We Are Entitled to Ask President Trump for His Brain Scan

Instead of Twitter speculation, the public craves a scan and honest answers.

Posted Oct 13, 2020

 Tumisu/Pixabay commons
Secrecy and evasion only prompt more questions.
Source: Tumisu/Pixabay commons

President Trump’s pre-COVID halting gait, bent posture, and jerking right arm have caused much speculation on social media. Armchair critics, without any apparent medical background, have freely diagnosed him as having a series of mini-strokes, frontotemporal dementia, or other neurological illness such as the Lewy Body dementia that afflicted comedian and actor Robin Williams.

This speculation is problematic and unwise. And yet the American public deserves an accurate account of our president’s health.

As a textbook author and professor of neurology at George Washington University, I know something about political figures and observable signs of illness from afar. (I once wrote a Pulitzer Prize-nominated New York Times Magazine cover story about James Brady, President Reagan’s Press Secretary, who was shot in the head.)

Neurologists by profession rely on direct observation more than other clinical skills. Like Sherlock Holmes, we are attuned to the odd remark, the unexpected detail or action that doesn’t fit. We are trained to probe past face value because superficial appearances often turn out to hide the actual problem. Here then are my observations about the social media buzz surrounding the president.

Trump’s Tilting Posture and Jerking Limbs

Trump’s forward-listing posture—illustrated by nearly every political cartoonist—was initially attributed to the high-heeled elevator shoes readily observed in photographs. But his torso leans so markedly off-center that it suggests the possibility of a neurological problem rather than vanity. In medical terms, the Bent Spine Syndrome is called camptocormia, first documented in the 17th century by Francisco de Zurbaran, a Spanish painter. The mean age of onset is 65 years (Trump is 74).

 Political Flare
Camptocormia, or bent spine syndrome, first described centuries ago.
Source: Political Flare

While most frequently observed in Parkinson’s Disease, the bent posture so evident in Trump may also be seen in Alzheimer’s Dementia, movement disorders of the basal ganglia, and as the side effect of certain medications. 

Also noted are the sudden, jerking movements of Trump’s right arm. Since they occur only on one side, the prefix “hemi” is applied, while “ballistic” means sudden or flinging in the manner of a projectile. Trump’s hemiballistic arm movements are evident in news clips from Memorial Day (also here via C-Span) at the Tomb of the Unknown Soldier, as are his uncontrolled swaying and forward tilt. He is seen to grab his wayward arm with the left one in an effort to keep it under control.

It is common for affected individuals to incorporate the flinging into deliberate movements such as scratching or smoothing the hair as if to make them less noticeable. Most recently at the end of the first debate, Trump appears as though he may be trying to camouflage his jerking arm by grabbing Melania’s hand.

Cognition in older people has a strong influence on gait, especially the frontal kind. Trump “aced” a 10-minute mental status screening in August, although the test is one an average adult should easily pass. To a neurologist, his way of walking, posture, and jerky movements are concerning and in want of an explanation. Lesions in the subthalamic nucleus due to, say, a tiny lacunar stroke, produce the same jerky, involuntary ballistic movements of an extremity on the opposite side. In the absence of reliable data, these questions are left unresolved.

Trump’s Apparent Arm Weakness, Slurred Speech, and Odd Circular Gait

Evaluating gait and muscle strength is always part of the neurological exam because posture and locomotion call on vast swaths of the brain, spinal cord, and peripheral nerves. In June 2020, the president spoke at the West Point graduation ceremony. When he paused to take a sip of water, it appeared that his right arm couldn’t lift the glass all the way. As seen in this C–Span clip, he used his left hand to push it up from the bottom until it met his lips. During his address, you hear slurred speech and mispronunciation of well-known historical names such as Ulysses S. Grant and Douglas MacArthur.

When it came time to exit, Trump hesitantly edged down the ramp. He appeared to have difficulty raising his right leg sufficiently to clear it, as video spread of his struggle on the Drudge Report and major news sites. In September, as Trump walks down the White House driveway to meet the press, you see a clear example of the inability to gain adequate clearance for the right foot to swing normally. To compensate, he abducts his thigh and swings the leg in a semicircle: This is the circumducted gait, or spastic hemiparesis, the most common abnormal gait in neurology. Other photos show his right foot turned in, or inverted, which is part of the hemiparetic gait.

Ulrike Leone/Pixabay
What's on the inside trumps official assurances.
Source: Ulrike Leone/Pixabay

The fact that the leg makes a circle is what makes this way of walking distinctive. Stroke patients with weakness on one side (hemiparesis) almost always show it, along with increased muscle tone (spasticity) on the affected side and a turned in (inverted) foot. When mild, loss of the normal arm swing and a slight circumduction of the leg may be the only outwardly visible abnormalities. But Trump exhibited this spastic circumducted gait back in July during his visit to a North Carolina Lab. Exactly when it began is as yet unknown.

Atypical 2016 Visit to Walter Reed

In November 2016, President Trump made a visit to Walter Reed National Military Medical Center. According to The Washington Post, the administration described it as an early part of his annual physical, but the hurried departure raised flags because there wasn’t the usual advance notice, the president traveled by motorcade rather than helicopter, and White House Doctor Sean Conley traveled with him instead of meeting him there as is customary.

The visit supposedly took advantage of a “free weekend” to have part of his physical performed, even though it had been less than a year since his last one; he was free the weekend before and the weekend after; the visit didn’t follow protocol for a routine presidential medical exam; he never went back for the rest of the examination, and no report was ever released, again contrary to custom.

On September 1 of this year, The Associated Press revisited the circumstances surrounding Trump’s impromptu visit to Walter Reed, and The Lincoln Project released an ad asking about the president’s health. Recent news reporting indicates that Walter Reed staff were asked to sign non-disclosure agreements before being allowed to attend the president.

The Twittersphere has since tried to put the various facts and fragments together, which has predictably led to further confusion and speculation.

What we do know from observation is that the president sometimes slurs his speech and appears to struggle to control his right limbs. He is impulsive and mercurial, perhaps easily flustered, observed to flit from one idea to the next and frequently interrupt other speakers. Dr. Anthony Fauci allegedly said that his attention span “is a negative number.” But can these be signs of frontal lobe disease or mini-strokes as speculators claim?

Can We See President Trump's Brain Scan?

It is true that individuals who have balance and gait issues similar to those observed in Trump can have degenerative brain disease in the frontal lobes, such as fronto-temporal dementia or Pick’s Disease. Other possibilities are normal pressure hydrocephalus, sensory ataxia, peripheral neuropathy, small lacunar strokes in the basal ganglia, supranuclear palsy, the effects of too many medications, and Parkinson’s Disease, which can begin on one side and also show early cognitive impairment.

Of course, it may be that Trump has none of these conditions, which only argues for having .greater and more reliable disclosure as opposed to compulsory nondisclosure agreements.

Having available the entirety of the president’s brain scan would answer many questions. The exam in mind is an MRI with NeuroQuant, which not only detects degenerative brain disease but also compares brain volumes to normal populations adjusted for age and sex

The president is a public figure whose judgment we must trust. The American public is entitled to know about his neurological health given the enormous responsibilities placed on our Commander in Chief.

Please send comments via the Author Profile, where you can also ask Dr. Cytowic for copies of articles and papers, including "Your Brain on Screens."

References

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