Brain death Quiz: Ace Your Exams

A 59-year-old woman is being managed in the intensive care unit following an out-of-hospital cardiac arrest. The patient was found unresponsive on the kitchen floor by a family member. Emergency medical services initiated advanced cardiac life support, intubated the patient in the field, and achieved return of spontaneous circulation (ROSC) after 12 minutes. Medical history includes chronic alcohol use and major depressive disorder, for which citalopram is prescribed. Temperature is 36.6°C (98.0°F), heart rate is 55 beats per minute, blood pressure is 98/52 mmHg on a norepinephrine infusion, respiratory rate is 16 breaths per minute (via mechanical ventilation), and oxygen saturation is 96% on FiO₂ 40%. On examination off sedation, the patient is comatose and does not open her eyes or move in response to noxious stimuli. The right pupil is dilated and nonreactive, while the left pupil is pinpoint and sluggishly reactive. There is no gag or cough reflex during endotracheal tube suctioning. A noncontrast computed tomography (CT) of the brain is unremarkable. The care team is concerned that the patient is unlikely to achieve meaningful neurologic recovery. Which of the following physical examination findings is most supportive of this concern?