The occurrence of spinal reflexes in brain-dead patients may certainly delay decision making, such as starting a transplantation procedure, because of difficulties in convincing the family or even a physician taking part in the diagnosis of brain death. The other reflex movements observed in our brain-dead patients were finger and toe jerks, extension at arms and shoulders, and flexion of arms and feet. Lazarus sign, the most dramatic and complex movement seen in brain-dead patients, was observed a few times in two patients during an apnea test, an oculocephalic test, after a painful stimulus, and after removal of a ventilator. Spinal reflex movements were observed in 18 out of 134 (13.4%) brain-dead patients during the study period. We also prefer to document the diagnosis of brain death with an EEG and/or TCD.

Clinical brain death was diagnosed according to our national law.

Patients admitted to our department between January 2000 and March 2003 and diagnosed as brain-dead were prospectively evaluated in terms of spinal reflexes. In this study, we sought to determine the frequency and characteristics of motor movements in patients who fulfilled diagnostic criteria for brain death. These movements originate from spinal cord neurons and do not preclude a brain-death diagnosis. They may frighten those who witness the movement, and have been viewed by some as miraculous events.Abstract: Spontaneous and reflex movements may occur in brain-dead patients. Occurrences of the Lazarus sign in intensive-care units have been mistaken for evidence of resuscitation of patients. It also occurs during testing for apnea-that is, suspension of external breathing and motion of the lung muscles-which is one of the criteria for determining brain death used for example by the American Academy of Neurology. The phenomenon has been observed to occur several minutes after the removal of medical ventilators used to pump air in and out of brain-dead patients. Short exhalations have also been observed coinciding with the action. They are often brought from here towards the neck or chin and touch or cross over. The arms then begin to flex at the elbows before lifting to be held above the sternum. The reflex is often preceded by slight shivering motions of the patient's arms, or the appearance of goose bumps on the arms and torso. It has been suggested by neurologists studying the phenomenon that increased awareness of this and similar reflexes 'may prevent delays in brain-dead diagnosis and misinterpretations.' As a consequence, the movement is possible in brain-dead patients whose organs have been kept functioning by life-support machines, precluding the use of complex involuntary motions as a test for brain activity. Like the knee jerk reflex, the Lazarus sign is an example of a reflex mediated by a reflex arc-a neural pathway which passes via the spinal column but not through the brain. The phenomenon is named after the Biblical figure Lazarus of Bethany, whom Jesus raised from the dead according to the Gospel of John. The Lazarus sign or Lazarus reflex is a reflex movement in brain-dead or brainstem failure patients, which causes them to briefly raise their arms and drop them crossed on their chests (in a position similar to some Egyptian mummies). Reflex movement in brain-dead or brainstem failure patients