How John McCain’s Brain Became 'Fake News'

A polarizing debate about a reversible cause of dementia

Senator John McCain during the James Comey testimony in June 2017
Jonathan Ernst / Reuters

A blood clot in John McCain’s head has caused confusion, not necessarily on the part of the senator.

On Saturday evening, multiple news organizations reported that McCain had been hospitalized for removal of a blood clot “above his left eye.” This was based on a statement from McCain’s office, which said he “underwent a procedure to remove a blood clot from above his left eye.”

The phrasing was accurate, if potentially misleading, taken in isolation.

The clot was technically above McCain’s eyeball, meaning inside the skull, as is made clear by the rest of the senator’s statement: “Surgeons successfully removed the five-centimeter blood clot during a minimally invasive craniotomy with an eyebrow incision.”

Though the precise location of the clot has not been disclosed by the senator and his medical team, excising a superficial clot on a person’s face would be a rare procedure. And it should not involve craniotomy, a hole in the skull.

Craniotomy is always a serious procedure, so “minimimally invasive” could sound like downplaying, but it’s a common phrase among neurosurgeons, drawing contrast to an “open” craniotomy, in which a section of skull is removed. The minimally invasive, or “keyhole,” craniotomy involves a small burr hole and faster recovery. In this case, above McCain’s left eye.

So all of this is what’s known based on the brief report from McCain’s office, which managed to spark a wave of armchair-theorizing from doctors. For example, in the Donald Trump subreddit, one user wrote in a popular post: “Fake news has EVERYTHING wrong. First off, I’m a physician. There are reports of John McCain having a ‘clot above his eye removed.’ I was curious. This is a very odd thing to say, as it doesn’t really happen … FACTS: They said it was a five centimeter clot. There isn’t enough room in the orbit (around the eyeball) for a five cm clot. They referred to it as a craniotomy, i.e., they went into his cranium. This has nothing to do with the neighboring orbit. Fake news is so garbage at medical reporting.”

Another doctor named Milton Wolf told his 19,500 twitter followers: “REALITY: Senator John McCain’s office successfully misled MSM [mainstream media] to report his brain surgery was ‘eye surgery.’ Clintonesque. Lost credibility … I think this demonstrates just how easily misled the press is—and then the public—by willfully granting blind trust to some sources.”

So, a note on intracranial bleeds and also on garbage medical reporting.

Within hours of McCain’s statement, The New York Times ran a detailed story with the headline, “McCain’s Surgery May Be More Serious Than Thought, Experts Say.” It remains unclear to whom “thought” refers, since the initial statement from McCain made clear that the senator had a new hole in his skull. Some headlines used the term “eye surgery,” but did imply that it was at least serious enough to derail the cornerstone of the Republican legislative agenda.

The Times went on to quote multiple neurosurgeons who contextualized and interpreted the meaning of the prior evening’s statement. Based on the information released by McCain and his caretakers at the Mayo Clinic in Arizona, the clot was most likely in the subdural space between his brain and the dural tissue that separates the cortex from the cranium.

Subdural hematomas are a fascinating and ever-more-common problem, given that they occur commonly in old age. Our brains shrink over time, and our skulls do not. This means that time creates space between brain and bone. The veins that drain the brain run along the bone and so must traverse the distance between the two. As that distance grows, those veins come under pressure. At the same time, the aging veins become more tenuous, and it’s not uncommon for them to tear and bleed slowly.

(U.S. National Library of Medicine / Argentina-Fernandez / Reuters)

Sometimes the accumulating blood presses on the brain causing vague and wide-ranging symptoms that can come on over long periods. Depending on how much pressure is exerted, and where, the symptoms can vary dramatically from one case to the next, so much so that neurologists refer to subdural hematomas as “the great imitator,” manifesting variously as headaches, transient weakness or paralysis, altered mental state, and dementia, among other symptoms.

The Times and the Trump-advocate doctor on Reddit both implied that such a hematoma could explain McCain’s uncharacteristically disjointed comments during the James Comey testimony in June. This is retroactive speculation on a cause that can’t be known. Confusion is among the many possible symptoms of the great imitator, and five centimeters is large enough to cause impairment, but the clinical effect of a five-centimeter hematoma is only meaningful in the context of how much negative space was there to fill in the first place. An 80-year-old person might have a large hematoma that barely compresses the brain, while the exact same hematoma may have debilitated that same person at age 20.

The fact that a clot was discovered in McCain’s head means that he had a CT scan at some point, which is not part of a “routine annual physical,” as his statement says. Though this is also not necessarily inaccurate. The scan could have been done for numerous reasons, including concern about bouts of confusion, if they were indeed noted during the course of an annual physical.

Given the vast distrust in American journalism—distrust being actively fueled by the president and playing out even in cases like the story of a hospitalized senator—it’s important to emphasize that despite all this discussion, it remains unknown if McCain’s reported clot is a subdural hematoma. This is simply the most likely diagnosis based on expert analyses of what has been disclosed. The senator’s statement emphasized that pathology reports were pending, indicating at least some uncertainty as to the bigger clinical picture. For example, McCain also has a history of melanoma, which commonly metastasizes to the brain. If it turns out that the hematoma was the result of a tumor, the fact of it not being reported here will not make this article fake.

When a public figure is hospitalized, journalists report what has been said in statements with a level of scrutiny that reflects more good faith than might typically be given to a politician’s press team. Ethics of medicine and journalism preclude investigative work in many cases. No reporter will attempt to break into the Mayo Clinic’s medical-record system. And waiting outside the hospital to pry medical information out of caregivers is to demand something that is unethical for them to disclose.

So what can be said at this point is that according to the senator’s statement, this is his medical condition, and it appears to be neither trivial nor career-ending. The certainty is that this story will unfold in ways expected and otherwise. In medical science as in the journalism surrounding it, this is a feature, not a bug.