[Neurological problems in the diagnosis of brain death--observation of spinally-mediated movements in brain-dead patients and proposal of a "brain death judging doctor" system].

We report two cases in which neurological examination met the Second Tentative Criteria for Brain Death of Chiba University Medical School, except for spontaneous contractions of the rectus abdominis muscle during apnea testing. In Case 1, a 54-year-old man with brainstem infarction, judgement of brain death was suspended initially, but was ultimately declared after the contractions were deemed to be spinal in origin. MRI findings after declaration and autopsy were compatible with brain death. In Case 2, a 27-year-old man with fulminant hepatitis and subsequent severe brain edema, judgement was postponed due to detection of the contractions at the second testing, and was ceased with family intent. Several cases of abnormal gross and fine movements in brain-dead patients have been reported. These paradoxical phenomena may confuse an inexperienced examiner and delay the declaration of brain death. Whether brain death should be considered real death of the person or not, neurologists should be aware of the occasional presence of neurological problems in the diagnosis of brain death, such as spinally-mediated movements. Since the major opposition to brain death is the distrust of medical doctors, we propose a pilot system of a "brain death judging doctor".