Repetitive leg movements mimicking periodic leg movement during sleep in a brain-dead patient

[Irreversible brain death-Part 2. Spinalization phenomena]

Spinal automatisms and reflexes, peripheral neurogenic and myogenic reactions are common in patients with irreversible brain death. They are therefore compatible and are even understood by experienced investigators as confirmation of irreversible brain death. This article provides an overview of the phenomenology of irreversible brain death and discusses it from a neuropathological perspective. Furthermore, irreversible brain death is described in order to distinguish it from pathological movements and motor reactions in comatose patients or patients with disturbed consciousness due to severe brain disorders.

Abnormal movements in critical care patients with brain injury: a diagnostic approach

Abnormal movements are frequently encountered in patients with brain injury hospitalized in intensive care units (ICUs), yet characterization of these movements and their underlying pathophysiology is difficult due to the comatose or uncooperative state of the patient. In addition, the available diagnostic approaches are largely derived from outpatients with neurodegenerative or developmental disorders frequently encountered in the outpatient setting, thereby limiting the applicability to inpatients with acute brain injuries. Thus, we reviewed the available literature regarding abnormal movements encountered in acutely ill patients with brain injuries. We classified the brain injury into the following categories: anoxic, vascular, infectious, inflammatory, traumatic, toxic-metabolic, tumor-related and seizures. Then, we identified the abnormal movements seen in each category as well as their epidemiologic, semiologic and clinicopathologic correlates. We propose a practical paradigm that can be applied at the bedside for diagnosing abnormal movements in the ICU. This model seeks to classify observed abnormal movements in light of various patient-specific factors. It begins with classifying the patient’s level of consciousness. Then, it integrates the frequency and type of each movement with the availability of ancillary diagnostic tests and the specific etiology of brain injury.

Brain death

The diagnosis of brain death should be based on a simple premise. If every possible confounder has been excluded and all possible treatments have been tried or considered, irreversible loss of brain function is clinically recognized as the absence of brainstem reflexes, verified apnea, loss of vascular tone, invariant heart rate, and, eventually, cardiac standstill. This condition cannot be reversed - not even partly - by medical or surgical intervention, and thus is final. Many countries in the world have introduced laws that acknowledge that a patient can be declared brain-dead by neurologic standards. The U.S. law differs substantially from all other brain death legislation in the world because the U.S. law does not spell out details of the neurologic examination. Evidence-based practice guidelines serve as a standard. In this chapter, I discuss the history of development of the criteria, the current clinical examination, and some of the ethical and legal issues that have emerged. Generally, the concept of brain death has been accepted by all major religions. But patients' families may have different ideas and are mostly influenced by cultural attitudes, traditional customs, and personal beliefs. Suggestions are offered to support these families.

Ventilator Autotriggering: A Caution in Brain Death Diagnosis

The Uniform Determination of Death Act and the American Academy of Neurology's Guidelines for Determination of Death define procedures for diagnosis of brain death before organ procurement for transplantation, including clinical assessment and apnea test. Autotriggering of mechanical ventilators can occur in both brain dead and living patients. A case is reported in which procurement was delayed because ventilator self-cycling was confused for brainstem-mediated respiratory effort. Background knowledge to effectively troubleshoot ventilator self-cycling is offered so that unnecessary delays in brain death testing can be avoided.

Sleep in disorders of consciousness

From a behavioral as well as neurobiological point of view, sleep and consciousness are intimately connected. A better understanding of sleep cycles and sleep architecture of patients suffering from disorders of consciousness (DOC) might therefore improve the clinical care for these patients as well as our understanding of the neural correlations of consciousness. Defining sleep in severely brain-injured patients is however problematic as both their electrophysiological and sleep patterns differ in many ways from healthy individuals. This paper discusses the concepts involved in the study of sleep of patients suffering from DOC and critically assesses the applicability of standard sleep criteria in these patients. The available literature on comatose and vegetative states as well as that on locked-in and related states following traumatic or non-traumatic severe brain injury will be reviewed. A wide spectrum of sleep disturbances ranging from almost normal patterns to severe loss and architecture disorganization are reported in cases of DOC and some patterns correlate with diagnosis and prognosis. At the present time the interactions of sleep and consciousness in brain-injured patients are a little studied subject but, the authors suggest, a potentially very interesting field of research.

Pitfalls in the diagnosis of brain death

Since the establishment of the concept of declaring death by brain criteria, a large extent of variability in the determination of brain death has been reported. There are no standardized practical guidelines, and major differences exist in the requirements for the declaration of brain death throughout the USA and internationally. The American Academy of Neurology published evidence-based practice parameters for the determination of brain death in adults in 1995, requiring the irreversible absence of clinical brain function with the cardinal features of coma, absent brainstem reflexes, and apnea, as well as the exclusion of reversible confounders. Ancillary tests are recommended in cases of uncertainty of the clinical diagnosis. Every step in the determination of brain death bears potential pitfalls which can lead to errors in the diagnosis of brain death. These pitfalls are presented here, and possible solutions identified. Suggestions are made for improvement in the standardization of the declaration of brain death.

Reflex movements in patients with brain death: a prospective study in a tertiary medical center

Reflex movements have been reported to occur in up to 75% of brain-dead patients, but this issue has not been addressed in Korea. The patients admitted to our hospital who met the criteria for brain death were enrolled between March 2003 and February 2005. The frequency and type of reflex movements in these patients were evaluated prospectively using a standardized protocol. Brain death was determined according to the guideline of Korean Medical Association. Of 26 patients who were included, five (19.2%) exhibited reflex movements such as the pronation-extension reflex, abdominal reflex, flexion reflex, the Lazarus sign, and periodic leg movements. This finding suggests that the frequency of spinal reflex movements is not rare and the awareness of these movements may prevent delays in brain-dead diagnosis and misinterpretations.