Unusual movements, "spontaneous" breathing, and unclear cerebral vessels sonography in a brain-dead patient: a case report.

A patient with a brain injury fulfilled all clinical criteria for brainstem death diagnosis. Two standard sets of tests were performed; according to Polish regulations, the patient could be declared brain dead. However, shortly after the completion of the tests and before the final brain death declaration, 6 triggered "assisted" breaths/min were noticed. After careful analysis of the ventilator settings, it was concluded that low trigger sensitivity and airway pressure oscillations during heart contractions were the reasons. Additionally, a few minutes later, spontaneous jerking movements of lower limbs and clonic movements of neck muscles secondary to painful stimuli were noticed. The situation became confusing; therefore, cerebral Doppler sonography was performed, showing circulatory arrest in both of the internal carotid, middle cerebral, and left vertebral arteries. The basilar artery was not visualized. Forward flow with increased pulsatility was recorded in extracranial and intracranial segments of the right vertebral artery. Cerebral circulatory arrest was still uncertain; therefore, the diagnostic procedures were completed with conventional cerebral angiography, which showed a lack of cerebral blood flow. Finally, the patient was declared brain dead; kidneys and bones were harvested. Cardiogenic oscillations associated with incorrect low ventilator trigger settings may falsely suggest persistence of breathing efforts in a brain-dead patient. In the case of any unusual events during brain death diagnosis, cerebral perfusion tests should be performed with cerebral angiography as the "gold standard."