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At Face Value: Obama and Neurology Letter to the Editor At Face Value: Obama and Neurology emifacial spasm is characterized by intermit- medications including carbamazepine, clonazepam, tent involuntary twitching of muscles of the phenytoin, gababentin, and baclofen is often of limit- face, which is usually unilateral.1,2 The preva- ed or no benefit. Microsurgical vascular decompres- Hlence is about 10/100,000, occurring more com- sion is usually curative, although there is a risk of monly in women (2:1) with onset typically between various complications (including hearing loss and the second and eighth decades of life with an average facial weakness) and recurrence. Botulinum toxin between 45-50 years of age. injections are often the preferred treatment with long- Although a diagnosis based upon a video is not a term safety and good to excellent improvement in 76- substitute for a careful history and neurological exam- 100 percent of patients. ination, in numerous television interviews over three —Randolph W. Evans, MD years with close-up views, President Barack Obama Houston, TX appears to have frequent involuntary muscle twitch- 1. Shannon KM. Hemifacial spasm. In: Gilman S, editor. MedLink Neurology. San Diego: MedLink ing of the right side of his face just inferior to the Corporation. Available at www.medlink.com. Accessed 12/02/09. right orbit.3-7 2. Kenney C, Jankovic JM. Botulinum toxin in the treatment of blepharospasm and hemifacial spasm. J Neural Transm 2008;115:585–591. The twitching is consistent with hemifacial spasm. 3. Meet the Press. 10/22/06. NBC News. (was available on www.youtube.com when letter initially In a health summary released by his presidential prepared but recently removed and not available on NBC site) campaign on May 29, 2008,8 his internist described 4. Barbara Walters Special: Barack Obama Interview. 11/26/08. abc News. (was available on www.youtube.com when letter initially prepared but recently removed and available for sale only on him as being in excellent health without any mention abc site). of hemifacial spasm. I am unaware of any mention by 5. 60 Minutes. President Obama. 3/22/09. CBS News. Available at http://www.cbsnews.com/video/watch/?id=4883166n&tag=topHome;topStory the President about this facial twitching although 6. Nightline. 7/23/09. abc News. Available at ttp://www.youtube.com/watch?v=RiYCle98xj0 there is one media report, that I believe is incorrect, 7. 60 Minutes. President Obama. 9/13/09. CBS News. Available at of a “chronic facial tic.”9 In contrast to hemifacial http://www.cbsnews.com/video/watch/?id=5307949n&tag=cbsnewsSidebarArea.0 8. Obama Health Summary. 5/29/08. Available at spasm, a motor tic is an arrhythmic, rapid, stereo- http://firstread.msnbc.msn.com/archive/2008/05/29/1076277.aspx typed movement that resembles normal, coordinated 9. “Changing of the guard. Stress takes toll on Obama, develops chronic facial tic Michelle said to be 1 distraught over spasms under right eye.” WorldNetDaily. Posted 11/29/08. Available at movement. A person with a tic can usually voluntari- http://www.wnd.com/?pageId=82364 ly reproduce and transiently suppress the movements. Examples of simple motor facial tics include blinking, Editor’s Note: Presidential health has become a eye rolling, grimacing, and mouth opening. matter of public record in recent years as Many patients with hemifacial spasm are unaware Commanders-in-Chief and even presidential candi- of their condition. Hemifacial spasm is usually due to dates have issued health records and regular health compression of the facial nerve at its exit zone in the status reports. There is also significant historical inter- brainstem by blood vessels (anterior inferior cerebel- est in the health of presidents, from speculation about lar artery, the posterior inferior cerebellar artery, the Thomas Jefferson’s affliction with migraines vertebral artery, or combinations of two of these (Headache. 2006;46:492-497), JFK’s Addison’s Disease, arteries ). About five percent of cases have a prior his- the impact of Ronald Reagan’s Alzheimer’s, to emerg- tory of Bell’s palsy. Rare causes include tumors (epi- ing suggestions that FDR actually died of cancer dermoid, neuroma, astrocytoma of the cerebellopon- (FDR's Deadly Secret. In press, Due Jan. 2010). tine angle, meningioma, and parotid), Chiari I malfor- Please note that Dr. Evans has investigated footage mation, and cysticercosis which can be excluded with dating back at least three years—prior to Mr. Obama’s a magnetic resonance imaging scan of the brain. attaining the presidency—in his assessment of the Hemifacial spasm is a chronic condition that usual- President’s involuntary muscle twitch. This contra- ly progresses to involve additional facial muscles with dicts some observations in the non-medical media of uncommon spontaneous remissions. Treatment with a “tic” developing in the past few months. ■ 16 | Practical Neurology | November/December 2009.
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