Hillary’s fainting spell

And I thought I’d retired as a neurologist. What is there to say about the video that shows Hillary Clinton being held up by a woman on her left, later by others, and then collapsing sufficiently that her head is at most 3 feet from the pavement in one frame. You don’t have to go to medical school to call this a fainting spell.

As to what caused the episode, we can only speculate. I see no reason to trust what the campaign is putting out, that she had ‘pneumonia’ for the previous two days. Since I’ve already gone on record that she had a stroke in December 2012 ( https://luysii.wordpress.com/2016/08/24/hillary-clintons-stroke-in-2012/ ), not due to head trauma sustained in what was said to another fainting spell, people have asked me what the event could be neurologically.

But I’m a neurologist not an internist, so I talked to a very smart one for his take.

“Somewhat oddly, her campaign now reports that pneumonia had been “diagnosed” as of two days before her collapse. However, she was not acting as if she is infectious, going out into crowds and getting close to small children. The Clintons are known for lawyerly parsing of phrases carefully, so it may matter what the meaning of pneumonia “is.” Therein may lie a clue which puts the chronic non-productive cough of many months duration, along with apparent decreased stamina and a carefully tuned and truncated schedule over a similar period into perspective.

Chronic lung disease, particularly a mildly progressive idiopathic pulmonary fibrosis/interstitial pneumonia could fit that picture. It would also be technically true as a diagnosis. Whatever pulmonary condition she has does not appear to be acute.”

He also had an interesting observation on the way the faint was handled. “There must be some chronic known condition, as she has two attendants with her now at all times–large black male and heavyset white woman. Her collapse was handled as if it were familiar territory. Hustling a woman of her age into a van and driving to her daughter’s apartment is a highly unusual way to handle such a loss of consciousness in a 68-year old woman, particularly when there had to be a number of emergency vehicles loaded with EMT’s on the scene and well as several hospitals at least as close as her daughter’s apartment.” To which a friend noted that the secret service is trained to react immediately to situations like this, going through dry runs of all sorts of eventualities etc. etc.

Taking her to her daughter’s apartment is quite strange, given the way the secret service was acting 40 or so years ago. Back then, a neurosurgeon in Billings Montana told me that the secret service had called him up and asked him to be available in the coming weekend as the president would be visiting Yellowstone, a mere 140 miles away by the nearest road. It seems likely that some hospital close by was on alert that Hillary was in the neighborhood.

The internist has been watching her a lot more closely than I have and noted the following “There were shots a month or so ago of her needing help to get up outdoor stairs and also needing a small step-stool to get up into a Secret Service Suburban. My wife and I hop in and out of a Yukon and do not need any step device (they are of comparable age). After a photo of her doing that was published, she started getting in and out of vehicles on the side away from cameras and was also switched to a taller van with a step mounted on the vehicle. In February, press was forbidden by her staff from filming her climbing the stairs to board her private jet.” He wondered if she could have something like limb girdle dystrophy — watching her walk and stand during the upcoming debates will be helpful for determining that.

Finally he noted — “There are also a number of cardiovascular causes (transient arrhythmia for starters) as well as pulmonary microemboli which can cause collapse like that.”

Now for the neurologic possibilities.

There are peculiar videos purporting to show Hillary having a ‘seizure’ during a press conference. They look doctored to me. She appears to be compulsively laughing. Such seizures are called gelastic epilepsy. They are rare but I’ve seen them. They arise from the hypothalamus and the temporal lobes. Nothing in the current video is suggestive of a seizure. Loss of consciousness at this age rarely is due to a seizure. Cardiovascular causes are far more likely.

Another possible cause is a brainstem transient ischemic attack (TIA), since we have been told that the clot of 2012 was in a draining sinus of the posterior fossa (we have no pictures of any sort from that episode). Recovery in 90 minutes is consistent with either syncope or TIA.

The final possibility is that the event is a warning of an impending second stroke. If you look again at the post about the events of 2012, you’ll see that I speculated that the ‘faint’ occuring in the week of 9 December could have been a transient warning of the cerebral venous thrombosis she suffered that month. I don’t think this likely, but when I examined for the Neurology boards, fellow examiners always wanted to see how many possibilities for diagnoses the candidates can muster.

So what do I think it was? A fainting spell (syncope if you want to be impressive). Her blood pressure dropped for some reason or other, the brainstem which maintains alertness didn’t get enough fresh blood and she passed out nearly. The people with her did NOT help by keeping her erect, which kept the brainstem from getting the blood (and the oxygen it delivers) it needed. In fact holding someone up who has fainted is the perfect crime, as the brain deprived of oxygen long enough begins to die, and no marks will be found on the body.

Why out of the thousands there, on a warm but not excessively hot day, she was the only one to pass out can only be the subject of speculation until more details are forthcoming. The health of a possible future president is simply too important not to speculate about.

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  • Peter Lund  On September 14, 2016 at 5:13 pm

    She was able to walk out (mostly) on her own but on the other hand she had some kind of warning that something was wrong.

    What would give her such a warning with enough time to walk out?

  • luysii  On September 14, 2016 at 8:58 pm

    Apparently you’ve never passed out from low blood pressure. There often is a warning that something is very wrong. She probably noted dizziness, lightheadedness and weakness from the low blood pressure. Not sure how far she actually had to walk.

  • Glen L. Weaver  On September 15, 2016 at 2:53 pm

    I would expect, like many her age, she has several minor problems. Mild COPD causing the coughing attacks; stress incontinence, so avoiding fluids prior to public events.

    What I found shocking was the response of her team. For a post stroke victim on Coumadin, I would have expected any episode of syncope to result in a fast trip to ED to rule out a bleed, and the follow up MRI/MRA with neurologist the following day. Perhaps she travels with a physician who can carefully monitor her condition.

    The consequences of a brain bleed when on anticoagulants are scary.

  • luysii  On September 15, 2016 at 6:49 pm

    Have seen many intracerebral hemorrhages, many in the 70s and 80s due to anticoagulation with coumadin (monitored using prothrombin times not INRs back then) for TIA’s, only 1/3 of which (due to atrial fibrillation) would be indicated now.

    Your point was raised by others in the post, and implies that her team has seen her faint many times.

  • YoYo  On September 18, 2016 at 8:17 pm

    There is a theory that she has Parkinson’s disease. A web search for this will turn up a list of videos. The “seizure” video does bear some resemblance to a movement disorder. Note that the muscle movement is bilateral and muscle tone in the trunk is altered.

    There is another video of her freezing at a political rally. She suddenly just stops, like somebody turned off a switch. The bald, black agent (doctor?) has to touch her to get her going again and tells her “OK … keep talking [inaudible]” after which she eventually restarts and repeats his words “OK [prolonged laughter] We’ll keep talking.” This episode is so unusual, and so completely atypical for her, that there must be some sort of neurological change that caused it. It is arguably compatible with both gelastic epilepsy and Parkonsinism.

    There are some other videos out there with odd head movements and eye movements.

    Thanks for reading my conspiracy theory. I feel like a Cold War Kremlinologist.

    • luysii  On September 18, 2016 at 8:47 pm

      I haven’t been watching her as closely as some. However, because of this and similar comments,I did look at a video of her at some Black churchladies conference or other. She showed NONE of the typical signs of Parkinsonism
      l. Her face was full of expression and NOT masklike
      2. She walked briskly, and had no problem climbing stairs
      3. Her voice showed the usual musicality normal people show when they speak — this is called prosody — https://en.wikipedia.org/wiki/Prosody_(linguistics)

      The freezing can be seen in Parkinsonian patients on long term medication — it is called the on/off effect. It is very unusual in new onset or mild disease.

      However, I will say, that in a patient with early disease, the medication works so very well that they (fortunately) appear completely normal.

      The point has been made that pneumonia is seen in Parkinson’s disease — true but only in immobile (usually bedridden) patients.

      I doubt very much that she has it.

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