Branham sign


Nicoladoni-Israel-Branham sign: Compression of the arterial supply to an arteriovenous fistula causes a decrease in pulse and increase in blood pressure if there is a significant circulation through the fistula.

History of Nicoladoni-Israel-Branham sign

1875Carl Nicoladoni (1847-1902) described a case of phlebarteriectasia of the right arm in a 17-year-old worker, which had developed since the age of eight involving the arterial system of the whole right upper extremity. He noted the phenomenon of a slowing down of the pulse, when the brachialis was compressed.

Nicoladoni-Israel-Branham sign 1875
First graphic record of slowing of the pulse rate following occlusion of an artery proximal to an arteriovenous fistula
Nicoladoni, 1875: 268

1877James Adolf Israël (1848-1926) published his paper on Angiectasie im Stromgebiete der A. tibilais antica. Beobachtung einiger bemerkenswerther Phaenomene nach Unterbindung der A. femoralis, the observation of some remarkable phenomena after ligation of the femoral artery in a case of tibial arterial AV malformation. In particular, on March 16th, after ligation of the femoral artery the pulse dropped from 108 to 42 bpm

Es wird aus dem Folgenden hervorgehen, dass die Unterbindung der Femoralis eine Ueberfüllung der Herzhöhlen begünstigen musste. Denn der Effect der Unterbindung bestand, wie dargethan werden wird, 1) in stärkerer Füllung des Gefässystems, 2) in Steigerung der arteriellen Spannung, 3) in bedeutender Pulsverlangsamung.

Israël, 1877

From the following we observe that the femoral vessel acts as a reservoir for the heart chambers. The effect of this synergy results in 1. enhanced  vascular filing 2. increased arterial blood pressure 3. marked bradycardia…

Israël, 1877

Branham sign. Israel bradycardia post femoral artery ligation 1877
Marked bradycardia day 1 post femoral artery ligation. Israël, 1877

1890Harris Miller Branham (1862-1936) reported a case of aneurysmal varix of the femoral artery and vein following a gunshot wound, and noted slowing of the heart rate if he occluded the femoral artery above the varix. In his own words:

The most mysterious phenomenon connected with the case, one which I have not been able to explain myself, or to obtain a satisfactory reason for from others, was slowing of the heart’s beat, when compression of the common femoral was employed.

This symptom became more marked until pressure on the artery above the wound caused the heart’s beat to fall from 80 to 35 per minute, and so to remain until the pressure was relieved

Branham 1890

1914 – Sign rediscovered by Wigdorowitsch and published in the Deutsche Medizinische Wochenschrift in 1915

Ein bemerkenswertes Reflexphänomen bei einem Aneurysma der A. femoralis. Von Dr. Wigdorowitsch, Russischer Arzt im Gefangenenlazarett Guben.

Der russische Kriegsgefangene O. hat am 24. August 1914 einen Schuß durch das obere Drittel des rechten Oberschenkels erhalten. Die Wunde ist schnell verheilt, dagegen hat sich ein Aneurysma der A. femoralis ausgebildet. Sitz des Aneurysmas wahrscheinlich im unteren Drittel des Scarpaschen Dreiecks. Der Puls ist sonst normal, gut gefüllt, durchschnittlich 72 in der Minute. Drückt man aber die A. femoralis unter dem Ligamentum Pouparti des verwundeten Beinas zusammen, so sinkt der Puls sofort auf 42–45 Schläge. Dasselbe Verfahren am gesunden Beine beeinflußt den Puls nicht.

Die Erscheinung verdient jedenfalls Nachprüfung auch an an- deren Fällen von Aneurysma

Wigdorowitsch DMW, 1915

A remarkable reflex phenomenon in a femoral artery aneurysm. From Dr. Wigdorowitsch, Russian doctor in the prison hospital in Guben.

The Russian prisoner of war O. was shot through the upper third of his right thigh on August 24, 1914. The wound healed quickly, but an aneurysm of the femoral artery has developed. The aneurysm is probably located in the lower third of the Scarpa triangle. The pulse is otherwise normal, well filled, an average of 72 per minute. But if the femoral artery is compressed under the Poupart ligament of the wounded leg, the pulse immediately drops to 42-45 beats. The same procedure on a healthy leg does not affect the pulse.

In any case, the phenomenon deserves to be examined in other cases of aneurysms as well

Wigdorowitsch DMW, 1915

1923 Rudolph Matas (1860-1957) emphasised the systemic effects of arteriovenous aneurysm; called attention to the desirability of delaying repair in order to favour the development of collaterals. He popularised Branham sign, which he believed held not only diagnostic but prognostic value in arteriovenous aneurysm

Branham’s Bradycardiac Reaction…This is by far the most important early sign of cardiovascular disturbance brought about by an arteriovenous fistula and is of great diagnostic significance in all cases in which arteriovenous communication is accessible to compression

Matas, 1923

1940’s – Lewis and Drury (1923) analyzed the response in detail and demonstrated that it was mediated through the vagus and that atropine would abolish the response. They pointed out that the response was stereotyped under standard conditions, and remained unchanged for a considerable period. Nickerson et al confirmed the fact that atropinization can block the change in pulse rate.

The changes in heart rate and output occurring upon temporary compression of an arteriovenous fistula have been studied in a group of 25 patients. In 68 per cent of the patients there was a significant decrease in heart rate (Branham’s sign) which occurred almost immediately upon compression of the fistula and which was blocked by use of atropine.

Nickerson et al 1950

1958Howard B. Burchell (1907-2010) studied a group of children with femoral arteriovenous communications created by Janes, for the purpose of increasing leg growth, at the Mayo Clinic in the 1950’s. He found that when the femoral artery above a large arteriovenous fistula in the thigh is occluded, the bradycardic response has an individualized pattern over several years which is reproducible under standardized conditions. As a general rule the maximal response is obtained within one to two seconds or one to two heart beats.

Branham sign Change in heart rate during occlusion of the proximal artery supplying the arteriovenous fistula
Fig. 125. Changes in aortic pressure and heart rate during occlusion of the proximal artery supplying the arteriovenous fistula. The response occurs within two heart beats after the fistulous flow is stopped. Burchell, 1958

1997 – Somkiat Wattanasirichaigoon and Frank B. Pomposelli, Jr proposed that Branham sign is an exaggerated Bezold-Jarisch reflex

Associated Persons

Alternative names
  • Branham’s Bradycardiac reaction (Matas 1923)
  • Nicoladoni-Branham sign (Burchell 1958)
  • Nicoladoni-Israel-Branham sign
  • Branham’s sign
  • Nicoladoni sign


Historical references

Eponymous term review




the person behind the name

BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

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