Tag Archives: MRI

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.

Today

“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.

https://luysii.wordpress.com/wp-admin/post.php?post=5200&action=edit&calypsoify=1

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).

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.

Two disconcerting papers

We all know that mutations cause cancer and that MRI lesions cause disability in multiple sclerosis. We do, don’t we? Maybe we don’t, say two papers out this October.

First: cancer. The number of mutations in stem cells from 3 organs (liver, colon, small intestine) was determined in biopsy samples from 19 people ranging in age 3 to 87 [ Nature vol. 538 pp. 260 – 264 ’16 ].th How did they get stem cells? An in vitro system was sued to expand single stem cells into epithelial organoids, and then the whole genome was sequenced of each. Some 45 organoids were used. Some 79,790 heterozygous clonal mutations were found. They then plotted the number of mutations vs. the age of the patient. When you have a spread in patient ages (which they did) you can calculate a tissue mutation rate for its stem cells. What is remarkable, is that all 3 tissues had the same mutation rate — about 40 mutations per year. Not bad. That’s only 4,000 if you live to 100 in your 3.2 BILLION nucleotide genome.

This is so  remarkable because the incidence of cancer is wildly different in the 3 tissues, so if mutations occurring randomly cause cancer, all 3 tissues should have the same cancer incidence (and there is much less liver cancer than gut cancer).

Of course there’s a hooker. The numbers are quite small, only 9 organoids from liver with a relatively small age range spanning only 25 years. There were more organoids from colon and small and the age ranges was wider but, clearly, the work needs o be replicated with a lot more samples. However, a look at figure one shows that the slope of the plot of mutation number vs. age is quite similar.

Second: Multiple sclerosis. First, some ancient history. I started in neurology before there were CAT scans and MRIs. All we had to evaluate the MS patient was the neurologic exam. So we’d see if new neurologic signs had developed, or the old ones worsened. There were all sorts of clinical staging scores and indices. Not terribly objective, but at least they measured function which is what physician and patient cared about the most.

The MRI revolutionized both diagnosis and our understanding of MS. We quickly found that even when the exam remained constant, that new lesions appeared and disappeared on the MRI totally silent to both patient and physician. I used to say that prior to MRI neurologists managed patients the way a hematologist would manage leukemics without blood counts, by looking at them to see how pale they were.

In general the more lesions that remained fixed, the worse shape the patient was in. So new drugs against MS could easily be evaluated without waiting years for the clinical exam to change, if a given drug just stopped lesions from appearing — stability was assumed to ensue (or at least it was when I retired almost exactly 4 presidential elections ago).

Enter Laquinimod [ Proc. Natl. Acad. Sci. vol. 113 pp. E6145 – E6152 ’16 ] which has a much greater beneficial effect on disability progression (e.g. less) than it does on clinical relapse rate (also less) and lesion appearance rate on MRI (also less). So again there is a dissociation between the MRI findings and the patient’s clinical status. Here are references to relevant papers — which I’ve not read —
Comi G, et al.; ALLEGRO Study Group (2012) Placebo-controlled trial of oral laquini- mod for multiple sclerosis. N Engl J Med 366(11):1000–1009.

Filippi M, et al.; ALLEGRO Study Group (2014) Placebo-controlled trial of oral laqui- nimod in multiple sclerosis: MRI evidence of an effect on brain tissue damage. J Neurol Neurosurg Psychiatry 85(8):851–858.

Vollmer TL, et al.; BRAVO Study Group (2014) A randomized placebo-controlled phase III trial of oral laquinimod for multiple sclerosis. J Neurol 261(4):773–783.

It is well known that there are different kinds of lesions in MS (some destroying axons, others just stripping off their myelin). Since I’ve left the field, I don’t know if MRI can distinguish the two types, and whether this was looked at.

The disconcerting thing about this paper, is that we may have given up on drugs which would  clinically help patients (rather than a biological marker) because they didn’t help the MRI ! ! !

Would you be smarter if your mother received different prenatal advice?

Back in the day we worried a lot about the amount of weight a woman gained during pregnancy.  Too much weight gain increased the risk of pregnancy associated hypertension (and worse pre-eclampsia, and even worse eclampsia with fetal and even maternal death).  It also increases the likelihood of pregnancy associated diabetes, with its adverse effects on the fetus.

So when my wife was carrying our two boys, we watched her weight like a hawk (particularly since there was diabetes in her family).  Fellow med students and their wives did the same.

That may have not been so good according to a recent study of birth weight differences between identical twins [ Proc. Natl. Acad. Sci. vol. 109 pp. 11366 – 11371 ’12 ].  To cut to the chase, they found that the bigger twin had a bigger brain and was smarter (by a few IQ points).   It was a big study (139 twin pairs or which 85 were identical — monozygotic if you want to impress your friends).  They only looked at mild levels of weight disparity — the difference in birth weight had to be less than 20% of the weight of the heavier twin.

Greater birth weight resulted in greater  brain volume as shown by magnetic resonance imaging (MRI), mostly due to more cerebral cortex.  Interestingly the cortex wasn’t any thicker in the heavier twin, there was just more of it (the brain was more wrinkled).

Interestingly, the fraternal twins were smarter than the monozygotics by having full scale IQs of 112 vs. 109.  What’s going on? The average IQ should be 100.  However, they excluded twins with IQs under 80, e.g. they only looked at 1.3 standard deviations (which is 15 points) below the mean, while keeping everything above it.   It’s an interesting mathematical problem, which I don’t have time to solve, to integrate the bell curve from 1.3 standard deviations below the mean to all the way above it, and see what the average would be — my guess is that this is why the average IQs are so high.

There is also something called the Flynn effect which you should know about, as long as we’re talking IQ. [ Science vol. 323 p. 989 ’09 ] It was described  nearly 30 years about by  James Flynn of New Zealand.  He noted  that IQ scores rose steadily in the 20th century for children and adults in Western nations.  Using the late 20th century average IQ score of 100, the comparative score for the year 1900 was calculated to 60 — something clearly not true.  Actually the improvements were not in general knowledge or mathematics, but in abstract reasoning.

The conclusions of the PNAS paper seem solid, but behind your back I’ve made several inferential leaps, some of which can be checked fairly easily.  Do bigger babies have bigger brains, and if they do, does this persist throughout life.  Second do people with bigger brains have higher IQs — again the extremes must be cut off — down 2 -3 standard deviations from the average brain size, IQ is way down, and the smaller the brain down here the smaller the IQ.  Similarly with macrocephaly (large brain) — usually there is something wrong.  These are factual matters, whose results are probably in the literature already.

What’s great about the paper is that it controls for heredity, as the genomes of identical twins should be nearly identical — I’m not sure anyone has looked, and given the recent haphazard way our genomes vary between us, it should be.  For details please see https://luysii.wordpress.com/2012/07/31/how-badly-are-thy-genomes-oh-humanity/

The fourth inferential leap, is that bigger birth weight in a twin has to do with better nutrition in utero.  Clearly the bigger twin had more proliferation of cortical precursors resulting in more cerebral cortex.  So maybe your mother should have had a few more fudge cakes and ice creams when she was carrying you.

I don’t know the answer to these questions, but as Mark Twain said :”There is something fascinating about science.  One gets such wholesale returns of conjecture out of such a trifling investment in fact”.