Some questions about brain death: a case report.

A 13-year-old girl had an anaphylactic cardiac arrest with 45 minutes of resuscitation. After rewarming on day 3, a first examination was compatible with brain death, including an apnea test. Shortly thereafter, a stimulus to the trapezius muscle above the clavicles resulted in bilateral lower-limb withdrawal. A subsequent examination by another intensivist found, during vestibulo-ocular testing, bilateral lower-limb withdrawal. A radionuclide cerebral blood-flow test indicated no intracranial flow, and a computed tomography scan indicated diffuse severe cerebral edema. After these tests, stimulus to the trapezius muscle resulted in bilateral lower-limb extensor posturing. The next day, on repeated examination, the patient no longer had any response to stimulus, and was declared brain dead. This case raised two questions. Why should an intermittent lower-limb withdrawal response to supraclavicular stimulus be a more critical brain function, precluding a diagnosis of brain death (indicating that the patient has not lost integrative unity of the organism), than all other clinical and radiological findings? Was the withdrawal response of spinal origin or brainstem origin? How one chooses to interpret the withdrawal of lower limbs elicited by supraclavicular stimulus directly determines whether the patient in this case was dead.