SUMMARY
REPORT
on
MRI-T2 Imaging of
Chen Shui Bian's
brain on Jan. 16, 2013
by
Samuel
M. Chou, M.D., Ph.D., Prof.
Clinical history
As provided by Prof. S-S. Chen (陳順勝教授) who was requested as a neurologist to
see Chen Shui Bian (CSB)
in Sept. of 2012, for the first time, during the past 4 years' imprisonment. Therefore the onset of his slowly
developing neurological disease especially at its onset is difficult to assess.
This
62 year old man developed progressively worsened neurological symptoms and
signs since about 6 months earlier. The neurological deficits have steadily and step-wisely
worsened and now displaying tremors in the right hand, and stuttering for brief
wording. For this reason, it was decided to take MRI every 3 months apart.
Neurological finding since
Sept. 2012
a) Speech impediments: stuttering speech, nominal aphasia (disturbance in formulation and
comprehension of language),
partial expressive aphasia (loss of ability to produce language), however echolalia was possible.
b) Emotional disturbance: extensive depression,
mask-like expressionless face (a common description of Parkinson’s facies)
c) Cerebellar signs: F-N-F (finger-nose-finger, implying upper extremity superior
cerebellar defect, right side) +
K-H-T (knee-heel-toe, implying lower limb cerebellar defect bilaterally), Romberg's sign (implying cerebellar
or posterior spinal column deficit).
d) Memory disturbance; poor recent memory,
especially for dealing with the daily life.
e) Cognitive disorders or early signs of
dementia.
f) Abnormal reflexes
Motor systems: unsteady or ataxic gait, Extrapyramidal
signs: cogwheel rigidity of Rt arm, Tremor: resting and action, Rt hand, with weakness, Bradykinesia, Mask-like expressionless
face resembling Parkinsonism.
Sensory system: double
stimulation test showed neglect of right side, agraphesthesia.
More recently, CSB has started to display urinary incontinence
once; cognitive disorders and wide-based gait, they began to slowly progressed
and developed as so-called Adam's triad
of Normal Pressure Hydrocephalus (NPH): (1) urinary Incontinence; (2) cognitive
disorders and or early dementia;
and (3) wide-based gait disturbance.
Cognitive disorders or Dementia: in
the form of apathy, dullness and forgetfulness, frontal-lobish, or subcortical
in type which resemble Parkinson's and can be distinguished from the cortical,
or Alzheimer type. Also with its hydrocephalic changes with the MRI findings.
Urinary urgency: in the form of spastic hypereflexic to lack of concern so called frontal- lobe
incontinence.
Gait disturbance: occur most frequently from the early
stages characterizes by broad-base gait may change to short shuffling gait resembling that in Parkinson's
disease.
MRI Findings (MRI-T2 and
Voxel MRI)
Multiple cystic lesions can be identified. The largest
are located at Sylvian fissures, infraorbital, infratemporal fossa, interhemispherical sulcus.
Some of them appear ruptured forming hygroma. The gyri are flattened and
shortened over the convexity, or atrophic with fibro-gliosis over the under
surfaces of the brain. Topographically the largest cystic lesions appear associated with Limbic system.
The clinical findings and diagnosis of NPH may lead to brain
imaging, either CT or MRI, followed by lumbar puncture for measurement of the
CSF pressure, the evidence for trauma or tumor.
Pathogenesis
The pathogenesis for the hygroma formation is not fully
understood although the strategy for the treatment for the ventriculoperitoneal
shunt to drain the excess CSF is the same. However, the prognosis depends
heavily on clinical measurements of the clinical "triad", the
cortical sulci, gyri and periventricular lucency.
Diagnosis
Normal Pressure Hydrocephalus (NPH) or NPH-like
syndrome secondary to multiple large subdural arachnoidal cysts (some probably
ruptured), with resultant
pan-subdural hygromas (the largest in the Sylvian fissures, bilateral and
symmetrical) compressing the major components of the Limbic system (including Ammon’s horns, amygdaloid nuclei,
hippocampal, orbitofrontal, anterior cingulate and insular cortices and
hypothalamus). Comparing the September 2012 to December 2012 brain MRI, the
findings have worsened, correlating with the patient’s worsening neurologic
symptoms some of which did not exist before September 2012.
Concerns over human rights for CSB
The
conditions of continuous light exposure and sleep deprivation which CSB has
been subjected to for a number of years has caused severe, probably
irreversible damage to his brain as evidenced in the recent detailed medical
evaluation. I concur with Nicole Bieske, spokeswoman for Amnesty International
Australia, whose statement regarding sleep deprivation is as follows: "We
are fundamentally opposed to cruel, inhumane and degrading treatment of any
person". Sleep deprivation, Ms. Bieske said, was considered cruel but if
used for prolonged periods of time, it was torture. "At the very least it
is cruel, inhumane and degrading. If used for prolonged periods of time it is
torture". It has been confirmed that CSB was subjected to continuous light
exposure coupled with sleep deprivation for a prolonged period of time in
addition to internationally unacceptable physical condition of the cell in
which he was incarcerated.
In a real sense, based on
international standards, CSB was subjected to torture for a prolonged period of
time preceding his transfer to the current hospital in which he now is
receiving care.
Recommendations
Trauma resulting from continuous
light exposure and sleep deprivation cannot be dismissed and in fact are the
causes of the neurological abnormalities. Detrimental effects such as those
experience by CSB have been
widely substantiated and confirmed in numerous clinical and animal studies in
the last few decades and must be considered direct consequences of confirmed
prison conditions imposed on the former president.
Based on established guidelines set by
the Mayo Clinic, American Autonomic Society, the American Academy of Neurology,
and other professional organizations, the most effective treatment for CSB is IMMEDIATE HOME CARE with supervising
medical professionals and management by rehabilitation specialists in a home environment
surrounded by family and loved ones. This home environment will be an important
factor in halting further deterioration and with intensive therapy help begin
the slow and long process towards alleviating the symptoms.
The critical nature of his illness
cannot be overemphasized and must be addressed immediately.
References
1) Adams RD, Fisher CM, Haskim S. et al. Symptomatic occult hydrocephalus with "normal" cerebrospinal
fluid pressure. a treatable syndrome. N Eng J Med 1965;273: 117-126.
2) Chou S, Gutmann L. Deteriorating parkinsonism and subdural hematomas. Neurology
2001; 57:1295
3) Tamburrini G, Caldarelli M, Massimi
L, Santini P. Subdural
hygroma: an unwanted result of Sylvian arachnoid cyst marsupialization. Childs Nerv Syst. 2003;19(3):159-165
4) Albuquerque
FC, Giannotta SL. Arachnoid cyst rupture producing subdural and intracranial
hypertension: case report. Neurosurgery 1997:41(4):951-956
5) Copinschi G. Metabolic
and endocrine effects of sleep deprivation. Essent
Psychopharmacol 2005; 6(6):341-347
6) Everson CA, Find all citations by this author (default).
Bergmann BM, Find all citations by this author (default).
Rechtschaffen A. Sleep deprivation in the rat: lll. Total sleep
deprivation. Sleep
1989; 12(1):13-21.
7) Everson CA, Szabo A.
Recurrent restriction of sleep and inadequate
recuperation induce both adaptive and pathological changes. Am J Physiol Regul Integr Comp Physiol 2009; 297(5):R1430-40.
《本文已刊登於2013-4-4台灣守護周刊第64期》
