Abstract Details

Title Recognition of Unilateral Eye Opening as Spinal Motor Reflex in Brain Death

Topic Neuro Trauma and Critical Care

Presentation(s) P14 - Poster Session 14 (11:45 AM-12:45 PM)

Poster/Presentation
Number 1-002

Objective To highlight reflex unilateral eye-opening to noxious stimulation in a brain-dead patient.

Background Spinal motor reflexes have been seen in brain dead patients and they do not preclude brain death (BD) declaration. However, reflex eye-opening in brain dead patients has been described only twice in modern medical literature.

Design/Methods Case report

Results A 67-year-old African American male arrived at emergency room after found unresponsive. Arrival exam revealed comatose patient, absent pupillary light reflex, absent cough, weak corneal reflex and bilateral extensor posturing. Admission head CT revealed diffuse subarachnoid hemorrhage and large right frontotemporal intraparenchymal hemorrhage from ruptured middle cerebral artery aneurysm, causing diffuse cerebral edema, uncal and tonsillar herniation. Patient’s follow up exam suspected brain death. Patient satisfied all prerequisites for BD assessment. All clinical components of assessment were consistent with BD, except that patient was found to have partial right eye opening on noxious stimulation using sternal rub and trapezius pinch (not with supraorbital or nailbed pressure). Repeated assessments over next six hours revealed persistent stereotypic findings. Hypercapnia after ten minutes of apnea test was consistent with diagnosis of BD. Ancillary tests were performed for further confirmation. Nuclear medicine cerebral blood flow study using Technetium-99m supported BD diagnosis by absence of intracranial tracer uptake. Transcranial Doppler (TCD), however, showed slow velocities in basilar artery. Although, TCD has high false negative rate, its combination with unrecognized reflex eye opening caused uncertainty among providers and death declaration using BD criteria was deferred. Family withdrew care and patient died subsequently.

Conclusions Stereotypic unilateral eye-opening is extremely rare finding and may suggest spinal reflex due to surviving sympathetic trunk function. Recognition of this reflex may be helpful for brain death determination and avoid uncertainty among providers and family.

Authors/Disclosures
Eesha Oza, MD PRESENTER	Dr. Oza has nothing to disclose.
Nilufer Yalcin, MD	Dr. Yalcin has nothing to disclose.
Klepper Alfredo Garcia, MD (Augusta University - Neurocritical Care Division)	Dr. Garcia has nothing to disclose.
Manan Shah, MD, MBBS (Augusta University Medical Center, Dept Of Neurology)	Dr. Shah has nothing to disclose.

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