KASU

Neurosurgeon: McCain's Recovery From Brain Surgery Might Take Weeks

Jul 17, 2017
Originally published on July 18, 2017 10:08 pm

The initial report of Sen. John McCain's surgery sounded simple: the removal of a blood clot above his left eye. But it was actually brain surgery, and the clot was almost 2 inches long.

The surgery prompted Senate Majority Leader Mitch McConnell to delay a vote on the health care bill until the 80-year-old McCain is well enough to return to the Senate.

As NPR's Geoff Bennett and Tamara Keith reported, "the Republican senator's absence from the Capitol would have complicated the already tight math surrounding a planned Senate health care vote to repeal and replace the Affordable Care Act."

But it remains unclear how long McCain's convalescence will last.

NPR's Robert Siegel spoke with Dr. Peter Najaki, director of the neurosurgery residency program at the Barrow Neurological Institute in Phoenix, about the kind of surgery McCain had and how long his recovery might take. He was not involved in McCain's care. These excerpts have been edited for length and clarity.

Sen. McCain's office describes the procedure as a minimally invasive craniotomy with an eyebrow incision. What does that mean?

So there are a lot of ways to get into the head, and some are more invasive and some are less. What that really means is that instead of making a large opening in the head and opening a large window through the skull, we make a small one right over the eye through the eyebrow and open a little window and really make a direct route to whatever we need to get to, assuming it's right under that spot.

The blood clot was described as 5 centimeters, about 2 inches. Is that average, relatively large or small, and what danger would it have posed?

The real key is 5 centimeters in which direction? Something which is 5 centimeters around is really pretty big for the frontal lobe, whereas if it's shaped like a pancake, it's not very big. So if the blood is outside the brain, it may not be that impactful. If it's inside, it may or may not be impactful.

When you use the word impactful in this case, what kind of impact are you alluding to?

The left frontal lobe in most people is considered the dominant one, meaning it's responsible for a lot of high-level thinking. ... If you're a very high functioning person like he is, a lot of things like judgment and speech can be in that area. Happily, it sounds like he's out quickly and doing very well.

How long might it typically take a robust 80-year-old to recover and be back on the job?

Reasonably, we would send someone home in a day or two, which nowadays for this kind of minimally invasive neurosurgery is realistic. But I wouldn't counsel anybody to go back to normal activity for at least weeks. And many people may take even four to six weeks to feel really up to snuff.

Last month, McCain seemed confused in his questioning of former FBI Director James Comey. He later said, "I was up late watching the Diamondbacks baseball game." Is there any link between confused speech or thinking and a blood clot of this size?

I think in this case it would be speculation, because this might well have started after that, for all we know. But if you had something in that location, I suppose it's possible. As I say, probably speculation at this point.

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ROBERT SIEGEL, HOST:

As we've heard, Senator John McCain is recuperating from neurosurgery. He had a blood clot removed from over his eye. And to learn more about the kind of surgery he underwent, its risks and what a recuperation might be like, we turn now to Dr. Peter Nakaji, who is director of the neurosurgery residency program at the Barrow Neurological Institute in Phoenix. Welcome to the program.

PETER NAKAJI: Thank you, Robert.

SIEGEL: And we should say you are not treating Senator McCain. We're just calling you as someone who does this kind of work. Senator McCain's office describes the procedure as a minimally invasive craniotomy with an eyebrow incision. What does that mean?

NAKAJI: So there are a lot of ways to get into the head, and some are more invasive, and some are less. And what that really means is that instead of making a large opening in the head and opening a large window through the skull, we make a small one right over the eye through the eyebrow and open a little window and really make a direct route to whatever we need to get to, assuming it's right under that spot. So that's a less-invasive, easier-to-recover-from kind of surgery.

SIEGEL: The blood clot was described as 5 centimeters or about 2 inches. Is that average, relatively large, small? And what danger would it have posed?

NAKAJI: So as you point out, I'm not a treating physician, so I don't have all of the information. And the real key is 5 centimeters in which direction. So something which is 5 centimeters around is actually pretty big for the frontal lobe, whereas if it's shaped like a pancake, it's not very big. So if the blood is outside the brain, it may not be that impactful. If it's inside, it may or may not be impactful. It really matters a bit more what it's caused by.

SIEGEL: But when you use the word impactful in this case, what kind of impact are you alluding to?

NAKAJI: Well, the left frontal lobe in most people is considered the dominant one, meaning it's responsible for a lot of high-level thinking. And if you're a very high-functioning person like he is, a lot of things like judgment and speech can be in that area. Happily, it sounds like he was out quickly and doing very well, so it may not have had a lot of impact. Draining a blood clot that expands like a balloon and then deflates like a balloon sometimes can be recovered from very well.

SIEGEL: Well, obviously much depends on the details here of the blood clot, but how long might it typically take, say, a robust 80-year-old to recover and be back on the job?

NAKAJI: Yeah, well, fortunately he is a very robust 80-year-old. He's in good shape, and that's where I like to start. I mean reasonably we would send someone home in a day or two, which nowadays for this kind of minimum-invasive neurosurgery is realistic. But I wouldn't counsel anybody to go back to normal activity for at least two weeks. And many people may take even four to six weeks to feel really up to snuff.

SIEGEL: Yeah. We're told that tissue pathology reports are pending within the next several days. What are the answers doctors are looking for there?

NAKAJI: Well, I think what we're all hoping to see for the sake of Senator McCain is that we don't see something underlying like the melanoma that we know is in his history. This is one of the tumors more likely to bleed in the brain. And we'd like to see that that's not it and that it's something else. But you know, pathology - we get it because we don't know what it'll show to be sure.

SIEGEL: After Senator McCain's melanoma, which was over 15 years ago, he said that he was being followed very closely. Would that mean regular scans? And would that mean that something grew to this size even despite his being looked at very recently?

NAKAJI: Yeah, surprisingly we do see bleeding in the brain. You know, the brain is not sensitive to pain, so you can see things expand without really seeing them happen, sometimes to rather alarming sizes. And we do see it all the time. So the fact that they would be looking a little bit more at him because of his history might have mean that they did pick it up and it did get to be very big despite all. But it is hard to say without knowing a bit more about it.

SIEGEL: The only thing I would ask - and I would respect your not answering if you chose. But I'm just curious to hear...

NAKAJI: Yeah.

SIEGEL: ...What you would say was. Not too long ago in his questioning of former FBI Director James Comey, Senator McCain betrayed a confusion in public. He later said, I was up late watching the Diamondbacks baseball game. Is there any link between confused speech or thinking and a blood clot of this size?

NAKAJI: Yeah, I mean I think in this case, it would be speculation because this might well have started after that for all we know. But if you had something in that location, I suppose it's possible - as I say, probably speculation at this point.

SIEGEL: That's Dr. Peter Nakaji, director of the neurosurgery residency program at the Barrow Neurological Institute in Phoenix, Ariz. Thanks for talking with us.

NAKAJI: Thank you. Transcript provided by NPR, Copyright NPR.