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.
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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Wijdicks EFM, Rabinstein AA, Manno EM, Atkinson JD. Pronouncing brain death: contemporary practice and safety of the apnea test. Neurology. 2008;71:1240–4.
Saposnik G, Basile VS, Young GB. Movements in brain death: a systematic review. Can J Neurol Sci. 2009;36:154–60.
Pugh J, Clarke L, Gray J, Haveman J, Lawler P, Bonner S. Presence of relatives during testing for brain stem death: questionnaire study. BMJ. 2000;321:1505–6.
Nakagawa TA, Ashwal S, Mathur M, et al. Guidelines for the determination of brain death in infants and children: an update of the 1987 task force recommendations. Pediatrics. 2011;128:e720–40.
Saposnik G, Bueri JA, Maurino J, Saizar R, Garretto NS. Spontaneous and reflex movements in brain death. Neurology. 2000;54:221–3.
Fackler JC, Troncoso JC, Gioia FR. Age-specific characteristics of brain death in children. Am J Dis Child. 1988;142:999–1003.
Spittler JF, Wortmann D, Von Düring M, Gehlen W. Phenomenological diversity of spinal reflexes in brain death. Eur J Neurol. 2000;7:315–21.
Martí-Fàbregas J, López-Navidad A, Caballero F, Otermin P. Decerebrate-like posturing with mechanical ventilation in brain death. Neurology. 2000;54:224–7.
Conci F, Procaccio F, Arosio M, Boselli L. Viscero-somatic and viscero-visceral reflexes in brain death. J Neurol Neurosurg Psychiatry. 1986;49:695–8.
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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
- Spinal reflexes
- Organ donation
- Brain death