The Neurology of JFK’s Assassination

As a devout conspiracy theorist, I could not resist posting about the John F. Kennedy assassination during its 50th anniversary.

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This story contains at least 3 neurological issues of interest.

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First, there’s the head wound, and what it tells us about the location of the shooter:
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Conspiracy theorists have stressed witness testimony that the back of Kennedy’s head was blown out, suggesting a shot from the Grassy Knoll.

Lone assassin theorists have stressed the photographic evidence and the autopsy x-rays, which show the back of the head intact. The panel (inserted above) shows four of the dozens of versions of Kennedy’s head wound.

Click here to find out more.

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The Manchurian Candidate 1

Second, even if you believe Lee Harvey Oswald was the lone assassin, some conspiracy theorists would have you believe he was a Manchurian Candidate, manipulated by mind-control experts to carry out the assassination of JFK.

These theories are supported by what is known about the CIA’s experiments with mind control in the 1950s, and Oswald’s alleged CIA connections.

Click here to read more about this.

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Finally, there is Jack Ruby‘s murder of Lee Harvey Oswald:

The matter of neurologic interest here is that Ruby’s defense at trial was based on an abnormal electroencephalograph.

Defense expert Frederick Gibbs, one of the pioneers in the use of electroencephalography for the diagnosis and management of epilepsy,  testified that Ruby’s EEG showed right temporal 6/s sharp waves, and that this was evidence of “psychomotor epilepsy”.

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Gibbs suggested that affected patients manifest personality instability, lack of emotional control, convulsive and excessive types of behavior.  He, and other physician experts at the trial further postulated that Ruby killed Oswald during a fugue state induced by a psychomotor seizure.

Middle finger

This image of Ruby shooting Oswald was used at trial – Ruby is seen using his middle finger to pull the trigger, with his left hand thrown out in the opposite direction, supposedly indicating a seizure.

The prosecution’s neurology expert disagreed, stating that the EEG findings were a “slight abnormality” and didn’t indicate epilepsy.  Furthermore, he indicated that Ruby’s demeanor and behavior, as described by witnesses, were not consistent with a psychomotor seizure.

Ruby was convicted, and sentenced to death.

Click here to find out more about the neurology at the trial.

This EEG “finding” is now known to be a normal variant with no clinical significance.

This case underscores the importance of treating the patient, not the test result, an adage well known to true clinicians everywhere.

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Blackout – was it a fit or a faint?

People generally experience a blackout (temporary loss of consciousness) from one of two common problems: (1) Insufficient blood flow to the brain (syncope)  or (2) Abnormal electrical activity within the brain (seizure).

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Syncope (or a faint) is caused by insufficient blood flow to the brain because of low blood pressure.  There may be a prodrome of dizziness loss of vision and hearing weakness, flushing, nausea (sometimes referred to pre-syncope).  Then there will be overt loss of consciousness that leads to the faint.  The affected patient will typically fall by dropping forwards from loss of muscle tone. The affected patient might look pale and clammy, and will usually come around quickly of they are allowed to lay down on floor allowing blood flow to return to the brain.  Syncope can be caused by dehydration, irregular heart beat, or emotion (vasovagal or “neurocardiogenic” syncope).

http://www.youtube.com/watch?v=rrjQW7UIvMU&start=35&rel=0

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A seizure (or a “fit”) is caused by abnormal electrical activity in the brain, usually accompanied by a clinical event that can vary from a brief loss of awareness (an absence seizure or “petit mal”) to loss of awareness with thrashing limb movements (a tonic-clonic or grand mal seizure).  A generalized tonic-clonic seizure will usually be associated with increased muscle tone, so the patient will stiffen up and fall backwards not forward and may bite their tongue.  The eyes will be open, and their may be loss of bladder and bowel control.  There may be flailing limb movements that lead to injury.  After the seizure stops, the patient will usually be confused or dazed, and not come around immediately like the syncope patient.

http://www.youtube.com/watch?v=wHTPfPcOHyo&start=285&rel=0

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Here is a table that emphasizes the differences between fits (seizures) and faints (syncope):

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If you have experienced a blackout, what should you do? A simple faint in an otherwise young healthy person may not need emergent medical care.  However, syncope in an older person with a cardiac history, or syncope associated with chest pain and breathlessness could indicate a heart problem and usually justify an emergency room visit.  Similarly a new onset seizure in somebody not previously know to have epilepsy should justify an emergency room visit.

Epilepsy surgery and functional MRI

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Epilepsy surgery is an option for patients with intractable partial onset seizures that are not controlled by oral medications.  Epilepsy monitoring is used to localize the seizure focus, often a lesion or abnormal area of brain located in the temporal lobe.  That part of the brain is then carefully removed to prevent future seizures:

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A patient with a brain abnormality in the R temporal lobe (top) undergoes brain surgery to remove that area of brain and prevent future seizures.

Epilepsy surgery is very effective and yet still underutilized for treating seizures.

Left temporal lobe resections are more risky that right-sided cases, because the left hemisphere controls language functions in most (even left handed) patients.  Surgeons have to be very careful planning seizure surgery on the left side to be sure that they do not damage brain critical for speech and language and leave the patient with aphasia.

That’s where functional magnetic resonance imaging (fMRI) comes in.  fMRI goes beyond the conventional imaging of brain structure, and can actually localize regional brain functions by detecting changes in regional blood flow in response actual or imagined activity.

fMRI is increasingly being used to evaluate candidates for epilepsy surgery by identifying important functional regions within the brain, including unpredictable patterns of functional reorganization, to prevent unexpected post-operative deficits.  Click here for a link to a paper with illustrative cases.

Monmouth’s New Onset Seizure Center Opens in June!

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New onset seizures can be isolated events or the harbinger of future epilepsy.

Decisions about starting medications and restricting driving are complicated, and are best made by neurology sub-specialists (“epileptologists“) after a detailed evaluation that usually includes an electroencephalogram (EEG) and brain magnetic imaging study (MRI).

Monmouth Neuroscience Institute is pleased to announce the opening of the region’s first New Onset Seizure Center in June 2013.

Patients who come to the emergency room with their first seizure can be stabilized and then sent home with instructions to follow-up in New Onset Seizure Center, an integral part our Certified Epilepsy Center within one week.

All patients coming to the center they will undergo an EEG, MRI of the brain and a visit with one of our board certified fellowship-trained epilepsy experts during a single visit.

This avoids hospitalization and hasty decisions about medical management.

Click here to find out more about the center.

Monmouth Epilepsy Program Receives NAEC Certification

Monmouth Medical Center’s Epilepsy Program was awarded prestigious level 3 certification today by the National Association of Epilepsy Centers!

Monmouth certificateThe National Association of Epilepsy Centers (NAEC) is a non-profit  association with the primary objective of connecting people with epilepsy to specialized epilepsy care and epilepsy centers.

Founded in 1987 by physician leaders committed to setting a national agenda for quality epilepsy care, the NAEC educates public and private policymakers and regulators about appropriate patient care standards, reimbursement and medical services policies.

NAEC works in conjunction with existing scientific and charitable epilepsy organizations.

A third-level center must provide all the medical, neuropsychological, and psychosocial services needed to treat patients with refractory epilepsy to achieve certification.

Click here to find out more about Monmouth’s Epilepsy Program.

Click here to find out more about seizures and epilepsy.

American Academy of Neurology Identifies 5 Questionable Practices

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It’s no secret that health care costs are escalating.

Although physicians value their independence, part of the problem here is the unregulated use of costly tests, medications and procedures, many of which are unproven and of questionable benefit.

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Evidence based medicine assess the strength of the evidence of risks and benefits of treatments (including lack of treatment) and diagnostic tests in an attempt to help clinicians predict whether a treatment will do more good than harm.

However, less than 1 in 5 medical decisions in the USA are made based on evidence-based medicine.

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neurology

The American Academy of Neurology has recently taken a step in the right direction by publishing a list of 5 costly neurology practices which continue to be widely performed despite being of little proven benefit:

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1. Don’t perform electroencephalography (EEG) for headaches.

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2. Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.

Syncope is caused by global cerebral hypoperfusion, not carotid artery disease, so even if a carotid stenosis is identified, it would be asymptomatic (see point number 5)

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3. Don’t use opioid or butalbital treatment for migraine except as a last resort.

Butalbital is effective short term treatment for migraine, but commonly leads to rebound, which ultimately exacerbates migraine.  Click here for more information about migraine.

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4. Don’t prescribe interferon-β or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of MS.

Interferon-β and glatiramer acetate, are effective for  relapsing phases of MS, but do not prevent the development of permanent disability in progressive forms of multiple sclerosis.  These medications cost more than $40,000 a year, and put a financial strain on the patients and their families to make the co-pays.  In some series as many as 10%-15% MS patients have progressive forms of the disease and yet are still taking one of these medications.

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5. Don’t recommend carotid endarterectomy (CEA) for all patients with asymptomatic carotid stenosis.

Surgery is of much less benefit for asymptomatic carotid stenosis, and should be reserved for those with a perioperative complication risk of less than 3% and a life expectancy of greater than 3 to 5 years. Click here for more information about surgery for carotid artery disease.

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Click here for more details.