Levent DÖŞEMECİ, Melike CENGİZ, Firuze GÜRPINAR, Babür DORA, ATİLLA RAMAZANOĞLU

Spinal refleksler beyin ölümü tanısında kuşku yaratabilir (Olgu sunumu)

Beyin ölümü gelişen hastalarda spontan ve refleks hareketler görülebilir. Bu hareketler beyin ve beyin sapı nöronlarından değil spinal kord nöronlarından kaynaklanmaktadır ve beyin ölümü tanısından uzaklaştırmaz. Olgumuzda klinik ve yardımcı testlerle beyin ölümü tanısı konulduktan sonra her iki üst ekstremitede abduksiyon, dirseklerde fleksiyon, el bileği ve parmaklarda fleksiyon, yakalama hareketleri ve boyunda fleksiyon şeklinde gözlenen spinal refleksler (Lazarus işareti) tespit edilmiştir. Spinal refleksler beyin ölümü tanısında kuşkulara ve gecikmelere yol açarak donör kaybına veya yoğun bakım ünitesinin gereksiz kullanımına neden olabileceğinden yoğun bakım doktorları ve anestezistler tarafından iyi bilinmelidir.

Anahtar Kelimeler:

Refleks, Tanı, Beyin ölümü

Spinal reflexes may lead to doubts in the diagnosis of brain death (Case report)

Spontaneous and reflex movements may be seen in patients with brain death. The living cells that these movements originate from are not brain stem neurons but neurons located in the spinal cord. The presence of movements does not preclude the diagnosis of brain death. In our case, spinal reflexes as abduction of upper extremities, flexion of elbows, flexion of wrists and fingers, grasping movements and flexion of neck (Lazarus sign) were observed after brain death was diagnosed by clinical and confirmatory tests. Since spinal reflexes can cause loss of donors or misutilization of ICU and lead to delays and doubts on the diagnosis of brain death, they should be well known by ICU physicians and anesthesiologists.

Keywords:

Reflex, Diagnosis, Brain Death,

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1. Marti-Fabregas i, Lopez-Navidad A, Caballero F,Otermin P. Deserebrate like posturing with mechanical ventilation in brain death. Neurology 2000; 54: 224-7
2. Ramazanoğlu A, Döşemeci L. Erişkin hastalarda beyin ölümü tanısı. Anestezi Dergisi 1997; 5: 1-7
3. Bohatyrewicz R, Kojder I, Krawczyk L, et al. Spinal reflexes in the determination of brain death. Neurol Neurochir Pol 1997; 31: 281-5
4. Saposnik G, Bueri JA, Maurino J, Saizar R, Garretto NS. Spontaneus and reflex movements in brain death. Neurology 2000; 54:221-3 5. Chiristie JM, O'Lenic TD, Cane RD. Head turning in brain death. J Clin Anesth 1996; 8: 141-3
6. Ikeda H, Aruga T, Hayashi M, Miyake Y, Sugimoto K, Mastumoto K. Two cases in which the presence of ciliospina response led to indecisiveness in the evaluation of brain death. No To Shinkei 1999; 51: 161-6
7. Jorgensen EO. Spinal man after brain death. The unilateral ex-tension-pronation reflex of the upper limb as an indication of brain death. Acta Neurochir (Wien) 1973; 28: 259-73
8. Ivan LP. Spinal reflexes in cerebral death. Neurology 1973;23:650-2
9. Miller RD. Anesthesia,Philadelphia, Harcourt Braee and Company 2000; II: 2567
10. Walker AE, Diamond EL, Moseley J. The neuropathological findings in irreversible coma: A critique of the 'respirâtuar brain'. J Neuropathol Exp Neurol 1975; 34: 295
11. Mandel S, Arenas A, Scasto D. Spinal automatism in cerebral death. N Engl J Med 1982; 307: 501
12. Heytens L, Verlooy J, Gheuens J, Bossâert L. Lazarus sign and extensor posturing in a brain death patient. J Neurosurg 1989; 71:449-51
13. Urasaki E, Fukumura A, Itho Y, et al. Lazarus sign and respiratory like movement in a patient with brain death. No To .Shinkei 1988; 40: 1111-6
14. Urasaki E. Preserved spinal dorsal horn potentials in a brain death patient with Lazarus sign. J Neurosurg 1992; 76: 710-3
15. Pallis C. ABC of brain stem death. Diagnosis of brain stem death II. Br Med J 1982; 285: 1641-4
16. David B, Warsel MD. The end of life sequence. Am Soc Anesth 1997; 87: 676-84
17. Benrubi GI. Euthanasia: The need for procedural safeguards. N Eng J Med 1992; 326: 197-9
18. The multisociety task force on PVS. Medical aspects of the persistent vegetative state. N Engl J Med 1994; 330: 1572-9
19. Swinbanks D. Japan reaches a compromise on organ transplants. Nature 1997;387:835
20. Paolin A, Manuali A, Di Paolo F,et al. Reliability in diagnosis of brain death. Inten Care Med 1995; 21: 657-62
21. Burger R, Schlake HP, Seybold S, Reiners C. Value of transcranial doppler ultrasonography compared with scintigraphic techniques and EEG in brain death. Zentralbl Neurochir 2000; 61:7-13
22. Ducrocq X, Braun M, Debouverie M, Junges C. Brain death and transcranial doppler experience in 130 cases brain death patients. J Neurol Sci 1998; 160: 41-6
23. Hadani M, Bruk B, Ram Z, Knoller N. Application of transcranial doppler ultrasonography for the diagnosis of brain death. Inten Care Med 1999; 25: 822-8
24. Chen CL, Chen TL, Sun WZ, Fan SZ, Susetio L, Lin SY. He-modynamic responses to surgical stimuli in brain death organ donors. Ma Tsui Hsueh Tsa Chi 1993; 31: 135-8
25. Ballaris MA, Bersano T, Bosco R, et al. 5 patients in irreversible coma in which it was not possible to remove the organs for therapeutic transplant. Minerva Anesthesiol 1989; 55: 403-7
26. Van den Bent MJ, Ronday M, Oosterlee A. Unexpected movements in brain death patient. Ned Tijdschr Geneeskd 1993;137: 2653-5
27. Ulvic A, Salvesen R, Nielsen EW. Reflexes in brain death patients. Tidsskr Nor Laegeforen 1998; 118:2025-6
28. Gail A, Van Norman A. Matter of life and death: What every anesthesiologist should know about the medical, legal and ethical aspects of declaring brain death. Am Soc Anesth 1999; 91:3-4