Brain death-associated reflexes and automatisms

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.