title: Spinal Decerebrate-Like Posturing After Brain Death: A Case Report and Review of the Literature.
abstract: BACKGROUND
  Criteria for establishing brain death (BD) require absence of all brainstem-mediated reflexes including motor (ie, decerebrate or decorticate) posturing. A number of spinal cord automatisms may emerge after BD, but occurrence of decerebrate-like spinal reflexes may be particularly problematic; confusion of such stereotypic extension-pronation movements with brain stem reflexes may confound or delay definitive diagnosis of BD. We present a case in which we verified the noncerebral (ie, likely spinal) origin of such decerebrate-like reflexes.
  
  
  METHODS
  Case report and systematic review of literature.
  
  
  RESULTS
  A 63-year-old woman presented with large pontine hemorrhage and complete loss of cerebral function, including no motor response to pain. Apnea testing confirmed death by neurologic criteria. Thirty-six hours after BD declaration, during assessment for organ donation, she began to exhibit spontaneous and stimulus-induced stereotypic extension-pronation of the upper extremities. The similarity of these movements to decerebrate posturing prompted concern for retained brain stem function, but repeat neurological examination of cranial nerves and apnea testing did not reveal any cerebral responses. Electrocerebral silence on electroencephalogram and absent perfusion on nuclear medicine brain imaging further confirmed BD. Review of PubMed yielded 5 additional case reports and 4 cohorts describing cases of decerebrate-like extension-pronation movements presenting in a delayed fashion after BD.
  
  
  CONCLUSIONS
  Extension-pronation movements that mimic decerebrate posturing may be seen in a delayed fashion after BD. Verification of lack of any brain activity (by both examination and multiple ancillary tests) in this case and others prompts us to attribute these movements as spinal cord reflexes and propose they be recognized within the rubric of accepted post-BD automatisms that should not delay diagnosis or necessitate confirmatory testing.
authors.affiliation: Department of Neurology, Saint Louis University School of Medicine, St Louis, MO, USA abhay.kumarjha@gmail.com.
authors.forename: Abhay
authors.initials: A
authors.lastname: Kumar
authors.affiliation: Department of Neurology, Saint Louis University School of Medicine, St Louis, MO, USA.
authors.forename: Pavan
authors.initials: P
authors.lastname: Tummala
authors.affiliation: Department of Neurology, Saint Louis University School of Medicine, St Louis, MO, USA.
authors.forename: Eliahu S
authors.initials: ES
authors.lastname: Feen
authors.affiliation: Department of Neurology, Washington University School of Medicine, St Louis, MO, USA.
authors.forename: Rajat
authors.initials: R
authors.lastname: Dhar
mesh_terms: D001926:Brain Death / Q000503:physiopathology*; D001933:Brain Stem / Q000503:physiopathology*; D003655:Decerebrate State / Q000175:diagnosis / Q000503:physiopathology*; D004569:Electroencephalography; D005260:Female; D006801:Humans; D008875:Middle Aged; D009119:Muscle Contraction; D009460:Neurologic Examination / Q000379:methods*; D013127:Spinal Nerves / Q000503:physiopathology*; D009927:Tissue and Organ Procurement
keywords: brain death; decerebrate posturing; decision-making; neurocritical care; spinal cord reflexes