title: Complex spinal reflexes during transcranial Doppler ultrasound examination for the confirmation of brain death.
abstract: OBJECTIVE
  Complex sets of movements of the extremities can be seen in patients with brain death (BD), and are typically observed during apnea testing or removal of ventilatory support (also called the Lazarus sign). We here describe brain-dead patients who had not shown previous movements, even during apnea testing, but presented complex spinal reflexes during transcranial Doppler (TCD) examination elicited by neck flexion.
  
  
  METHODS
  We performed a prospective TCD study of patients with the clinical diagnosis of BD.
  
  
  RESULTS
  Four (2.5%) of 161 brain-dead patients presented complex spinal reflexes exclusively during TCD examination. TCD showed vertebro-basilar circulatory arrest in all four. Their systolic blood pressure was significantly lower than that of brain-dead patients not presenting movements during TCD examination.
  
  
  CONCLUSIONS
  Hypotension and mechanical stimulation play a role in the pathophysiology of complex spinal reflexes present in BD, which are not exclusively seen in terminal hypoxia. Intensive care personnel and neurologists who perform TCD to confirm BD should be aware of these movements.
authors.affiliation: Department of Neurology, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. gfreitas@nitnet.com.br
authors.forename: G R
authors.initials: GR
authors.lastname: de Freitas
authors.forename: M A S D
authors.initials: MA
authors.lastname: Lima
authors.forename: C
authors.initials: C
authors.lastname: André
mesh_terms: D000328:Adult; D001926:Brain Death / Q000000981:diagnostic imaging* / Q000503:physiopathology; D005207:Fasciculation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009068:Movement; D009333:Neck; D012018:Reflex; D013116:Spinal Cord / Q000503:physiopathology*; D017585:Ultrasonography, Doppler, Transcranial