Finger Flexion to Noxious Stimulation in a Brain-dead Patient: A Case Report and Review of Literature

Several guidelines and definitions for brain death have been proposed. The Uniform Determination of Death Act (UDDA) in 1980, the American Academy of Neurology (AAN) guidelines in 1995 and the later update in 2010 have all described standards for diagnosing brain death. As brain death testing became more commonly performed, several abnormal reflexive movements were recognized and led to ambiguities that falsely suggested retained brain function. Movements in the upper extremities have been under-recognized. We report a brain-dead patient with finger flexion in the upper extremities with noxious stimulation and suspect a pathogenesis similar to that of Hoffman's reflex sign. We present a case of an asthmatic patient who presented with pulseless electrical activity (PEA). The patient was managed emergently and subsequently deteriorated to a comatose state. She remained in a comatose state following management and showed diffuse cerebral edema secondary to anoxic brain injury on computed tomography (CT) scan. Subsequent apnea testing, transcranial Doppler studies (TCD) and detailed neurological examinations were performed. She was eventually declared brain dead. On nailbed pressure to her fourth finger, she had flexion of her third finger, similar to the finding of a Hoffman’s sign in an upper motor neuron injury. We have described this case in detail and reviewed the literature on abnormal movements in brain-dead patients.