MRI: magnetic resonance imaging
In a companion article in this issue of the journal, Howard S. Kirshner, MD, comments on the case history and outlines the current state of knowledge about transient global amnesia (Kirshner, 2017).
Do you remember June 27, 2015? If you knew you had been on a sailboat, and the weather was miserable, and afterward you had a beer with the other sailors, would you not expect to recall—even more than a year later—at least a few details?
I was on that boat, on a blustery Saturday on Long Island Sound, but every detail is missing from my memory as if wiped clean by a computer program meant to free up disk space.
The earliest moment I recall of the day is lying in an industrial tube with a kind of overturned colander covering my face. I heard tapping and chirping noises, while a wave of claustrophobia washed over me. My mind felt shrouded in dense fog, but I grasped that I was in an MRI (magnetic resonance imaging) machine. I had been in one a few years earlier during a health scare that turned out to be harmless. I forced down the fear of being in the confined space. Someone, I realized, was scanning my brain.
Other scenes unfolded that I dimly followed at the time and only hazily recall now. An orderly wheeled me from the MRI suite to a hospital room. My wife, Alice, hovered in the background. Propped up in bed, I faced an institutional clock that read a few minutes to midnight. An astonishing piece of information. What had happened to the day?
After Alice left—I can’t remember any conversation or the circumstances—I saw two yellow Post-it® Notes on the bedside table in her familiar graceful handwriting.
“You have a condition called transient global amnesia,” the notes began. “It will last HOURS, not DAYS. You’re going to be fine. Your MRI scan was clear. You sailed today and drove yourself home. The neurologist says your prognosis is GREAT. You have not had a stroke! There will be no permanent damage.”
I had never heard of transient global amnesia (Owen et al, 2007), an uncommon syndrome in which people suddenly and temporarily become unable to recall recent events and to form new memories (Quinette et al, 2006). Unlike other conditions that can trigger temporary memory loss, like a stroke or epileptic seizures, transient global amnesia is considered harmless. An episode is over within 24 hours.
The syndrome was first described only in 1956 (Bender, 1956; Guyotat and Courjon, 1956). A review of dozens of studies that were published in the medical literature over the next half-century totaled up only about 1300 reported cases (Quinette et al, 2006).
Many doctors miss the diagnosis, according to scientific journal articles I read later. Even neurologists may see only one or two cases a year. Owen and colleagues (2007) called the disorder “an intriguing clinical entity.” This is true for clinicians. Then the authors noted that for patients and their families “it is a very traumatic event.”
This was certainly the case for me. Taking a hiatus from my conscious waking life—all the time while being fully awake—filled me with a profound sense of strangeness and feelings of disorientation tinged with fear, and ultimately prompted philosophical musings about the interconnectedness of memory and identity.
This is the strangest thing I have ever experienced, I remember thinking late at night in my hospital room, which, like all hospital rooms, was featureless if comfortable. Am I in some way station to the afterlife?, I wondered. Is this death?
My hand went to my scalp, and I realized I had gotten a haircut that morning. I did not have the slightest memory of it. How is that possible?, I wondered.
Research into people’s medical histories and their actions before an episode of transient global amnesia has been unable to pinpoint its cause or immediate triggers. As a neurologist who saw me in the hospital would say, “We don’t understand why it happens. There are a million theories.”
Researchers have noted some activities that can trigger attacks, including strenuous exercise, contact with water, emotional stress, and even sexual intercourse. Lane (1997) called the syndrome “recurrent coital amnesia.”
Studies based on brain scans of patients during an episode of transient global amnesia show that blood flow decreases to the temporal lobe (which we use to understand speech) and the hippocampus (which processes short-term into long-term memories) (Sander and Sander, 2005). The disorder affects men and women equally (Owen et al, 2007).
Various theories have linked transient global amnesia to a history of migraines, psychiatric disease, and vascular diseases. I have none of these, but I fall in the target age range, which is 40 to 80. In fact, I had a start when I read that an attack occurs “at an average age of 61 years” (Marazzi et al, 2014). I was 59 when my amnesia struck.
Since the end of my episode I have been able to recall details beginning about midway through my attack, from the time when I awoke in the guts of the MRI machine. Because I am a journalist by profession, my instinct was to take notes, which I began to do the morning after the attack started. But the 12 hours prior to that first hazy scene in the MRI scanner are a complete blank. They are lost to retrograde amnesia, an inability to remember past events.
At the same time, starting with my awakening in the scanner, I became aware of the second feature of transient global amnesia: anterograde amnesia, an inability to form new memories. Very little of what I was experiencing after I awoke stuck to whatever neural networks I had where memories are recorded. I read Alice’s bedside note over and over. By the time I reached the end, I had forgotten what I had just read and began all over again.
“You’ll spend the night in the hospital,” Alice had written, “until you feel YOURSELF.”
That was comforting, but I slept that night only in fits and starts. I was still befuddled when a neurologist, Dr Eugene Tuolunsky, visited me in the morning.
I asked him if he had seen Memento, a 2000 movie about a man who was unable to form short-term memories. The film seemed to show exquisitely what I was going through. To give viewers a sense of the utter mental disorientation suffered by the protagonist, played by Guy Pearce, director Christopher Nolan reveals the plot in reverse. Each scene ends where the previous one began. Effects precede causes.
As a footnote, that protagonist was inspired by the famous neurology patient H.M., who underwent surgery at age 27 to cure his severe epilepsy and was left unable to form new explicit memories for the rest of his long life (Dittrich, 2016).
Dr Tuolunsky did not know Memento. Because I was failing to create new short-term memories, I immediately repeated my question. “Have you ever seen Memento?” I asked.
He was unfazed, which in a way was reassuring. If I was losing my mind, I thought, or was stuck in some purgatory beyond death, there would probably be more of a fuss.
By midday, my memory-making capacity had gradually returned. I was ready to be discharged. A second neurologist, Dr Leslie Saland, looked in on me to answer questions. “The good news is, this is a good diagnosis to get,” she said. Transient global amnesia is almost always a once-in-a-lifetime experience, and I didn’t have to worry about a recurrence.
“You’ll get home and find little things that will not make sense,” Dr Saland said. “You’ll never recover those memories of yesterday.”
How could a day—and such a highly eventful one—disappear entirely? I have been a reporter for The New York Times for over 20 years. My response to this blackout of personal information was to set out over the next few days to try to reconstruct what had happened that Saturday, as though I were pursuing a story. I hoped that learning a few details from other people would jog the events back into my mind.
The skipper of the boat I had sailed on, my friend Malcolm, told me we finished two races in strong winds and rain. “It was blowing,” he said. “You were up on the foredeck working like a monkey.”
At no point did I seem to be spacing out, Malcolm related. “You were absolutely lucid. You weren’t staring off into space.”
One intriguing thing I learned from reading the scientific literature about transient global amnesia is that it is sometimes called “amnesia by the seaside.” Martin (1970) coined the term and theorized that immersion in water caused a sudden change in some patients’ body temperature, constricting blood flow to the brain’s memory centers.
In 1999, Tubridy and colleagues’ study of 27 patients showed that nine had been swimming before their amnesic episodes. Four had just washed their hair.
Statistically, the link between immersion in water and the amnesia is not definitive. But it was a tantalizing clue for me, since I had been on a 30-foot sailboat in high winds. As the crewman on the foredeck, I had to unhook the spinnaker pole from the mast during jibes, swing the pole around, and reattach it to a fitting on the mast, all while being doused by sea spray and rain.
Perhaps the greatest mystery of transient global amnesia is that your memory abandons you while you are in clear consciousness and able to continue performing complex tasks. People have kept playing music, driving, or, in my case, racing a sailboat with no loss of control.
I have often wondered just when my attack began. Malcolm said he became aware that I was slightly confused once we were back on shore and had had a beer in the clubhouse. At that point, I could not remember where I had parked earlier in the day. He drove me through the lot until I spotted my car.
But what if my attack began earlier, while still on the boat? We sailed two races, the first in 17-knot winds, the second when the wind had calmed to about 10 knots. Although I had raced on this class of sloop for years, I had missed most weekends of the current racing season because of work.
“In the second race you were saying to me, ‘Tell me what you want me to do if I’m not doing anything right,’” Malcolm recalled. “You said, ‘I haven’t been out for a while.’ In the first race, you weren’t saying that.”
If that was the onset of my episode, between the two races and when it had started to rain, my grasp of my surroundings deteriorated quickly.
Alice, whom I quizzed at length in the days after my recovery, picked up the story where Malcolm left off. When I had not returned home by 6 PM—we had plans to attend a Lucinda Williams concert with friends that evening—she grew impatient and called.
“Where are you?” she said.
“On the water,” I said.
“What, are you still sailing?”
No, I was in the car, close to the water, but I did not recognize the buildings or the parking lot.
Alarmed, Alice asked where I was, thinking she would come get me. She wondered if I had become hypothermic while sailing. But I could not tell her where I was. And I had no memory of sailing. She tapped “disorientation” into an online health guide.
I knew who my wife was, but I did not know where I lived. Alice talked me through entering our address into my phone’s GPS and following it home.
From there, she drove me to the hospital, where doctors declared a “Code Gray” for a possible stroke, and I was hurried in for the head and neck MRI.
Another theory of my amnesia is that episodes are brought on by stress. Certainly, the racing that day sounded stressful. The evening before being on the boat, I had flown home from Iowa after a lengthy day spent reporting on the early-stage presidential campaign. I had arrived late at our home in the New York suburbs, and crawled into bed close to midnight. There was a lot on my mind.
In the hospital, Alice was concerned about whether my schedule was responsible for the episode. “If it’s work-related stress, I’d like to know,” she asked Dr Saland.
“I don’t think we’re going to pin it down like this,” the doctor replied.
My efforts to recover the day by interviewing Malcolm and Alice were unsuccessful. I might as well have been trying to recall a sleepwalking episode. Even after sifting through my few shards of memory to write about the day, I have not pried open whatever neural chambers might conceal a record of what happened.
Dr Saland was correct that I would find clues back at my house that made no sense. On my desk was a pair of sailing gloves, still wet, evidence that someone had been on a boat. I had no memory of peeling them off and leaving them there.
How do we make sense of extraordinary events that pull us up short in our everyday lives? For me, the movies are an ideal place to seek an explanation of the surreal. Movies are escapist everyday entertainment, but they can also impose coherent and emotionally satisfying order on the most fantastic flight of imagination.
Memento neatly represented the experience of my anterograde amnesia.
Another movie, Inside Out, helped answer the more existential questions about my day that went missing. If you saw the movie, you’ll recall that this animated feature, from the wonderful minds at Pixar Studios, takes place entirely in the head of an 11-year-old girl. The emotions of the heroine, Riley, are cartoon characters. A “Jetsons”-esque city inside her mind is a metaphor for the human psyche.
As Riley encounters the world, her experiences are processed into small orbs of memories like snow globes. They are stored in long racks. Special short-term memories become permanent memories, which in turn are the foundation stones of Riley’s personality, represented by towering islands. When she has an 11-year-old’s life crisis, the islands begin to disintegrate.
Inside Out is a cartoon, not a psychology textbook. But its portrayal of memories as the bedrock of personality feels fundamentally correct. Without our memories, who are we? The mind’s ability to hold short-term recollections, and to retrieve longer-term memories and the feelings they evoke, is essential to being human. As I emerged from my amnesia, I felt grateful to have my life back. I remember it like it was yesterday.