أكذوبة موت المخ

ظاهرة لازاروس : مرضى موت المخ المزعوم يتحركون حركات عضلية ( تلقائية ومركبة وهادفة ) بالاطراف والايدى والاقدام .... ومحاولة المريض النهوض من الفراش ومحاولة التقىء والسعال وهى كلها علامات قاطعة على استمرار الحياة واستمرار عمل المخ والجهاز العصبى

Neurocritical care

Neurocrit Care.2005,3(2):122-6

Brain death-associated reflexes and automatisms

Samay Jain¹  and Michael DeGeorgia²

Abstract   Background: In several instances, the diagnosis of brain death has been questioned due to the presence of movements. This case report and review of the literature illustrates the spectrum of movements that have been encountered in brain death.

Methods: A case report and review of the literature on movements seen in brain death was conducted.

Results: Movements in brain death are common and have a wide range of phenomenology. Several movements wax and wane over time, making movements in brain death difficult to classify. In addition, varying terminology has been used (e.g., Lazarus sign, spinal man, spinal reflexes, spinal automatisms). Although evidence points to a spinal origin for such movements, the pathophysiology in many cases remains speculative. Characteristics of movements in brain death have been identified that can help differentiate them from brainstem or voluntary origin.

Conclusions: Based on our review, we suggest referring to stimulus-provoked movements as reflexes and spontaneous movements as automatisms. We propose using the terms brain death-associated reflexes and brain death-associated automatisms as two main categories for movements that occur in brain death. These terms do not imply a specific pathophysiology, but consistent clinically oriented nomenclature may be useful when reporting such phenomena.

__________________________________________________________

European Journal of Neurology

Eur J Neurol. 2004 Nov;11(11):723-7.

Undulating toe movements in brain death

Saposnik G, Mauriño J, Saizar R, Bueri JA.

Movements in Brain Death Study Group, Department of Neurology, Hospital JM Ramos Mejía, Universidad de Buenos Aires, Buenos Aires, Argentina. gsaposnik@yahoo.com

For many years, death implied immobility. Nevertheless, there are anecdotal reports of spontaneous or reflex movements (SRMs) in patients with Brain death (BD). The presence of some movements can preclude the diagnosis of BD, and consequently, the possibility of organ donation for transplantation. McNair and Meador [(1992), Mov Dord7: 345-347] described the presence of undulating toe flexion movements (UTF) in BD patients. UTF consists in a sequential brief plantar flexion of the toes. Our aim was to determine the frequency, characteristics and predisposing factors of UTF movements in a prospective multicenter cohort study of patients with BD. Patients with confirmed diagnosis of BD were assessed to evaluate the presence of UTF using a standardized protocol. All patients had a routine laboratory evaluation, CT scan of the head, and EEG. Demographic, clinical, hemodynamic and blood gas concentration factors were analyzed. amongst 107 BD patients who fulfilled the AAN requirements, 47 patients (44%) had abnormal movements. UTF was observed in 25 (23%) being the most common movement (53%). Early evaluation (OR 4.3, CI95% 1.5-11.9) was a predictor of UTF in a multivariate regression model. The somato-sensory evoked potential (SSEPs) as well as brainstem auditory evoked potentials (BAEPs) did not elicit a cortical response in studied patients with UTF. This spinal reflex is probably integrated in the L5 and S1 segments of the spinal cord. Abnormal movements are common in BD, being present in more than 40% of individuals. UTF was the most common spinal reflex. In our sample, early evaluation was a predictor of UTF. Health care professionals, especially those involved in organ procurement for transplantation, must be aware of this sign. The presence of this motor phenomenon does not preclude the diagnosis of BD.

__________________________________________________________

Transplantation Proceedings

Transplant Proc.2004 Jan-Feb,36(1):17-9

Frequency of spinal reflex movements in brain-dead patients

Authors: Dosemeci L.¹; Cengiz M.; Yilmaz M.; Ramazanoglu A.

Spontaneous and reflex movements may occur in brain-dead patients. These movements originate from spinal cord neurons and do not preclude a brain-death diagnosis. In this study, we sought to determine the frequency and characteristics of motor movements in patients who fulfilled diagnostic criteria for brain death. Patients admitted to our department between January 2000 and March 2003 and diagnosed as brain-dead were prospectively evaluated in terms of spinal reflexes. Clinical brain death was diagnosed according to our national law. We also prefer to document the diagnosis of brain death with an EEG and/or TCD. Spinal reflex movements were observed in 18 out of 134 (13.4%) brain-dead patients during the study period. Lazarus sign, the most dramatic and complex movement seen in brain-dead patients, was observed a few times in two patients during an apnea test, an oculocephalic test, after a painful stimulus, and after removal of a ventilator. The other reflex movements observed in our brain-dead patients were finger and toe jerks, extension at arms and shoulders, and flexion of arms and feet. The occurrence of spinal reflexes in brain-dead patients may certainly delay decision making, such as starting a transplantation procedure, because of difficulties in convincing the family or even a physician taking part in the diagnosis of brain death. An awareness of spinal reflexes may prevent delays in and misinterpretations of the brain-death diagnosis

__________________________________________________________

Acta Neurol Scand. 2003 Sep,108(3):170-3

Complex spinal reflexes during transcranial Doppler ultrasound examination for the confirmation of brain death

Authors: de Freitas, G. R.1; Lima, M. A. S. D.1; André, C.1

Abstract:

de Freitas GR, Lima MASD, André C. Complex spinal reflexes during transcranial Doppler ultrasound examination for the confirmation of brain death.

Acta Neurol Scand 2003: 108: 170-173. © Blackwell Munksgaard 2003. 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.

__________________________________________________________

Journal of the American Academy of Neurology

Neurology 2000,54:221

Spontaneous Movements Often Occur After Brain Death

Science Daily — ST. PAUL, MN - Many brain-dead patients have spontaneous movements such as jerking of fingers or bending of toes that can be disturbing to family members and health care professionals and even cause them to question the brain-death diagnosis. These movements occur in 39 percent of brain-dead patients, according to a study published in the January 11 issue of Neurology, the scientific journal of the American Academy of Neurology.

"We found that these movements are more common than has been reported or believed," said neurologist and study author José Bueri, MD, of J. M. Ramos Mejia Hospital in Buenos Aires, Argentina. "People need to know that these movements are spinal reflexes that do not involve any brain activity."

The study examined all patients at the hospital during an 18-month period with a diagnosis of brain death. Of the 38 patients, 15 had these motor movements. In all cases, the movements were seen in the first 24 hours after brain death diagnosis, and no movements were seen after 72 hours.

Some of the movements occurred spontaneously; others were triggered by touch. Examiners used tests designed to elicit motor movements, such as lifting the arms or legs or touching the palm of the hand.

Electroencephalogram (EEG) tests did not show any brain activity in any of the patients with movements.

"If the lack of understanding of these movements leads to a delay in the brain death diagnosis or questions about the diagnosis afterwards, there can be important practical and legal implications, especially for organ procurement for transplantation," Bueri said. "Family members and others need to understand that these movements originate in the spinal cord, not in the brain, and their presence does not mean that there is brain activity.

One of the most startling movements for family members and health care professionals is called the 'Lazarus sign.' It is a sequence of movements lasting for a few seconds that can occur in some brain dead patients, either spontaneously or right after the ventilator is disconnected," Bueri said. It is named for the episode in the Bible where Lazarus is raised from the dead.

"It starts with stretching of the arms, followed by crossing or touching of the arms on the chest, and finally falling of the arms alongside the torso," he said. "It is also a spinal reflex, but it can be disturbing to family members and others who see this."

Another article in this issue of Neurology describes unusual movements in two brain dead patients. The movements occurred in a 30-year-old woman and an 11-month-old baby at a hospital in Barcelona, Spain. Both patients extended their arms, flexed their wrists and curled up their fingers each time the mechanical ventilator inflated their lungs. The movements stopped after the patients were disconnected from the ventilator.

"We had never seen these type of movements before, and they hadn't been reported in the medical journals," said neurologist Joan Martí-Fàbregas, MD, PhD, of the Hospital de la Santa Creu i Sant Pau.

The doctors conducted additional tests and confirmed that there was no brain activity. "The living cells that were ordering these muscles to move were not brain cells or brain stem cells, but cells located in the spinal cord," he said. "It's important for family members and health care professionals to be aware of this possibility."

A neurologist is a medical doctor with specialized training in diagnosing, treating and managing disorders of the brain and nervous system.

The American Academy of Neurology, an association of more than 16,000 neurologists and neuroscience professionals, is dedicated to improving patient care through education and research .

__________________________________________________________

The American Journal of Medicine

Volume 118, Issue 3, March 2005, Pages 311-314

Spontaneous and reflex movements in brain death

G. Saposnik, MD, J. A. Bueri, MD, J. Mauriño, MD, R. Saizar, MD and N. S. Garretto, MD

From the Department of Neurology, Hospital J.M. Ramos Mejía, Buenos Aires, Argentina.

Address correspondence and reprint requests to Dr. José A. Bueri, Department of Neurology, Hospital J.M. Ramos Mejía, Urquiza 609, Buenos Aires (1221), Argentina.

Spontaneous and reflex movements may be found in patients with brain death (BD). The authors prospectively evaluated their frequency using a standardized protocol. Among 38 patients who fulfilled criteria for BD, the authors found 15 (39%) with spontaneous or reflex movements. The most common movement was finger jerks. Undulating toe flexion sign, triple flexion response, Lazarus sign, pronation–extension reflex, and facial myokymia also were seen. These movements may be more common than reported and do not preclude the diagnosis of BD.

__________________________________________________________

J Korean Med Sci 2006; 21: 588-90

ISSN 1011-8934

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 .

(Ref PM4)__________________________________________________________