Neurocritical Care

, Volume 17, Issue 2, pp 265–267 | Cite as

Thumbs Up Sign in Brain Death

  • Manoj K. MittalEmail author
  • Grace M. Arteaga
  • Eelco F. M. Wijdicks
Practical Pearl



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.


Spinal reflexes Child Organ donation Brain death 


Financial Support and Disclosure


Conflict of interest


Supplementary material

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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Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Manoj K. Mittal
    • 1
    Email author
  • Grace M. Arteaga
    • 2
  • Eelco F. M. Wijdicks
    • 1
  1. 1.Department of NeurologyMayo ClinicRochesterUSA
  2. 2.Department of PediatricsMayo ClinicRochesterUSA

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