Tag Archives: cerebrospinal fluid

President Biden possibly has Occult Hydrocephalus (Normal Pressure Hydrocephalus)

President Biden possibly has Occult Hydrocephalus (Normal Pressure Hydrocephalus).  That’s quite a mouthful. Here are  three levels of explanation, short, medium and long depending on what you already know.

The short explanation — justification for each statement later  – “Extraordinary claims require extraordinary evidence.”  ― Carl Sagan

l. President Biden had a subarachnoid hemorrhage due to an aneurysm in his head years ago.

2. President Biden is in early dementia

3. President Biden is having changes in his walking, one of the reasons leading to his recent medical evaluation

Subarachnoid hemorrhage is one of the most common causes of Occult Hydrocephalus (Normal Pressure Hydrocephalus { NPH } )

Symptoms of NPH are progressive dementia and gait disturbance. So he fits the pattern.

A brief primer on hydrocephalus.  We all have water on the brain (e.g. cerebrospinal fluid  {CSF } ).  We make about two pints a day in the ventricular system of the brain which lies deep in the brain — https://en.wikipedia.org/wiki/Ventricular_system.  It flows out of the ventricles to the surface of the brain where it flows over the surface and is absorbed.   You can imagine what happens if there is a problem absorbing CSF.  Secretion doesn’t stop and the ventricles get bigger  (the origin of the term hydrocephalus), and pressure rises usually along with headache and serious neurologic problems.

It is thought that after subarachnoid hemorrhage, scarring occurs impeding CSF flow, just enough to enlarge the ventricles, but not enough to raise pressure in the head.  Amazingly this can occur years after the bleed and is called normal pressure hydrocephalus (NPH) or occult hydrocephalus (occult because it doesn’t present in the usual way with headache etc. etc.)

NPH was discovered in the late 60s when I just entered neurology.  It was tremendously exciting for patients and docs, because it represented a treatable cause of dementia.  The treatment is placement of a shunt (hollow pipeline) from the ventricular system to the surface of the brain (or elsewhere).

It is extraordinarily easy to diagnose hydrocephalus these days. Just do an MRI or a CT scan and see how big the ventricles actually are.  It is important to note that President Biden should never have an MRI.  High magnetic fields are used, and if the clip placed on his aneurysm by the neurosurgeon contained any magnetic material, the clip would be ripped off the artery causing a fatal hemorrhage. This has actually happened to a few unfortunate patients in the early days of MRI and Biden’s aneurysm surgery was 1988 in the early days of MRI.

The medium explanation

l. Biden’s cerebral aneurysm — I have a whole post on the subject — https://luysii.wordpress.com/2020/12/08/bidens-cerebral-aneurysm/ which is reproduced below the ***

Interestingly, I knew the neurosurgeon who operated on him (Neal Cassell), back in the day when I was a neurology resident and he was a Penn undergraduate, already very interested in neurosurgery.

The post concludes with “I think the chances of occult hydrocephalus developing 32 years after the aneurysm are remote. If it were going to happen it would have already. In the meantime, watch him start to walk.”  Well that was written 8 December ’20, and he’s having trouble walking now.

2. Biden is in early dementia — certainly the most controversial statement in the post.  It’s based on years of clinical experience trying to taking care of demented patients.  Don’t take my work for it  please look at the following post — it contains lots of clips of him speaking (C-SPAN etc. etc.)– just look at them and make up your own mind if he is functioning normally during them.  Remember the symptoms of early dementia are always intermittent.  Here’s the link Vhttps://luysii.wordpress.com/2021/08/20/biden-is-in-early-dementia-yet-more-evidence/. The entire post is reproduced below the &&&&

3. Biden is having changes in his walking — this is the easiest — https://www.whitehouse.gov/wp-content/uploads/2021/11/President-Biden-Current-Health-Summary-November-2021.pdf.  It is incredibly detailed and thorough, I’m not going to reproduce it, but here are a few quotes “The president’s gait is perceptibly stiffer and less fluid than it was a year ago.”



They put down his gait disturbance to a mild peripheral neuropathy, old foot fracture, spinal arthritis, but they didn’t consider NPH.
I think he should have a CT scan of his head (never an MRI for the reasons above).  It might reveal a treatable cause of his early dementia.
The long explanations 

Biden’s cerebral aneurysm

A friend sent me a semi-hysterical rant from a neurosurgeron about the dangers of President Biden’s cerebral aneurysm. Not to worry. This happened in 1988 and was successfully clipped although it ruptured during surgery. The only possible complication at this point is normal pressure hydrocephalus (occult hydrocephalus). That’s a medical mouthful so here’s some background to put it all into context.

If you’ve ever seen a blister on an inner tube, that’s what a cerebral aneurysm looks like. They usually look like a round ball on the side of an artery in the brain. They look nothing like an aneurysm of the aorta. To treat them, one puts a clip around the neck of the aneurysm, so to prevent the pressure in the adjacent artery from bursting it. As Dr. Tom Langfitt, the neurosurgeon who taught medical students, interns and residents at Penn Med in the 60’s said “they’ll stare you down every time”. To put a clip around the neck of the aneurysm you have to jiggle and move it, which may cause it to break. This happened during surgery on President Biden in 1988.

Remarkably, Neal Kassell, the neurosurgeon operating on President Biden was an undergraduate at Penn when I was a neurology resident there in ’67 – ’68. Even before med school (graduating Penn Med in’72) he was vitally interested in neurosurgery and hung around the hospital and would observe Langfitt in action in the OR.

What is there to worry about? Relatively little. It is possible that Biden is developing another aneurysm. One well known complication of a ruptured intracranial aneurysm is something called occult hydrocephalus (or normal pressure hydrocephalus). Blood is extremely inflammatory, and the inflammation can resolve causing scarring (fibrosis) of the linings of the brain. This can impede the flow of spinal fluid.

What are the symptoms? Cognitive decline for one, something that’s been endlessly discussed by pundits, politicians and the voters. The other symptom which even you can look for is difficulty walking, in particular beginning to walk. People with this seem to have feet glued to the floor and have problems initiating walking.

Diagnosis — in Biden’s case, a CAT scan to see if the cerebral ventricles are larger than they should be — https://en.wikipedia.org/wiki/Ventricular_system has great pictures and explanation.

Why not an MRI — because the clips used back in 1988 contain magnetizable material, and entering the strong magnetic fields of an MRI scanning would rip the clips off the aneurysm and kill Biden.

I think the chances of occult hydrocephalus developing 32 years after the aneurysm are remote. If it were going to happen it would have already. In the meantime, watch him start to walk.

Biden is in early dementia — yet more evidence

This is the third post arguing that Biden is in early dementia.  Today’s post is  based on his performances on the 18th of August and today 20 August.  The previous 2 posts can be found below the ***

Addendum: 23 August.  Don’t take my word for it.  All the material in this post  is evidence — please look at the linked videos and quotations and decide for yourself.  Your conclusions may be different from mine, but at the least you will see the evidence on which mine are based.   If you disagree, I’d love to see a comment. 

On the 18th in an interview on ABC with George Stephanopoulos a transcript contains the following exchange

“STEPHANOPOULOS: I– I think a lot of– a lot of Americans, and a l– even a lot of veterans who served in Afghanistan agree with you on the big, strategic picture. They believe we had to get out. But I wonder how you respond to an Army Special Forces officer, Javier McKay (PH). He did seven tours. He was shot twice. He agrees with you. He says, “We have to cut our losses in Afghanistan.” But he adds, “I just wish we could’ve left with honor.”

BIDEN: Look, that’s like askin’ my deceased son Beau, who spent six months in Kosovo and a year in Iraq as a Navy captain and then major– I mean, as an Army major. And, you know, I’m sure h– he had regrets comin’ out of Afganista– I mean, out of Iraq.”

Doesn’t he know which branch of the service his son was in? Did he think his son was in Afghanistan?  My wife and I know where our 4 uncles served in world war two.

Unsurprisingly, ABC did not put this exchange on the air.  It was only found by reading the transcript.  Pravda could have done no better.


“President Biden: (12:15) Look, let’s put this thing in perspective here. What interest do we have in Afghanistan at this point with Al Qaeda gone? ”

They aren’t gone according to Pentagon spokesman John Kirby.  At a briefing following Biden’s remarks Kirby said that there remains an al Qaeda presence in Afghanistan.

Wasn’t Biden told this?  If he was did he forget it?  Where is the shrink from Yale who wanted remove Trump using article 25 of the Constitution back in the day.

At least the questions he’s getting are no longer of the “what’s your favorite ice cream?” variety.

Here are two such questions.

Stephanie Ramos: (18:42)
Yeah. Thank you, Mr. President, two questions for you. The military has secured the airport, as you mentioned, but will you sign off on sending US troops into Kabul to evacuate Americans who haven’t been able to get to the airport safely?

President Biden: (18:56)
We have no indication that they haven’t been able to get in Kabul through the airport.

Given the incompetence of our intelligence this may actually be what Biden has been told.  Reports from Kabul say exactly the opposite.  It is also possible that Biden has been told what is going on there and simply forgot or is lying.

I have friends who have told me they’d rather have a demented Biden than an undemented Trump.  It looks like they’re getting their wish.

Here’s the previous post which contains older evidence.


Biden is in early dementia — more evidence

In an earlier post (reproduced below the ***) I gave my reasons based on (presumably unedited) tapes of the President for concluding that President Biden is in the early stages of dementia.  I am a retired board certified neurologist and occasional board examiner with 34 years of clinical experience.

Here is further evidence.

In a town hall meeting put on by CNN 21 July President Biden became rather incoherent and confused when answering “When will children under 12 be able to get vaccinated.”

Here is the (presumably) unedited video of the meeting — https://www.cnn.com/2021/07/21/politics/full-president-joe-biden-cnn-town-hall-july-21/index.html.

The question was asked 6 minutes and 20 seconds into the recording.  The response starts to make not much sense at 7 minutes and at 7 minutes 21 seconds, he briefly becomes incoherent.  He continues on in this vein up to about 8 minutes.

This is what early dementia looks like.

Well that’s my opinion.  Look at the tape and make your own.

****  The earlier post

Biden is in early dementia — the evidence

As a neurologist I am often asked about Biden’s mental capacity.  My first post on the subject occurred after the first debate with Trump.  I thought he was intact — you can read about it here.


Then I was asked to comment on the possibility that his previous operation for aneurysm could be causing trouble. I didn’t think this was likely as so much time had passed.  Interestingly, I knew the neurosurgeon as a Penn undergraduate when I was a neurology resident.  You can read the post at the end — Biden’s cerebral aneurysm.

That was written last December.

I changed my opinion after his press conference. of 14 June ’21 https://www.youtube.com/watch?v=PAWRHM4i3Dg
I strongly suggest you look at the segment at 15 minutes where his response makes little sense, and then he shuts down completely for 7 seconds, apparently quite confused. That’s my reading of the video. Form your own opinion.

Then on June 23rd I was sent another clip where he was confused

It is an 8 minute speech, and the clip can be found at 2 minutes, again showing an episode of confusion.


But first a story:

As a third year medical student on psychiatry rotation,  I interviewed a Bryn Mawr student who was on the psych ward (my wife was also an undergraduate at the time).  I well knew the intensity of the place, and how much pressure the girls (see the end of the post) put on themselves.  So I talked and talked and commiserated with her.  After a pleasant enough time the I concluded the interview and left.   The teaching psychiatrist asked me what I thought, and I told him how frigtening I found it given what I knew about Bryn Mawr. He asked me if I found out that she thought the television was talking to her.  Basically by yapping when she went off track, I kept her sane.

So I learned to shut up, and let people tell me what was wrong with them.  This is why Biden likely did well during the debates. The short time given to answer and the barrage of questions and interruptions kept him focused.

It really came home as I looked at the whole 8 minutes of the second clip trying to find the brief period of confusion.  Please look at the whole clip yourself and draw your own conclusions.  I see a pleasant,  rambling, slow thinking,  occasionally confused old man.


This is what early dementia looks like.

I was severely criticized by a follower after the first post.  Here it is,  “Issuing alarmist statements about his mental health is reprehensible. You are not his physician. Moreover, armchair diagnosis is frowned upon by the American Psychiatric Association.I’ve been following your blog for several years and also have been reading you comments on the “in the pipeline” blog. On the basis of that experience I had not expected to stoop that low.”

In my defense, I was defeated by the new WordPress editor which wouldn’t let me bring in the evidence shown here.  Apparently it was a (still extant) incompatibility of Safari with the editor.   I was still impressed enough by how confused Biden looked that I posted it anyway.

As the late Carl Sagan said “extraordinary claims require extraordinary evidence”. So here is the evidence (finally).  Apologies for the delay.

As children, our least favorite explanation was ‘because I say so’.

Essentially that’s part of what I’m offering here.  I was involved in clinical neurology from ’67 to ’00, and at a minimum saw at least 1 demented patient a week during that time.  That’s an underestimate, as I’d make rounds on other neurologists patients when covering weekends.  I doubt that anyone reading this has similar extensive experience.

So Biden just looks like all the early dementia patients I saw during that time.  Given my experience, I think that should carry some weight.

The fact that Biden appears sharp at times is typical of early stage dementia.  I’ve certainly seen it in family and friends, with such things being excused as ‘it must have been the heat’ or ‘they must not have been feeling well’.

Why is this important?  Khrushchev’s estimate of President Kennedy’s weakness lead to the Cuban Missile Crisis of 1962. Khrushchev’s son confirmed this when he spoke at the Kennedy Center at Harvard.   Kennedy was receiving narcotics for his back.  The side effects of what little medicines we had back then weren’t appreciated.  Example: thyroid and amphetamines were used to help people lose weight.

Biden does not appear mentally strong to Putin or Xi (or me).

Is sleep deprivation like Alzheimer’s and why we need sleep in the first place

Ask a cardiologist why the heart needs to pump and you’ll get a strange look. Ask any neuroscientist why the brain needs to sleep, and they’ll scratch their head — until now perhaps. A paper in Science a few days ago may have the answer [ Science vol. 342 pp. 316 – 317, 373 – 377 ’13 ] Essentially the brain gets washed out during sleep.

First — a bit of history. The tissue of the brain is so tightly packed that it is impossible to see the cells that make it up with the usual stains used by light microscopists. People saw nuclei all right but they thought the brain was a mass of tissue with nuclei embedded in it (like a slime mold). Muscle is like that — long fibers with hundreds of nuclei here and there. It wasn’t until that late 1800′s that Camillo Golgi developed a stain which would now and then outline a neuron with all its processes. Another anatomist (Ramon Santiago y Cajal) used Golgi’s technique and argued with Golgi that yes the brain was made of cells. Fascinating that Golgi, the man responsible for showing nerve cells, didn’t buy it. This was a very hot issue at the time, and the two received a joint Nobel prize in 1906 (only 5 years after the prizes began).

How tightly packed are the cells in the brain? The shortest wavelength of visible light is 4000 Angstroms. Cells in the brain are packed far more tightly. To see the space between the brain cell external membranes you need an electron microscope (EM). Just preparing a sample for EM really fries the tissue. Neurons are packed together with less than 1000 Angstroms between them. So how much of this is artifact of preparation for electron microscopy has never been clear to me. One study injected a series of quantum dots of known diameter into the cerebral spinal fluid (CSF) to see the smallest sized dot that could insinuate itself between neurons [ Proc. Natl. Acad. Sci. vol. 103 pp. 5567 – 5572 ’06 ]. The upper limit was around 350 Angstroms. No wonder the issue was contentious when all they had was light microscopy.

Surprisingly, the PNAS paper comes up with an estimate that brain extracellular space comprises 20% of brain volume. I find this hard to accept given the above. So how does the brain get rid of waste products? It turns out that there is a circulation of cerebrospinal fluid (CSF) of sorts. Inject a tracer that you can follow into the CSF. After a period of time the tracer enters the brain along arteries (not veins) and after still more time it leaves the brain along the veins (not the arteries). How the tracer gets to veins isn’t discussed in the Science papers. This has been called by the horrible name of the glymphatic system (don’t ask).

Using a great deal of ingenuity, experimental finesse and some very cooperative mice, the flow of CSF into, through and out of the brain was studied. Several findings are striking — the extracellular space (aka interstitial volume) dearly doubles (from 14% to 23%) during sleep. More importantly, the flow into the brain decreases by 95% when you wake the mouse up. Presumably flow out of the brain decreases by the same amount during wake. CSF flow into the brain was present only in the surface exposed to bulk CSF when the animals were awake.

So what? The Abeta peptide is held by many to be the culprit in Alzheimer’s disease. When injected into the mouse cerebral cortex (hardly a physiologic procedure) Abeta peptide is cleared twice as fast from the brain during sleep. We all know that you don’t think as well when sleep deprived, and this may be why. The current thinking on Alzheimer’s is that it isn’t the visible plaques that you can see under the microscope (made largely of Abeta peptide aggregates), but the soluble form of Abeta which you can’t see which causes the trouble. This always struck me as a cop out similar to the way docs would say that labyrinthitis was due to a virus (not that anyone every isolated one). You might as well say both are due to angels (or devils).

So the difficulty thinking with sleep deprivation may be similar to Alzheimer’s disease, if similar goings on occur in our brain. Distinguish this from the sleepiness due to sleep deprivation –Alzheimer patients often have disturbed sleep patterns, but they aren’t particularly sleepy when they’re awake.

The sleepiness may be due to the build up of something else. Bulk flow of fluid is incredibly nonspecific, and will carry anything soluble along with it. Adenosine has been mentioned as one metabolite building up which makes us sleepy. Probably looking for a single compound washed out by CSF as ‘the’ cause of sleepiness or cognitive problems, is like looking for ‘the’ single compound in kidney failure causing similar symptoms. It’s everything the kidney/brain filters and gets rid of.

So, at very long last, we may have found out why we spend 1/3 of our lives asleep.