Lazarus phenomenon in a brain-dead patient: a case report

Abstract

BACKGROUND: Brain death is defined as the irreversible cessation of all cerebral and brainstem functions, confirmed through clinical examination and, when necessary, ancillary testing. While the diagnostic criteria are well established, certain spinal reflexes, such as the Lazarus phenomenon, can complicate clinical examinations and lead to diagnostic uncertainty. Most reported cases describe predominant upper-limb movements; however, atypical variants involving truncal or lower-limb responses have rarely been reported. CASE PRESENTATION: We report the case of a 33-year-old Iranian man with cerebellar hemangioblastoma who developed transtentorial herniation and fulfilled all clinical criteria for brain death. Brain death determination was performed independently by two neurologists 6 h apart after exclusion of sedative exposure, metabolic disturbances, neuromuscular blockade, and hypothermia. Apnea testing demonstrated an increase in PaCO(2) from 39 to 64 mmHg without spontaneous respiratory effort. During examination, reproducible reflex movements were triggered by passive neck flexion and painful stimulation, consisting predominantly of bilateral hip and knee flexion with lower-limb adduction, accompanied by limited upper-extremity flexion. These findings were interpreted as spinal reflex activity consistent with an atypical lower-limb-predominant Lazarus phenomenon. CONCLUSION: This variation reinforces the importance of recognizing spinal reflexes in brain-dead individuals and underscores the need for awareness of such findings to avoid misinterpretation. Clinicians must distinguish these movements from indicators of residual brain function to ensure accurate and timely determination of brain death.