Kumar Abhay, Tummala Pavan, Feen Eliahu S, Dhar Rajat
Department of Neurology, Saint Louis University School of Medicine, St Louis, MO, USA
Department of Neurology, Saint Louis University School of Medicine, St Louis, MO, USA.
J Intensive Care Med. 2016 Oct;31(9):622-4. doi: 10.1177/0885066616646076. Epub 2016 May 11.
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.
Case report and systematic review of literature.
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.
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.
确立脑死亡（BD）的标准要求所有脑干介导的反射消失，包括运动（即去大脑强直或去皮层强直）姿势。脑死亡后可能会出现一些脊髓自主性活动，但出现类似去大脑强直的脊髓反射可能特别成问题；这种刻板的伸展 - 旋前运动与脑干反射的混淆可能会混淆或延迟脑死亡的明确诊断。我们报告一例病例，其中我们证实了这种类似去大脑强直反射的非脑源性（即可能是脊髓源性）起源。
病例报告及文献系统综述。
一名63岁女性出现大面积脑桥出血，脑功能完全丧失，包括对疼痛无运动反应。呼吸暂停试验根据神经学标准确认死亡。在宣布脑死亡36小时后，在评估器官捐献期间，她开始出现上肢自发和刺激诱发的刻板伸展 - 旋前动作。这些动作与去大脑强直姿势的相似性引发了对脑干功能保留的担忧，但对颅神经的重复神经系统检查和呼吸暂停试验未发现任何脑部反应。脑电图显示脑电静息，核医学脑成像显示无灌注，进一步证实了脑死亡。检索PubMed又发现了5例病例报告和4个队列研究，描述了脑死亡后延迟出现类似去大脑强直伸展 - 旋前动作的病例。
脑死亡后可能会延迟出现模仿去大脑强直姿势的伸展 - 旋前动作。在本病例及其他病例中，通过检查和多项辅助检查证实缺乏任何脑活动，这促使我们将这些动作归因于脊髓反射，并建议在公认的脑死亡后自主性活动范围内认识到这些动作，它们不应延迟诊断或需要进行确认性检查。
