Reflex and Spontaneous Movements in Adult Patients during the Process of Determining Brain Death in Korea

Abstract

Background: Brain death is a clinical diagnosis that implies irreversible loss of function of the entire brain, including the brainstem and both hemispheres. Based on previous reports, it is not rare for reflex and spontaneous movements to occur in patients during the process of determining brain death. However, reports of the frequency and common types of these movements vary from study to study. Thus, we evaluated adult patients with impending brain death in Korea to determine the frequency and characteristics of reflex and spontaneous movements. Methods: Brain dead patients who were admitted to 15 hospitals in the Yeongnam region (Southeast) of Korea were recruited prospectively from January 2013 to September 2016. All patients met the criteria for brain death as established by the Korea Medical Association. All body movements occurred during the process of diagnosing brain death and were assessed by physicians and trained organ transplant coordinators. The frequency and characteristics of these movements were identified and the demographic and clinical factors of impending brain dead patients with and without these movements were compared. Results: A total of 436 patients who met the criteria for brain death were enrolled during the study period. Of these patients, 74 (17.0%) exhibited either reflex or spontaneous movements. Of this subset, 45 (60.8%) exhibited reflex movements only, 18 (24.3%) exhibited spontaneous movements only, and 11 (14.9%) exhibited both reflex and spontaneous movements. The most common reflex movements were the flexor/extensor plantar response and spinal myoclonus. Of the 74 patients, 52 (70.3%) exhibited one movement of the same pattern and 22 (29.7%) exhibited two or more different movement patterns. In addition, 45 (60.8%) exhibited these movements only on a limited area of the body with the leg being most common (n = 26, 57.8%). Patients with hypoxic brain damage and a higher systolic blood pressure exhibited significantly more reflex or spontaneous movements. Conclusion: 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.

A rare spinal reflex in brain death: Bilateral plantar flexion in nuchal rigidity examination

“…They reported that the most common reflex was the plantar extension and flexion response to painful stimuli, which were observed in 30 of the participating patients. 3 Beckman et al evaluated 144 patients diagnosed with brain death and showed that 32 patients, in whom toe fluctuations, increased deep tendon reflexes, Lazarus sign, arm-neck flexion, fasciculations, and finger twitches were observed, had spontaneous and spinal reflexive movements. 4 In a study conducted by Conci et al, viscero-visceral and viscero-somatic reflexes were investigated and the authors observed a contraction response in the abdominal muscles during the peritoneal incision in 15 of the 25 patients, who underwent laparotomy for donor nephrectomy,.…”

Factors Affecting the Time Taken to Determine Brain Death in Patients with Impending Brain Death

“…The frequency of movements including RMs and SMs observed in PWIBDs has reportedly ranged from 17.0% to 75.0%. 3 5 9 10 11 12 13 SMs reflect brain function while RMs reflect the function of the spinal cord, and so SMs do not appear in patients confirmed as brain death, whereas RMs such as spinal reflexes may appear in them. 2 14 A multicenter study conducted in Argentina applied a standardized protocol of stimuli to elicit reflexes in PWIBDs before and after performing apnea tests in 107 PWIBDs, and observed various types of RMs.…”

“…The present authors previously performed a prospective study that examined the RMs and SMs observed in 436 PWIBDs during the decision process about brain death. 5 The present study excluded 22 of those 436 PWIBDs, and so enrolled 414 PWIBDs who were the objects of the previous research. Sixteen of the 22 excluded PWIBDs had missing information on hypertension, diabetes mellitus, cardiac disease, smoking, and alcohol drinking, while the other 6 patients were excluded since the causative disease for brain death was not appropriate or there was only 1 case for 1 etiology: the KODA registry described the etiology of brain death as arteriovenous malformation, brain abscess, diffuse astrocytoma, encephalopathy, toxic encephalopathy, and unruptured aneurysm.…”

“…The present authors have previously reported on the RMs and SMs observed in 436 PWIBDs. 5 Movements appeared in 74 (17%) of those 436 PWIBDs during the process of determining brain death: 60.8% had only RMs, 24.3% had only SMs, and 14.9% had both RMs and SMs. Flexor/extensor plantar responses and spinal myoclonus were the most common types of RMs.…”

“…The two neurologists among the present authors reviewed the collected videos and classified RMs and SMs. 5…”