August 31, 2023
The symptoms manifested by the Hon. Sen. M. McConnell on August 30th I observed were sudden cessation of speech, freezing, gripping the podium, Face and upper body slightly turned, looking to his right, face slightly tilted up and away to his right for a few minutes. This is often attributed to an underlying irritative lesion in this case the posterior inferior frontal gyrus on the left side of his Brain. Broadman Areas 45 and 44 just anterior to the Face area of the motor cortex in the Precentral gyrus and just above the Sylvian fissure. Mr. McConnell had a similar episode of freezing in July in Capital Hill. https://www.pbs.org/video/minority-leader-1693422165/ .
I.
A.
This is the least likely to explain the symptoms of subject being assessed or ought to be assessed fully. But this possibility is extremely dangerous.
https://www.mayoclinic.org/diseases-conditions/intracranial-hematoma/symptoms-causes/syc-20356145. Post fall injury could have started a small bleed which can over time forma cyst like lesion and increase in size.
• Headache that gets worse
• Vomiting
• Drowsiness and progressive loss of consciousness
• Dizziness
• Confusion
• Unequal pupil size
• Slurred speech
• Loss of movement (paralysis) on the opposite side of the body from the head injury
As more blood fills your brain or the narrow space between your brain and skull, other signs and symptoms may appear, such as:
• Lethargy
• Seizures
• Unconsciousness
B.
Transient ischemic attack (TIA) - Symptoms and causes - Mayo Clinic
Overview
A transient ischemic attack (TIA) is a temporary period of symptoms similar to those of a stroke. A TIA usually lasts only a few minutes and doesn't cause permanent damage.
Often called a ministroke, a TIA may be a warning. About 1 in 3 people who has a TIA will eventually have a stroke, with about half occurring within a year after the TIA.
A TIA can serve as both a warning of a future stroke and an opportunity to prevent it.
Symptoms
Transient ischemic attacks usually last a few minutes. Most signs and symptoms disappear within an hour, though rarely symptoms may last up to 24 hours. The signs and symptoms of a TIA resemble those found early in a stroke and may include sudden onset of:
• Weakness, numbness or paralysis in the face, arm or leg, typically on one side of the body
• Slurred or garbled speech or difficulty understanding others
• Blindness in one or both eyes or double vision
• Vertigo or loss of balance or coordination
You may have more than one TIA, and the recurrent signs and symptoms may be similar or different depending on which area of the brain is involved.
C.
Petit Mal: These non-convulsive seizures look like staring spells.
1.. https://www.mayoclinic.org/diseases-conditions/petit-mal-seizure/symptoms-causes/syc-20359683
2. Johns Hopkins Medical. Absence Seizures.
3 a. Absence Seizures: Symptoms, Causes, Diagnosis, Treatment (verywellhealth.com) Illustrations provided.
What Are Absence Seizures?
These non-convulsive seizures look like staring spells
By Reza Shouri, MD, updated on February 05, 2023, Medically reviewed by Diana Apetauerova, MD
An absence seizure, often referred to as petit mal seizure, is a non-convulsive seizure that is often not recognized as a seizure at all. Absence seizures usually occur in children who have Epilepsy, but adults can have them as well. While absence seizures are not as disruptive or obvious as convulsive seizures, they cause impairment of consciousness and interfere with learning, driving, and other aspects of life.
Absence seizures can go unnoticed. They can occur several times a day and rarely cause disruption, noise, or clearly obvious manifestations. Sometimes, a person may experience them for months before others begin to take notice.
The person experiencing the seizure is usually not aware that it's happening. Consciousness is impaired, which means they're not aware of their surroundings or movements. Unlike other seizures, absence seizures do not cause jerking movements or physical convulsions, however.1
After the seizure, they will quickly resume awareness and continue what they were doing before it came on.
3. b. Illustrations for delineating Petit Mal Absence Seizures Google Image Result
3. c.
Differential Diagnosis for Absence Seizures: Epilepsy Foundation. Temporal Lobe Epilepsy (TLE). Complex Partial Seizures: It has been renamed: Focal Impaired Awareness:
• During this type of seizure, a person may have a fixed stare, be unaware or confused about what is going on around them, have fumbling with their fingers, or lip-smacking movements. The seizures last 30 seconds to a couple of minutes.
• There can be unusual posturing (movement or positioning) in an arm. This can help identify where seizures start in the brain.
• Some people also speak gibberish or lose their ability to speak in a sensible manner. Language problems are more common if the seizures are coming from the dominant temporal lobe.
• The focal seizure can go into generalized tonic - clonic jerking. The person may be weak after the seizure has stopped.
• Some people can also have prolonged seizures. Rarely, repeated or long seizures called status epilepticus may develop.
• Seizures in neocortical or lateral temporal lobe epilepsy often start with an auditory aura, such as buzzing or hearing a specific sound.
Patients often talk about experiencing a strange feeling that cannot be described. Major Risk factors include Brain injury including head trauma with loss of consciousness. Our subject has history of fall and concussion.
• 3 c i. Focal epilepsy: This link provides very clear discussion of focal seizures: Focal Seizures | Johns Hopkins Medicines begin in one area of the is medication. The doctor may also
Persons with Complex Seizures may stare blankly into space, or experience automatisms (non-purposeful, repetitive movements such as lip smacking, blinking, grunting, gulping or shouting.
Persons with Simple Focus Seizures which are also known as auras, occur in one area on one side of the brain, but may spread from there. [In the video of the in a real time report that I viewed repeatedly the process affect Hon Sen McConnell appeared to affect mainly the posterior inferior Frontal gyrus supplied by Superior Branch of the Middle Cerebral artery perfusing the Broca’s area in Dominant Hemisphere. The person does not lose consciousness during a simple focal seizure. Physicians typically break simple focal seizures down into the following four areas, depending on the location in the brain and parts of the body affected. This is described in the link from Johns Hopkins.
• 3. d
Often, brain magnetic resonance imaging (MRI) is needed to identify whether there is a lesion in the brain that could be causing the episodes. A temporal lobe lesion, for example, can cause temporal lobe seizures, which may also manifest with repetitive movements and be mistaken for absence seizures.
3. e.
An electroencephalogram (EEG) will show a symmetrical 3 Hz spike and wave pattern. This is described as generalized seizure activity because it involves both sides of the brain, in contrast to focal seizure activity, which involves only one region. 24-hour sleep deprived EEG can be helpful for establishing more complete diagnosis of the basis [Seizure disorders I have provided a link for overnight EEG record.
Often, the abnormalities on EEG can be elicited by hyperventilation, so your child may be asked to breathe rapidly during the EEG so that the pattern can emerge.
3.e.i.
How a Sleep-Deprived EEG May Diagnose Seizures (verywellhealth.com)
What is Sleep-Deprived EEG for Seizures? Especially useful for clarifying Differential Diagnosis and getting to treatable underlying disorders that affect speech abruptly without loss of consciousness and loss By Brandon Peters, MD, updated on October 21, 2022, Medically reviewed by Diana Apetauerova, MD
A Sleep-deprived EEG is a type of EEG that's done to detect subtle seizures, like absence seizures or focal seizures. Like standard EEGs, this non-invasive test records the electrical activity of the brain and can pick up on abnormal brain waves through electrodes attached to the scalp. When you fall asleep or doze during the test, the machine will continue to record activity in your brain.
4.
Transient ischemic attack (TIA) - Symptoms and causes - Mayo Clinic
Overview:
A transient ischemic attack (TIA) is a temporary period of symptoms similar to those of a stroke. A TIA usually lasts only a few minutes and doesn't cause permanent damage.
Often called a ministroke, a TIA may be a warning. About 1 in 3 people who has a TIA will eventually have a stroke, with about half occurring within a year after the TIA. A TIA can serve as both a warning of a future stroke and an opportunity to prevent it.
Symptoms. There could be symptoms of aphasia and freezing abruptly if the TIA is induced by pathology of the superior branch of the Middle Cerebral Artery. But the common symptoms are listed were not observed during the past several months when he developed these “Absence” type events.
Transient ischemic attacks usually last a few minutes. Most signs and symptoms disappear within an hour, though rarely symptoms may last up to 24 hours. The signs and symptoms of a TIA resemble those found early in a stroke and may include sudden onset of:
• Weakness, numbness or paralysis in the face, arm or leg, typically on one side of the body
• Slurred or garbled speech or difficulty understanding others
• Blindness in one or both eyes or double vision
• Vertigo or loss of balance or coordination
You may have more than one TIA, and the recurrent signs and symptoms may be similar or different depending on which area of the brain is involved. The striking behavioral change observed can be evoked by pathology affected the Superior branch of the Middle Cerebral Artery perfusing the Broca’s area.
II. I am experiencing discomfort of a significant degree about Adm. Monahan issuing the brief Fitness for duty attestation because he is using his Medical License to authenticate a speculative assertion because in the brief certificate that the Admiral posted which I have a copy of he didn’t certify that he had interviewed Sen. McConnell on Zoom and did whatever clinical Neurological examination that can be done without touching his patient plus the MOCA test for cognitive functions. Further he didn’t attest that he reviewed the lab and imaging testing that may have been ordered by the Senators Neuro Team and PCP. Most of all I am very unhappy that he didn’t insist the Neuro team and his PCP send their medical diagnosis and their opinion about the degree of impairment the Sen has experienced since the Fall and Concussion and the recent episode.
Finally does the Neuro team in their best Clinical judgement regardless of impairment if anything was identified as well if the prognosis that can be determined is compatible with Sen. McConnell being able to carry out his duties as minority Leader and to his constituents I would have strongly urged the Admiral not to step into the determination of fitness without reviewing all relevant information sent by the Neuro team especially if their conclusions about the diagnosis, prognosis, test results and what we all saw in real time match up well and support their fitness to return to work certification before issuing his short fitness to work statement bereft of specific critical data. The NYT report that Adm. Monahan did not personally examine Mr. McConnell before he issued a Medical Clearance to return to his duties. Conformed in ABC report. McConnell medically cleared by Capitol physician after apparent freeze episode - ABC News (go.com). This is Not Acceptable in any circumstances for any licensed physician to issue Medical Clearnce Certificate regardless of the occupation of the person who will be returning to work. This can potentially place this person, members of team and people he may be interacting with as part of his job. Admiral Monahan didn’t confirm the findings of the Teams of Physicians who provided care to Mr. McConnell examine Sen. McConnell and perform the MOCA or similar tests to make sure the higher cognitive functions are intact. Adm. Monahan’s actions in this vital matter falls woefully short of this ancient precept from the time of Hippocrates, “Primum Non Nocere. First Do no Harm.” In this text Of the Epidemics says, " The physician must be able to tell the antecedents, know the present, and foretell the future — must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm."
I concur with Dr. Arthur Caplan, MD, the Medical Ethicist at NYC Langone about the dual loyalties as it applies to the Complex competing loyalties of his patients who have very important roles to play in their own lives with their families in the health and well-being of the people of the United States and across the Globe. I was a member of the Bioethics committee of Mx Health, Middletown for twenty years and member of the CT State Medical Society Ethics Committee for many years. I had the honor of serving on the CT. Sate Medical Examining Board for perhaps a decade. for I am inclined to concur with Dr. Rand Paul’s assessment that the vacant spells are not symptoms of dehydration. I am offering a list of differential diagnosis that have to be considered and carefully narrowed down.
I tend to concur with these Assessments offered by Neurologists not connected with Sen. McConnell’s care and was published in the NYT and I totally concur with NYT that Adm Monahan didn’t thoroughly explain Sen. McConnell’s abrupt stops.
Of note: Neurologists not involved in McConnell's medical care see the senator's episodes as potential small seizures, The Times reported in early September.
• Monahan's note did not thoroughly explain his abrupt stops, the doctors said. To them, "the spells appeared most consistent with focal seizures, which are electrical surges in one region of the brain," per The Times.
Respectfully submitted.
I welcome comments and discussion to get fuller understanding of the observed phenomena.
Velandy Manohar, MD.,
Distinguished Life Fellow, Am. Psychiatric Association,
Current member of Ethics Committee of CT State Medical Society.
Past Member of Bioethics Committee of Mx. health for two decades,
Past member of CT. Medical Examining Board for about a decade.
Best in Medicine, American Health Council- 2018
Website: velandymanoharmd.com Has related links.
Linked In: (29) Velandy Manohar | LinkedIn