety of reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks. Because the aforementioned reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death
those who met the criteria for brain death:
(i) complete clinical neurological examination including documentation of coma, the absence of brainstem reflexes, and apnea,
(ii) persistence of above clinical features for at least 6 hr (to determine irreversibility),
(iii) exclusion of hypothermia, drug intoxication, and other metabolic causes of coma, and
(iv) demonstration of electrocerebral inactivity by electroencephalogram performed after the second examination
**Yes I will go ahead
reference:
Han, G., Kim, M., Lee, K. H., Chung, S., & Jung, Y. (2006). Reflex Movements in Patients with Brain Death: A Prospective Study in A Tertiary Medical Center. Journal of Korean Medical Science, 21(3), 588-590. https://doi.org/10.3346/jkms.2006.21.3.588
Last edited 2 years ago by MICHAEL Farag
Mohamed Ghanem
2 years ago
Some reflex movements were observed in brain-dead individuals, such as plantar flexion and extension responses, stretch reflexes, abdominal reflexes, and finger jerks which are spinal reflexes and don’t exclude the diagnosis of brain stem death.
I will go ahead after confirmation of brain stem death :
1- the presence of an unresponsive coma 2- Absence of brainstem reflexes : Pupillary reflex Corneal reflex Oculocephalic reflex Vestibulo-ocular response Cough reflex 3- The apnea test to confirm absence of respiratory muscles movements References : Wijdicks EF. The diagnosis of brain death. N Engl J Med. 2001;344(16):1215–1221
Saposnik G, Mauriño J, Bueri J. Movements in brain death. Eur J Neurol. 2001;8(3):209–213. Review.
How do you explain this event?
Brain death is defined as loss of function of cerebrum and brain stem
some of reflexes called spinal reflexes as planter reflex , abdominal reflexes , muscle stretch reflexes not depend on higher brain centers
Will you go ahead?
Yes I will proceed after full confirmation of brain death by loss of pupillary reflex , corneal reflexes , gag reflex, vestibulo occular reflex
apnea test
Nahla Allam
2 years ago
Brain death is a state of cessation of cerebral function wherein the proximate cause is known and is considered irreversible. The American Association of Neurology (AAN) has defined brain death with three cardinal signs, cessation of the functions of the brain including the brainstem, coma or unresponsiveness and apnea
Reflexes of spinal origin may be present and should not be confused against the diagnosis of brain death
The diagnosis of brain death is clinical and can be confirmed by apnea testing. Ancillary tests can be considered when the apnea test cannot be completed or is inconclusive
Will you go ahead: yes ,after talking to the family
Yes, the diagnosis of brain death is confirmed. If any doubts were raised, a ancillary test would be carried out.
Asmaa Khudhur
2 years ago
How do you explain this event?
these movements are spinal reflexes that do not involve any brain activity
Some of the movements occurred spontaneously; others were triggered by touch
Electroencephalogram (EEG) tests did not show any brain activity in any of the patients with movements.
Movements associated with brain dead patients are not rare and thus an awareness of these movements is important to brain death diagnosis. Physicians who perform brain death examinations should understand the frequency and characteristics of these movements to reduce delays in determining brain death.
Will you go ahead?
Yes I will
Reference :
Reflex and Spontaneous Movements in Adult Patients during the Process of Determining Brain Death in Korea
Do-Hyung Kim, Oh-Young Kwon, […], and Young-Soo Kim
Spontaneous Movements Often Occur After Brain Death Date:
January 13, 2000
AAN
Doaa Elwasly
2 years ago
– In a patient with confirmed brain stem death this can be attributed to the increase of intracranial pressure associated with the brain death thereby sparing the rostral portion beyond the second cervical spine and does not compromise blood supply to that area. This could be the explanation for moving the patient’s leg in response to a trivial stimulus considered as a complex motor movement at the spinal cord level after brain death diagnosis.
– Yes I shall proceed with the multiorgan retrieval.
Reference
Kumar L. Brain death and care of the organ donor. Journal of Anaesthesiology Clinical Pharmacology 2016 ,Vol 32 , Issue 2.
Huda Mazloum
2 years ago
● This movement of his leg in response to a trivial stimulus considered as spinal reflex and as for brain death which require absence of all response to noxious stimules with the exception of spinally mediated reflexes
● So I will continue organs retrieval
Abdul Rahim Khan
2 years ago
How do you explain this event? The movement of leg shows local response at spinal level. These reflexes are locally mediated and there is no cerebral input.This is not a contraindication to halt organ retrieval process. Will you go ahead? Yes I will proceed with organ retrieval. Reference. Han SG, Kim GM, Lee KH, Chung CS, Jung KY. Reflex movements in patients with brain death: a prospective study in a tertiary medical centre. J Korean Med Sci. 2006 Jun;21(3):588-90.
Reem Younis
2 years ago
How do you explain this event?
-A potential DBD donor (confirmed brain stem death) moved his leg in response to a trivial stimulus→spinal reflex.
-The increase in intracranial pressure (ICP) that accompanies brain death spares the rostral portion beyond the second cervical spine and does not compromise blood supply to this area.This could be the explanation for complex motor
movements at the spinal cord level even after diagnosing brain death. Will you go ahead?
Yes ,I will go ahead for multiorgan retrieval from this donor. Referrence :
-Lakshmi Kumar. Brain death and care of the organ donor. Journal of Anaesthesiology Clinical Pharmacology | April-June 2016 | Vol 32 | Issue 2
A potential DBD donor who moved his leg in response to a stimulus is likely showing a spinal reflex and should not be considered as a contraindication for donation ,as this and other spinal reflexes like jerking of fingers or bending of toes are present in around 39% percent of patient according to American academy of Neurology. Will you go ahead?
Yes,I will proceed for retrieval of organ because
REFERENCE:.
Kumar L. Brain death and care of the organ donor. Journal of Anaesthesiology Clinical Pharmacology,2016;32(2).
Busl KM, Greer DM. Pitfalls in the Diagnosis of Brain Death. Neurocrit Care (2009) 11:276–287
there are a set of spontaneous or stimulus-induced movements that are spinally mediated and not cerebral in origin.
The AAN Practice Parameters describe certain movements which do not preclude the clinical diagnosis of brain death, including spontaneous movements of limbs (other than pathological flexion or extension response), respiration-like movements, deep tendon reflexes, superficial abdominal reflexes, triple flexion response, and the Babinski sign.
Most movements seem to occur within the first 24 h, and rarely after 72 h.
Will you go ahead?
Yes after explaining the case to the family.
Reference:
Busl KM, Greer DM. Pitfalls in the Diagnosis of Brain Death. Neurocrit Care (2009) 11:276–287.
Just before multiorgan retrieval, a potential DBD donor (confirmed brain stem death) moved his leg in response to a trivial stimulus. How do you explain this event? Brain death is irreversible state with permanent loss of consciousness and brain brain stem function, approved by coma, absent brain stem reflexes for more than 4 hours done by two different physicians, and apnea test. However, the movement of leg to stimuli reflects spinal response. Will you go ahead? Sure, after explaining this issue to family as a team (intensivist, nephrologist and neurologist) Good ethical practice is integral to efforts to facilitate donation and achieve transplantation in the context of DCD. This includes decisions about allocation and consent in relation to both the organ donor and recipient. (B1).
References: [1] Andrews PA, Burnapp L, Manas D; British Transplantation Society. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70. doi: 10.1097/01.TP.0000438630.13967.c0. PMID: 24448588. [2] Kumar L. Brain death and care of the organ donor. J Anaesthesiol Clin Pharmacol. 2016 Apr-Jun;32(2):146-52. doi: 10.4103/0970-9185.168266. PMID: 27275040; PMCID: PMC4874065.
A variety of reflex movements have been reported in patients with brain death such as -Plantar responses -Muscle stretch reflexes -Abdominal reflexes -Finger jerks
The existence of such reflex movements does not preclude the diagnosis of brain death as these reflexes are spinal reflexes.
Proper explanation to the deceased patient’s family should be done and definitely will go ahead with the transplant
References:
1. Wijdicks EF. The diagnosis of brain death. N Engl J Med. 2001;344:1215–1221. [PubMed] [Google Scholar]
2. Saposnik G, Maurino J, Bueri J. Movements in brain death. Eur J Neurol. 2001;8:209–213. [PubMed] [Google Scholar]
Thank you, just check that the tests were done properly before you proceed.
mai shawky
2 years ago
_Movement of the leg on trivial stimulation is originated from spinal reflexes and it is not against brain stem death.
_ Organ retrieval should star after confirmed brain stem death with full explanation of the relatives by a senior staff and no value to delay this.
Thank you, just check that the tests were done properly before you proceed.
Assafi Mohammed
2 years ago
How do you explain this event?
This is an involuntary flexor spasm, a very poor prognostic sign of irreversible brain damage. Will you go ahead?
Of course, I will go ahead.
This sign doesn’t mean viability or well-functioning brain, it’s a very poor sign of neural damage, occurring as a result of nociceptive spinal release reflex.
Thank you, just check that the tests were done properly before you proceed.
Huda Saadeddin
2 years ago
How do you explain this event?
A person’s limbs or torso (the upper part of the body) may move, even after brain stem death has been diagnosed. These spinal reflex movements are generated by the spinal cord and don’t involve the brain at all. Therefore, they won’t affect the diagnosis of brain death.
Brain stem death and neurological examination
Performance of a complete neurological examination. Components of a complete neurological examination are:
Examination of the patient-absence of spontaneous movement, decerebrate or decorticate posturing, seizures, shivering, response to verbal stimuli, and response to noxious stimuli administered through a cranial nerve path way. During the examination spinal reflexes may be present.
Absent pupillary reflex to direct and consensual light; pupils need not be equal or dilated.
Absent corneal, oculocephalic, cough and gag reflexes. The corneal reflex may be altered as a result of facial weakness.
Absent oculovestibular reflex
Failure of the heart rate to increase by more than 5 beats per minute after 1- 2 mg of atropine intravenously.
Absent respiratory efforts in the presence of hypercarbia
Generally, the apnoea test is performed after the second examination of brainstem reflexes.
The following manifestations are occasionally seen and should not be misinterpreted as evidence for brainstem function:
spontaneous movements of limbs other than pathologic flexion or extension response
respiratory-like movements (shoulder elevation and adduction, back arching, intercostal expansion without significant tidal volumes)
sweating, flushing, tachycardia
normal blood pressure without pharmacologic support or sudden increases in blood pressure
absence of diabetes insipidus
deep tendon reflexes; superficial abdominal reflexes
The triple flexion reflex movement of the leg was observed in two patients.
Babinski reflex
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.
Will you go ahead?
Yes I will go ahead .
Reference
The diagnosis of brain death
Ajay Kumar Goila and Mridula Pawar
Frequency of spinal reflex movements in brain-dead patients
How do you explain this event?
This movement to a trivial external stimulus is likely to be an spinal reflex that do not involve the brain stem & it may not change the diagnosis of brain stem death. It will not preclude diagnosis of breath death.
However, there is a well documented story of a 21-year-old Oklahoman who was determined he was “brain dead” after a battery of tests including a brain scan that showed a complete absence of blood flow to the brain. While being prepared for organs harvesting, a relative scraped the bottom of his foot with a pocket knife & he jerked his foot away. Just months later, this Oklahoman was walking & talking.
Manifestations compatible with the diagnosis of BD (should not be mis-interpreted as evidence for brain stem function):
Spontaneous movements of limbs (due to spinal activity).
Deep tendon reflexes
Superficial abdominal reflexes
Babinski reflex.
Respiratory-like movements (shoulder elevation & adduction, & back arching).
Sweating, flushing, tachycardia.
Normal BP without pharmacologic support or sudden increases in BP
Absence of diabetes insipidus.
The following may interfere with the clinical diagnosis of BD (ancillary tests may be necessary in such cases):
Severe facial or cervical spine trauma con-founding cranial nerve assessment.
Toxic levels of CNS-depressant drugs or neuro-muscular blocking agents.
Severe electrolyte, acid-base, or endocrine disturbance
Severe chronic pulmonary disease or severe obesity resulting in chronic retention of CO2. So, in this index case, one might raise the possibility that some points were cut in testing, or a mistake was made, or the person doing the testing was not qualified, etc. ================== Will you go ahead?
For the reasons mentioned above, I would rather review the case & order for retesting before harvesting in organ from this index case. References
1. Re-examining ‘brain death’: Doctors may be harvesting organs before donors are dead – Life Site https://www.lifesitenews.com.
2. GUIDELINES FOR DETERMINING BRAIN DEATH NEW YORK STATE DEPARTMENT OF HEALTH AND NEW YORK STATE TASK FORCE ON LIFE & THE LAW November 2011
yes, I will go ahead as it is a spinal cord reflex
this movement could be observed within the first 24 hours after the declaration of brain death and might be days after. these spinal reflexes are present in brain death if the ischemic lesion is above C1–C4 due to interruption of the supraspinal inhibition
reference:
How do you explain this event?
Spinal cord reflex
Will you go ahead?
Yes, i shall proceed, as brain stem death is confirmed
Reflexes of spinal origin may be present and should not be confused against the diagnosis of brain death. Leg movements after stimulation considered as spinal reflexes
Spinal reflexes include the stretch reflex, the Golgi tendon reflex, the crossed extensor reflex, and the withdrawal reflex.
The increase in intracranial pressure (ICP) that accompanies brain death spares the rostral portion beyond the second cervical spine and does not compromise blood supply to this area.
This could be the explanation for complex motor movements at the spinal cord level even after diagnosing brain death.
Clinical testing for brain death
Will you go ahead?
Yes I will proceed the transplantation
▪︎How do you explain this event?
This is one of the spinal reflexex
Note:
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 [1].
▪︎Will you go ahead? Yes.
____________
Ref:
L Döşemeci et al. Frequency of spinal reflex movements in brain-dead patients.Transplant Proc. 2004.
This spinal reflex
yes
Spontaneous and reflex movements may be found in patients with brain death (BD). Saposnik et al prospectively evaluated their frequency using a standardized protocol. Among 38 patients who fulfilled criteria for BD, the authors found 15 (39%) with spontaneous or reflex movements. The most common movement was finger jerks. Undulating toe flexion sign, triple flexion response, Lazarus sign, pronation-extension reflex, and facial myokymia also were seen. These movements may be more common than reported and do not preclude the diagnosis of BD.
Saposnik G, Bueri JA, Mauriño J, Saizar R, Garretto NS. Spontaneous and reflex movements in brain death. Neurology. 2000 Jan 11;54(1):221-3. doi: 10.1212/wnl.54.1.221. PMID: 10636153.
1.this is a spontaneous and reflex movement originates from spinal cord neuron ( spinal reflex) and does not preclude a brain death diagnosis.
2.yes
Döşemeci L, Cengiz M, Yilmaz M, Ramazanoĝlu A. Frequency of spinal reflex movements in brain-dead patients. Transplant Proc. 2004 Jan-Feb;36(1):17-9.
This is a spinal reflex so will proceed for donor Nephrectomy and Kidny transplant
How do you explain this event?
This a spinal cord reflex.
Will you go ahead?
I will proceed.
Q1: This movement could be considered as spinal reflexes which may be present in brain-dead patients.
Q2: Will you go ahead?
Yes, I will proceed for the transplantation.
Han SG, Kim GM, Lee KH, Chung CS, Jung KY. Reflex movements in patients with brain death: a prospective study in a tertiary medical center. J Korean Med Sci. 2006 Jun;21(3):588-90.
It is a movement due to spinal cord reflex, may occur with brain stem death, we can go ahead with retrieval.
This event can be explained by the presence of spinal reflexes which can exist even after brain stem death for some time. Other movements may be found as undulating toe, increased deep tendon reflexes, plantar responses, Lazarus sign, flexion-withdrawal reflex, facial myokymia, neck-arm flexion, finger jerks and fasciculations.
No contraindication for proceeding for organ retrieval; after proper explanation for the relatives. It should be born in mind that brain death can be determined in the presence of spinal reflexes.
Neurological consultation may be beneficial for further decision approval.
Reference:
Acta Neurol Belg. 2014 Dec; 114(4):303-6. Doi: 10.1007/s13760-014-0284-0. Epub 2014 Mar 7.
Beckmann Y, Çiftçi Y, Incesu TK, Seçil Y, Akhan G. Spinal reflexes in brain death. Acta Neurol Belg. 2014 Dec;114(4):303-6. doi: 10.1007/s13760-014-0284-0. Epub 2014 Mar 7. PMID: 24604683.
How do you explain this event?
Criteria for clinical confirmation of brain stem death
1. Absent respiratory drive: Apnea test: no response to hypercapnia (PaCO2 above 6.5 Kapa Confirmed by ABG) and should be repeated twice by two different doctors.
2. Loss of brain stem function:
· Absent pupillary reflexes
· Absent corneal reflexes
· Absent cranial motor function
· Absent gag reflexes
· Absent vestibuli-ocular reflex.
Leg movements after stimulation are considered spinal reflexes which occur in up to 75% of brain-dead patients, such as the pronation-extension reflex, abdominal reflex, and flexion reflex and can be evoked by painful or tactile stimuli.
Will you go ahead?
Yes, I will precede the transplantation after counseling the family and reconfirming the diagnosis by a senior expert neurologist.
Reference:
1) Kumar L. Brain death and care of the organ donor. J Anaesthesiol Clin Pharmacol. 2016 Apr-Jun;32(2):146-52. doi: 10.4103/0970-9185.168266. PMID: 27275040; PMCID: PMC4874065.
2) Busl KM, Greer DM. Pitfalls in the diagnosis of brain death. Neurocrit Care. 2009;11(2):276-87. doi: 10.1007/s12028-009-9231-y. Epub 2009 May 15. PMID: 19444652
This is a spinal reflex , I will proceed.
This is spinal reflex.
Yes I will go ahead with DBD donation.
Reference
1) Quality Standards Subcommittee of the American Academy of Neurology (1995) Practice parameters for determining brain death in adults. Neurology 45:1012–1014.
2 ) Saposnik G, Maurino J, Saizar R et al (2005) Spontaneous and reflex movements in 107 patients with brain death. Am J Med 118:311–314
# How do you explain this event?
*Spontaneous and reflex movements may occur in brain-dead patients. These movements originate from spinal cord neurons.1
*Many of this reflex movements have been reported in patients with brain death, in the form of plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks. So as these reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death.2
# Will you go ahead?
*Yes, I will go a head because it is a normal phenomenon and the awareness of these movements may prevent delays in brain-dead diagnosis and misinterpretations.
Also we need to explain this to donor’s family properly, by the senior most clinician in ITU.
1.L Döşemeci et al. Transplant Proc. 2004 Jan-Feb.
2.Reflex Movements in Patients with Brain Death: A Prospective Study in A Tertiary Medical Center
Suk-Geun Han, Gyeong-Moon Kim, Kwang Ho Lee, Chin-Sang Chung, and Ki-Young Jung
2006 Jun; 21(3): 588–590.
Published online 2006 Jun 21.
A variety of reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks).Because the aforementioned reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death.
Yes. I will proceed as this is a local reflexive phenomenon at the spinal cord level.
So, this spinal reflex can be explained to the relatives, and we can proceed with organ retrieval.
Wijdicks EF. The diagnosis of brain death. N Engl J Med. 2001;344:1215–1221.
Saposnik G, Maurino J, Bueri J. Movements in brain death. Eur J Neurol. 2001;8:209–213
Han SG, Kim GM, Lee KH, Chung CS, Jung KY. Reflex movements in patients with brain death: a prospective study in a tertiary medical center. J Korean Med Sci. 2006 Jun;21(3):588-90. doi: 10.3346/jkms.2006.21.3.588. PMID: 16778413; PMCID: PMC2729975.
This is spinal reflex – complex motor movement at the spinal cord level. It is due to sparing of rostral portion of spinal cord beyond C2 by the increased intracranial pressure, leading to non-compromised blood supply to the area (1). A combination of mechanical stimuli and hypoxia may be the trigger for these reflexes (2).
Yes. I will proceed as this is a local reflexive phenomenon at the spinal cord level. This phenomenon should be explained to the family members
Reference:
1) Kumar L. Brain death and care of the organ donor. J Anaesthesiol Clin Pharmacol. 2016 Apr-Jun;32(2):146-52. doi: 10.4103/0970-9185.168266. PMID: 27275040; PMCID: PMC4874065.
2) Busl KM, Greer DM. Pitfalls in the diagnosis of brain death. Neurocrit Care. 2009;11(2):276-87. doi: 10.1007/s12028-009-9231-y. Epub 2009 May 15. PMID: 19444652.
– The potential DBD donor confirmed his brain stem death but moved his legs in response to trivial stimulus
-there are specific condition which required to confirm brain stem death deep coma dependant on ventilator or inversible damage of brain
– the criteria to confirm brain death which must be done by a clinicians with relevant experience where one must be a consultant and the other one is registrated with GMC for at least 5years provided that the clinicians are not a member of transplant team are:
– absent respiratory drive.
– absent brain stem reflex.
Yes, I will proceed INSHALLAH.
References:
Prof: Ahmed Halawa lectures deceased donor transplantation.
Conditions required to perform brain stem death test
Deep coma relaying entirely on ventilator (apnoeic coma)
Irreversible brain damage compatible with the diagnosis of brain stem death
Criteria for clinical confirmation of brain stem death
1– Absent respiratory drive
No response to hypercapnia (PaCO2 above 6.5 Kpa
2- Absent brain stem reflexes ( no brain stem function)
Absent pupillary reflexes
Absent corneal reflexes
Absent cranial motor function
Absent gag reflexes
Absent vestibulo-ocular reflex.
Apnea test should be repeated (done twice by two different doctors) after unspecified length of time
Leg movements after stimulation considered as spinal reflexes
Spinal reflexes include the stretch reflex, the Golgi tendon reflex, the crossed extensor reflex, and the withdrawal reflex.
In brain-dead patients, spinal reflexes may be present. Absent spinal reflexes is not an indication of brain stem death as spinal reflexes originate from the spinal cord rather than higher centres.
Yes I will precede the transplantation
Reference
Lecture of Deceased Donor Transplantation
By
Ahmed Halawa
Consultant Transplant Surgeon
Associate Professor, University of Liverpool – UK
Up to date 2022
Movements originating from the spinal cord (spinal reflexes) or peripheral nerve may occur after the declaration of brain death (1). These are common (33 to 75 %) and may be triggered by tactile stimuli or occur spontaneously (2). Examples of such movements include:
●Subtle, semi-rhythmic movements of facial nerve-innervated muscles can arise from the denervated facial nerve.
●Finger flexor movements.
●Triple flexion response with flexion at the hip, knee, and ankle upon foot stimulation (e.g., testing for a Babinski sign).
●Tonic neck reflexes. Passive neck displacements, especially flexion, may be accompanied by complex truncal and extremity movements, including adduction at the shoulders, flexion at the elbows, supination or pronation at the wrists, flexion of the trunk (“sitting up” type movements), neck-abdominal muscle contraction or head turning to one side. These might be pretty dramatic, often called a “Lazarus sign.”
●Other truncal movements, including asymmetric posturing of the trunk and preservation of superficial and deep abdominal reflexes.
● Pronation extension reflex of the upper limb.
●Alternating flexion-extension of the toes with a passive displacement of the foot (undulating toe sign), or flexion of the toes after foot percussion, or a Babinski sign.
●Occasional fasciculations of the trunk and extremity muscles.
These movements do not preclude the loss of higher centre functions nor the diagnosis of brain death (2).
References:
1) Wijdicks EF, Varelas PN, Gronseth GS, et al. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74(23):1911.
1) G Bryan Young. Diagnosis of brain death. © 2022 UpToDate (accessed on 15 October 2022).
A variety of reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks . Because the aforementioned reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death.
will you go a head?
Yes, as these movements are from spinal reflexes and does not exclude brain death.
Reference:
J Korean Med Sci 2006; 21: 588-90 ISSN 1011-8934
– Many brain-dead patients have spontaneous movements such as jerking of fingers or bending of toes that can be disturbing to family members and health care professionals and even cause them to question the brain-death diagnosis. These movements occur in 39 percent of brain-dead patients
( according to a study published in the January 11 issue of Neurology, the scientific journal of the American Academy of Neurology )
& as per BTS guidelines , death can be diagnosed when
1. Asystole has occurred, and
2. Brain function has been lost, and
3. The possibility of spontaneous return of cardiac function has passed, providing that
4. There will be no subsequent intervention that restores cerebral perfusion whilst the brain remains responsive to such restoration.
So , based on this scenario , death was confirmed & the retrieval team should be aware of that & I will go ahead without any delay .
Reflex movements have been reported in up to 75% of brain dead patients.
A variety of reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks ( Because the aforementioned reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death.The frequency of spinal reflex movements is not rare and the awareness of these movements may prevent delays in brain-dead diagnosis and misinterpretations.
I will go ahead.
Refernce
Reflex Movements in Patients with Brain Death: A Prospective Study in A Tertiary Medical CenterSuk-Geun Han, Gyeong-Moon Kim, […], and Ki-Young Jung
variety of reflex movements have been reported in 75% in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks. Because the aforementioned reflexes are spinal reflex and presence of this reflex movements does not preclude the diagnosis of brain death.
Q2: Yes i will go ahead
How do you explain this event
Reflex movements have been reported to occur in up to 75% of brain-dead patients(1).
reflex movements such as the pronation-extension reflex, abdominal reflex, flexion
reflex, the Lazarus sign, and periodic leg movements are reported.
yes .
References :
A Prospective Study in A Tertiary Medical Center. journal of Korean medical
science 21(3):588-90.
Spontaneous and reflex movements such as moving limbs may occur in brain-dead patients. These movements originate from spinal cord neurons (LMN) and do not preclude a brain-death diagnosis. They are considered spinal reflexes.
These reflexes may create difficulties to convince a family or even a physician unfamiliar with brain death that the patient is indeed dead despite these movements.
Increase Awareness of these reflexes will decrease the time from declaring brain death to organ procurement which is often longer than expected. And analyzing these factors that delay organ procurement may help to prevent damage to organs from marginal and unstable donors and aid in preparation for recipient operation.
In the current scenario ,I will proceed for organ retrieval and considered the case as DBD donor.
it is asinal cord reflux dont main that brain stem is working however i have to acertain that brain death protocol and diagnosis is done well
Brain death is based on 3 criteria:
*persistent coma (confirmed with pain stimulus without response, eye-opening), no limb movement, no verbal response etc
*absence of brainstem reflexes (no corneal reflex, no gag reflex, no reflex on tracheal suctioning etc)
*apnea or lack of spontaneous breathing (Apnea test is done in eligible cases with evaluation of respirations and increase in CO2 pressure ..); if not eligible radiographic tests like radionuclide studies or contrast CT/MRI) to evaluate blood perfusion
Reference:
(Walter K. Brain Death. JAMA. 2020;324(11):1116. doi:10.1001/jama.2020.15898)
***** After confirmation, the patient is taken to the operating room.
Leg response is probably spinal reflex. So after confirmation of brain death; the retrieval team is expected to proceed
The three essential findings in brain death are coma, absence of brainstem reflexes, and apnoea.
Performance of a complete neurological examination. Components of a complete neurological examination are: i. Examination of the patient- absence of spontaneous movement, decerebrate or decorticate posturing, seizures, shivering, response to verbal stimuli, and response to noxious stimuli administered through a cranial nerve path way. During the examination spinal reflexes may be present. So in this case the movement related to spinal reflexes so proceed in transplantation
References
1- Guidelines for the determination of death: Report of the medical consultants on the diagnosis of death to the President’s commission for the study of ethical problems in medicine and biomedical and behavioral research. JAMA 1981;246:2184-6.
2- The Quality Standards Subcommittee of the American Academy of Neurology. Practice parameters: Determining brain death in adults. Neurology 1995;45:1012-4.
o Brain death is loss of function of the entire cerebrum and brain stem functions
o Brain death include complete unresponsiveness, permanent apnea, and an absence of brainstem reflexes
o Some reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks and the knee jerk reflex movement observed in this patient. These are spinal reflexes, there existence does not preclude the diagnosis of brain death.
o Reflex movements have been reported to occur in up to 75% of brain-dead patient and the awareness of these movements may prevent delays in brain-dead diagnosis and misinterpretations.
yes , I will go ahead as these reflex movement originating from the spinal cord doesn’t exclude brain stem death.
References:
Suk-Geun Han et al. Reflex Movements in Patients with Brain Death: A Prospective Study in A Tertiary Medical Center. J Korean Med Sci 2006; 21: 588-90
Brain death is the state of irreversible loss of brain function due to organic brain lesions. Although there are minor variations among the criteria that are used to define brain death, the essential criteria for establishing brain death include complete unresponsiveness, permanent apnea, and an absence of brainstem reflexes. A variety of reflex movements have been reported in patients with brain death, such as plantar responses, muscle stretch reflexes, abdominal reflexes, and finger jerks. Because the aforementioned reflexes are spinal reflexes, the existence of such reflex movements does not preclude the diagnosis of brain death
those who met the criteria for brain death:
(i) complete clinical neurological examination including documentation of coma, the absence of brainstem reflexes, and apnea,
(ii) persistence of above clinical features for at least 6 hr (to determine irreversibility),
(iii) exclusion of hypothermia, drug intoxication, and other metabolic causes of coma, and
(iv) demonstration of electrocerebral inactivity by electroencephalogram performed after the second examination
**Yes I will go ahead
reference:
Han, G., Kim, M., Lee, K. H., Chung, S., & Jung, Y. (2006). Reflex Movements in Patients with Brain Death: A Prospective Study in A Tertiary Medical Center. Journal of Korean Medical Science, 21(3), 588-590. https://doi.org/10.3346/jkms.2006.21.3.588
Some reflex movements were observed in brain-dead individuals, such as plantar flexion and extension responses, stretch reflexes, abdominal reflexes, and finger jerks which are spinal reflexes and don’t exclude the diagnosis of brain stem death.
I will go ahead after confirmation of brain stem death :
1- the presence of an unresponsive coma
2- Absence of brainstem reflexes :
Pupillary reflex
Corneal reflex
Oculocephalic reflex
Vestibulo-ocular response
Cough reflex
3- The apnea test to confirm absence of respiratory muscles movements
References :
Wijdicks EF. The diagnosis of brain death. N Engl J Med. 2001;344(16):1215–1221
Saposnik G, Mauriño J, Bueri J. Movements in brain death. Eur J Neurol. 2001;8(3):209–213. Review.
How do you explain this event?
Brain death is defined as loss of function of cerebrum and brain stem
some of reflexes called spinal reflexes as planter reflex , abdominal reflexes , muscle stretch reflexes not depend on higher brain centers
Will you go ahead?
Yes I will proceed after full confirmation of brain death by loss of pupillary reflex , corneal reflexes , gag reflex, vestibulo occular reflex
apnea test
Brain death is a state of cessation of cerebral function wherein the proximate cause is known and is considered irreversible. The American Association of Neurology (AAN) has defined brain death with three cardinal signs, cessation of the functions of the brain including the brainstem, coma or unresponsiveness and apnea
Reflexes of spinal origin may be present and should not be confused against the diagnosis of brain death
The diagnosis of brain death is clinical and can be confirmed by apnea testing. Ancillary tests can be considered when the apnea test cannot be completed or is inconclusive
Will you go ahead: yes ,after talking to the family
Reference
Journal of Anaesthesiology Clinical Pharmacology | April-June 2016 | Vol 32 | Issue 2
This movement happened due to spinal reflex.
Yes, the diagnosis of brain death is confirmed. If any doubts were raised, a ancillary test would be carried out.
How do you explain this event?
these movements are spinal reflexes that do not involve any brain activity
Some of the movements occurred spontaneously; others were triggered by touch
Electroencephalogram (EEG) tests did not show any brain activity in any of the patients with movements.
Movements associated with brain dead patients are not rare and thus an awareness of these movements is important to brain death diagnosis. Physicians who perform brain death examinations should understand the frequency and characteristics of these movements to reduce delays in determining brain death.
Will you go ahead?
Yes I will
Reference :
Reflex and Spontaneous Movements in Adult Patients during the Process of Determining Brain Death in Korea
Do-Hyung Kim, Oh-Young Kwon, […], and Young-Soo Kim
Spontaneous Movements Often Occur After Brain Death
Date:
January 13, 2000
AAN
– In a patient with confirmed brain stem death this can be attributed to the increase of intracranial pressure associated with the brain death thereby sparing the rostral portion beyond the second cervical spine and does not compromise blood supply to that area. This could be the explanation for moving the patient’s leg in response to a trivial stimulus considered as a complex motor movement at the spinal cord level after brain death diagnosis.
– Yes I shall proceed with the multiorgan retrieval.
Reference
Kumar L. Brain death and care of the organ donor. Journal of Anaesthesiology Clinical Pharmacology 2016 ,Vol 32 , Issue 2.
● This movement of his leg in response to a trivial stimulus considered as spinal reflex and as for brain death which require absence of all response to noxious stimules with the exception of spinally mediated reflexes
● So I will continue organs retrieval
How do you explain this event?
The movement of leg shows local response at spinal level. These reflexes are locally mediated and there is no cerebral input.This is not a contraindication to halt organ retrieval process.
Will you go ahead?
Yes I will proceed with organ retrieval.
Reference.
Han SG, Kim GM, Lee KH, Chung CS, Jung KY. Reflex movements in patients with brain death: a prospective study in a tertiary medical centre. J Korean Med Sci. 2006 Jun;21(3):588-90.
How do you explain this event?
-A potential DBD donor (confirmed brain stem death) moved his leg in response to a trivial stimulus→spinal reflex.
-The increase in intracranial pressure (ICP) that accompanies brain death spares the rostral portion beyond the second cervical spine and does not compromise blood supply to this area.This could be the explanation for complex motor
movements at the spinal cord level even after diagnosing brain death.
Will you go ahead?
Yes ,I will go ahead for multiorgan retrieval from this donor.
Referrence :
-Lakshmi Kumar. Brain death and care of the organ donor. Journal of Anaesthesiology Clinical Pharmacology | April-June 2016 | Vol 32 | Issue 2
I agree, dear Dr Reem.
A potential DBD donor who moved his leg in response to a stimulus is likely showing a spinal reflex and should not be considered as a contraindication for donation ,as this and other spinal reflexes like jerking of fingers or bending of toes are present in around 39% percent of patient according to American academy of Neurology.
Will you go ahead?
Yes,I will proceed for retrieval of organ because
REFERENCE:.
Kumar L. Brain death and care of the organ donor. Journal of Anaesthesiology Clinical Pharmacology,2016;32(2).
Busl KM, Greer DM. Pitfalls in the Diagnosis of Brain Death. Neurocrit Care (2009) 11:276–287
I agree, dear Dr Butt.
there are a set of spontaneous or stimulus-induced movements that are spinally mediated and not cerebral in origin.
The AAN Practice Parameters describe certain movements which do not preclude the clinical diagnosis of brain death, including spontaneous movements of limbs (other than pathological flexion or extension response), respiration-like movements, deep tendon reflexes, superficial abdominal reflexes, triple flexion response, and the Babinski sign.
Most movements seem to occur within the first 24 h, and rarely after 72 h.
Yes after explaining the case to the family.
Reference:
Busl KM, Greer DM. Pitfalls in the Diagnosis of Brain Death. Neurocrit Care (2009) 11:276–287.
I agree, dear Dr Huda.
thank you
Just before multiorgan retrieval, a potential DBD donor (confirmed brain stem death) moved his leg in response to a trivial stimulus.
How do you explain this event?
Brain death is irreversible state with permanent loss of consciousness and brain brain stem function, approved by coma, absent brain stem reflexes for more than 4 hours done by two different physicians, and apnea test. However, the movement of leg to stimuli reflects spinal response.
Will you go ahead?
Sure, after explaining this issue to family as a team (intensivist, nephrologist and neurologist)
Good ethical practice is integral to efforts to facilitate donation and achieve transplantation in the context of DCD. This includes decisions about allocation and consent in relation to both the organ donor and recipient. (B1).
References:
[1] Andrews PA, Burnapp L, Manas D; British Transplantation Society. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70. doi: 10.1097/01.TP.0000438630.13967.c0. PMID: 24448588.
[2] Kumar L. Brain death and care of the organ donor. J Anaesthesiol Clin Pharmacol. 2016 Apr-Jun;32(2):146-52. doi: 10.4103/0970-9185.168266. PMID: 27275040; PMCID: PMC4874065.
I agree, dear Dr Alshaikh.
A variety of reflex movements have been reported in patients with brain death such as
-Plantar responses
-Muscle stretch reflexes
-Abdominal reflexes
-Finger jerks
The existence of such reflex movements does not preclude the diagnosis of brain death as these reflexes are spinal reflexes.
Proper explanation to the deceased patient’s family should be done and definitely will go ahead with the transplant
References:
1. Wijdicks EF. The diagnosis of brain death. N Engl J Med. 2001;344:1215–1221. [PubMed] [Google Scholar]
2. Saposnik G, Maurino J, Bueri J. Movements in brain death. Eur J Neurol. 2001;8:209–213. [PubMed] [Google Scholar]
Thank you, just check that the tests were done properly before you proceed.
_Movement of the leg on trivial stimulation is originated from spinal reflexes and it is not against brain stem death.
_ Organ retrieval should star after confirmed brain stem death with full explanation of the relatives by a senior staff and no value to delay this.
Thank you, just check that the tests were done properly before you proceed.
How do you explain this event?
This is an involuntary flexor spasm, a very poor prognostic sign of irreversible brain damage.
Will you go ahead?
Of course, I will go ahead.
This sign doesn’t mean viability or well-functioning brain, it’s a very poor sign of neural damage, occurring as a result of nociceptive spinal release reflex.
Thank you, just check that the tests were done properly before you proceed.
A person’s limbs or torso (the upper part of the body) may move, even after brain stem death has been diagnosed.
These spinal reflex movements are generated by the spinal cord and don’t involve the brain at all. Therefore, they won’t affect the diagnosis of brain death.
Brain stem death and neurological examination
Performance of a complete neurological examination. Components of a complete neurological examination are:
Generally, the apnoea test is performed after the second examination of brainstem reflexes.
The following manifestations are occasionally seen and should not be misinterpreted as evidence for brainstem function:
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.
Yes I will go ahead .
The diagnosis of brain death
Ajay Kumar Goila and Mridula Pawar
Frequency of spinal reflex movements in brain-dead patients
Thank you, just check that the tests were done properly before you proceed.
Thank you prof
How do you explain this event?
This movement to a trivial external stimulus is likely to be an spinal reflex that do not involve the brain stem & it may not change the diagnosis of brain stem death. It will not preclude diagnosis of breath death.
However, there is a well documented story of a 21-year-old Oklahoman who was determined he was “brain dead” after a battery of tests including a brain scan that showed a complete absence of blood flow to the brain. While being prepared for organs harvesting, a relative scraped the bottom of his foot with a pocket knife & he jerked his foot away. Just months later, this Oklahoman was walking & talking.
Manifestations compatible with the diagnosis of BD (should not be mis-interpreted as evidence for brain stem function):
Spontaneous movements of limbs (due to spinal activity).
Deep tendon reflexes
Superficial abdominal reflexes
Babinski reflex.
Respiratory-like movements (shoulder elevation & adduction, & back arching).
Sweating, flushing, tachycardia.
Normal BP without pharmacologic support or sudden increases in BP
Absence of diabetes insipidus.
The following may interfere with the clinical diagnosis of BD (ancillary tests may be necessary in such cases):
Severe facial or cervical spine trauma con-founding cranial nerve assessment.
Toxic levels of CNS-depressant drugs or neuro-muscular blocking agents.
Severe electrolyte, acid-base, or endocrine disturbance
Severe chronic pulmonary disease or severe obesity resulting in chronic retention of CO2.
So, in this index case, one might raise the possibility that some points were cut in testing, or a mistake was made, or the person doing the testing was not qualified, etc.
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Will you go ahead?
For the reasons mentioned above, I would rather review the case & order for retesting before harvesting in organ from this index case.
References
1. Re-examining ‘brain death’: Doctors may be harvesting organs before donors are dead – Life Site https://www.lifesitenews.com.
2. GUIDELINES FOR DETERMINING BRAIN DEATH NEW YORK STATE DEPARTMENT OF HEALTH AND NEW YORK STATE TASK FORCE ON LIFE & THE LAW November 2011
Thank you, you do not need to retest if the original tests are done properly