PHOENIX – While America awaits the verdict on the repeal and replace of the Affordable Care Act, eyes are on the recovery speed of Senator John McCain (R-AZ) following his surgery at Mayo Clinic, Phoenix, to remove a clot above his left eye. MedPage Today asked several experts to weigh in on the procedure and the senator's likely prognosis.
For the most part they agree that McCain's surgery, as reported in the press, is fairly routine and he should recover quickly, within a few weeks. However, given his medical history with melanoma, some noted there are some caveats and concerns.
John Sampson, MD, PhD, Chair of Neurosurgery and the Wilkins Professor at Duke University, North Carolina, said "While he may be tired for a few weeks, his immediate recovery should be swift."
"Initial surgical recovery is a week, as the brain expands to occupy the space previously taken by the hematoma and displaces the air introduced from the surgery," said Alexander A. Khalessi, MD, MS, FAANS, Acting Clinical Chief of Neurosurgery with UC San Diego Health.
But, Jamshid Ghajar, MD, PHD, FACS, Director of the Stanford Concussion and Brain Performance Center, Stanford University, told MedPage Today, that a lot depends on the preexisting condition of the patient going into the surgery.
"If the patient is confused or has speech difficulty or weakness, then one would want that to resolve before resuming work." That said, recovery is often rapid with patients going home one day post-surgery, he added. Stitches are typically removed the following week.
"In general, it may take anywhere from 2 - 6 weeks for a person to recover from an intracranial operation," said Daniel Barrow, MD, Professor and Chairman of the Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia. "From what I understand of his procedure, this was performed through a small eyebrow incision, which does speed up recovery. The fact he was discharged from the hospital so soon after the procedure would also suggest that he should be able to do the things required of him as a senator within a week or two, in my estimation."
The Elephant in the Room: Melanoma
Recurrence is the most common complication following surgery, but stroke and infection are also possible, Ghajar said. Of course, a major concern given McCain's medical history with melanoma is whether this clot could be in any way related to his cancer. "In this particular case, with a prior diagnosis of melanoma, the blood clot and brain (using imaging) need to be examined to make sure that this is not from the melanoma spreading."
Khalessi added: "In the setting of melanoma, there is a substantial risk of re-accumulation. In terms of full time return to demanding cognitive work, it would normally be 4 – 6 weeks and these patients may suffer long-term cognitive challenges. This is particularly true for left-sided, dominant hemisphere lesions like this one."
And, Khalessi noted, if Senator McCain experienced a hemorrhage from a melanoma metastasis, "the situation is much more serious. We occasionally manage these problems through a single burr hole." Barrow concurred and noted that this would be determined upon pathological examination.
Ghajar said that while in McCain's case it is good to send the clot for pathology, however, "most likely this is from a head injury and not melanoma."
Clinical presentation
The reports from Senator McCain's office is that the hematoma was found upon routine exam. Ghajar said usually a patient would complain of headache, speech impairment, weakness or others around him may notice confusion. Sampson noted that such symptoms could lead someone to get a scan or, in the case of someone like McCain, with his prior history of cancer, he might be getting routine surveillance scans. Nonetheless, in this age group, physicians look for neurological deficits and while "cognitive deficits can be fairly subtle in the elderly, clinicians look for the possibility of blood clots by looking for the same things we look at for stroke – speech, movement etc."
There has been some speculation in the press since former FBI director James Comey's testimony before the Senate Intelligence Committee that . When he questioned Comey, he was rambling and seemed confused. "Certainly, blood clots in the brain can cause neurologic deficits," Sampson pointed out. "These could be very subtle or not noticeable until someone is asked to perform at a higher level like public speaking."
The surgery
Ghajar said the surgery was most likely to excise a subdural hematoma. "Since it was an eyebrow incision, most probably a burr hole, which is a 1.5 cm hole made with a high-speed drill that may have been enlarged to get the clot out. Most likely the clot was liquefied so it could come out easily through the hole under pressure. Usually the incision for a burr hole is higher up, but always positioned so it is over the middle of the clot."
Such subdural hematomas are, Ghajar indicated, common in the elderly (Senator McCain is 80). "If the blood clot is within a week, then it is firm and requires a craniotomy (removal of the bone over the clot) to take it out. If the clot is over two weeks old, then it liquefies and can be taken out through a drill hole in the skull," he noted. The senator's office noted that the surgeons at Mayo Clinic performed an eyebrow craniotomy.
McCain's office gave this statement to MedPage Today: "Senator McCain is in good spirits and recovering comfortably at home with his family. On the advice of his doctors, he will be recovering in Arizona this week. As available, more information on Senator McCain's progress will be made public."
Senate Majority Leader Mitch McConnell (R-KY) is hoping to bring the Better Care and Reconciliation Act, the GOP's latest bill to repeal and replace the Affordable Care Act, to the Senate floor for a vote. Without McCain, it is possible that McConnell would lack the needed votes and as a result further action on the bill will be delayed until McCain returns.