Thumbs Up Sign in Brain Death

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Spinal reflexes can be seen in the setting of brain death. We present a new spinal reflex. We also review spinal movements in pediatric brain death and provide suggestions to distinguish them from movements generated by the brain.

Case Report

We report a five-year old girl admitted after an asystolic cardiac arrest and was soon declared brain death as a result of bilateral cerebellar hematoma. She had spinal movements including a “Thumbs up sign”. These findings delayed organ procurement.


“Thumbs up sign” should be added to the list of spinal reflexes seen with brain death. Spinal reflexes in brain death can be clinically recognized and should explained to all involved parties to avoid unnecessary testing, confusion for family members, and delay or refusal of organ donation.

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Correspondence to Manoj K. Mittal.

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Video title: Thumbs up sign in brain death. Video legend: Limbs are immobile at rest but with nailbed compression the thumb and index finger repeatedly extends. (MPG 12056 kb)

Video title: Thumbs up sign in brain death. Video legend: Limbs are immobile at rest but with nailbed compression the thumb and index finger repeatedly extends. (MPG 12056 kb)

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Mittal, M.K., Arteaga, G.M. & Wijdicks, E.F.M. Thumbs Up Sign in Brain Death. Neurocrit Care 17, 265–267 (2012) doi:10.1007/s12028-012-9729-6

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  • Spinal reflexes
  • Child
  • Organ donation
  • Brain death