Eye-opening in brain death: A case report and review of the literature

Spinal reflexes and brain death

“…In all these cases, the movement has been considered solely of cord origin, with no brainstem involvement. And yet – unlike the case of eye opening described by Focardi and colleagues ( Focardi et al, 2022 ) – the mechanism is often not known, particularly for complex movements. In a review of movements in brain death, Saposnik et al (2009) wrote “the pathophysiological basis of [many movements in brain death] has remained speculative … We can only propose … possible mechanisms … unfortunately, there are no well-documented human studies demonstrating these phenomena” ( Saposnik et al, 2009, p. 158 ).…”

“… Focardi et al (2022) describe a patient suspected of meeting diagnostic criteria for brain death, who demonstrated an unusual response of slow bilateral eyelid elevation in response to painful stimulation of both the right and left nipple. It was determined that the observed eyelid elevation was due to preserved function of sympathetic fibers arising from the superior cervical ganglion located in the neck, which innervate the superior tarsus (Mullers) muscle, and not due to preserved function of the oculomotor nucleus in the midbrain and its associated oculomotor nerve, which innervates the levator palpebrae superioris (eyelid elevator) muscle.…”

“…In the case of slow eyelid elevation in response to thoracic stimulation, Focardi et al have suggested that cerebral flow evaluation should be used as a prudential measure, and it should show absence of intracranial blood flow prior to determining brain death ( Focardi et al 2022 ). This is a reasonable approach, but it should be interpreted with caution, as false negatives can occur with any modality (i.e., the test shows intracranial circulatory arrest – it is negative for blood flow – yet some brain function or blood flow continues).…”