13 December 2006

Reading the Tea Leaves

The Senate is controlled by a single vote. A democratic senator, Tim Johnson, D-SD, is stricken ill and rushed to the hospital. Reports conflict. He's having a stroke. It's not a stroke. Will he survive? Will he serve out his term? Will a Republican governor appoint a replacement, flipping control of the Senate to the GOP?

This is always a maddening part of being a medical professional. Give me 30 seconds with the chart and I can tell you in exact detail what the situation (or at least the differential diagnosis) is. But the vague and contradictory reports, frequently written by media writers not familiar with medicine can be tough to interpret in the best of cases.

Here's my attempt at reading between the lines:

1. Senator Johnson had an episode of difficulty speaking, evidenced by stuttering and apparent word-finding difficulty. Audible here via CNN. This does clearly point to an acute central nervous system process such as an ischemic stroke causing expressive aphasia.

2. His condition "appeared to recover" to the extent that he was able to ask if there were any additional questions before ending the call. The neurologic deficit was mild and short-lived. This argues against a persistent structural lesion such as hemorrhagic stroke or tumor. The absence of complaint of headache further argues against such diagnoses.

3. However, after initial improvement, another problem developed: "[He] was able to walk back to his office in the Hart Senate Office Building, then began having problems with his right arm. He thought he was all right, she said, and went to his desk, but came out a few minutes later and it was apparent he needed help." The language symptoms having resolved, he developed new symptoms of a motor nature. The language centers (often called "Broca's area") are typically in the left brain, in the same vascular distribution as the left motor cortex, which controls movement of the right arm. Again, this is consistent with cerebral ischemia, though the intermittent nature of the symptoms and variable type of symptomology suggest transient ischemia (often called TIA or mini-stroke) versus true cerebral infarction, aka stroke.

4. His "spokeswoman Julianne Fisher said the senator did not suffer a stroke or heart attack." That helps a bit. Clearly she is repeating what a medical professional told her. "No stroke" implies a more or less clean CT scan -- if there was a hemorrhage, most folks would call it a stroke or aneurysm, and it's an affirmative enough finding that I do not expect that we would be told "no stroke." Also, "no stroke" might imply that his neurologic exam in the ER was not suggestive of a stroke, meaning no persistent neurologic deficit. And based on what I have heard, heart attack would not generally be high in the differential anyway.

5. But he went to surgery. What surgery? Don't know as of this moment. But if he had a TIA, that would generally involve a Carotid Ultrasound as part of the ER work-up. If that revealed a critical stenosis of the carotid artery, it is possible that he would proceed emergently to the operating room to open the offending artery via a procedure called carotid endarterectomy. Less likely, he could undergo some sort of interventional radiology procedure such as intra-vascular thrombolysis, thrombectomy, or angio-embolization of an aneurysm. These procedures, however, are less common and would generally be performed in the context of a true stroke, and given #4 above, would be less likely, in my estimation. Generally, carotid endarterectomies are not performed emergently, but in the case of a senator, VIP medicine might well motivate a vascular surgeon to do so. I would be surprised, but it is possible that carotid angioplasty/stenting might be possibly performed but it would be much less likely.

No further updates are expected tonight. Given the information at hand, I suspect that the Senator had either a TIA or possibly a mild stroke, and underwent carotid endarterectomy. This would imply that his illness might be mild enough to allow him to serve out his term, at the least, and make a full recovery, at the best. It is always possible, and alas, too common, that early media report are inaccurate or incomplete, so I would not hold this estimate out as definitive. Certainly, tomorrow is promised to nobody, and this is a serious condition for the senator, who is, after all, a young man. Regardless of the political implications, our thoughts go out to him and his family, and hopes for a speedy recovery.


Sounds like it was an AVM -- Arterio-venous malformation. AVMs can cause bleeding inside the brain which are essentially indistinguishable from a stroke, though as we are seeing with Senator Johnson, the treatment is quite different. It is interesting that he was never described as having a headache, which is typically the hallmark of a ruptured or bleeding AVM. Oh well, that's the risk one takes trying to read between the lines of the incomplete or inaccurate media reports.

Presuming that the senator underwent craniotomy to repair the damage, it is a big surgery, and a serious condition, but the outlook for survival and a functional recovery are good. The recuperation period, however, can be prolonged.


  1. Thank you for helping us to understand what is going on. I pray for his well-being for a number of reasons.

  2. The media wants to know everything too quickly. I know from my experience as a patient that it just doesn't work that way. Unfortunately, the public can't grasp that tests, analyses, and treatments take time.

    I had a major, but planned surgery, earlier this year. Everything went well, but it was still a good five days before they were sure I would be ok and let me go home. There's a lot of stuff that can pop up.

  3. Thanks for a great analysis.

  4. Prayers for the senator's speedy recovery and his family, of course.

    That said, please allow me to RUB IT IN! I've endured your tainted liberal diatribes for months and months now. By my own choice, of course. Study and understand your adversary, as the saying goes. Ooh how enjoy that it's killing you that the Republican gov. may appoint a REPUBLICAN and restore control back to the REPUBLICAN.

    BTW, I'm neither Republican nor Democrat. I'm a registered independent who votes for the lesser of 2 evil candidate.

  5. thanks, doc. i figured you'd have something to say on this topic - a combination of a medical emergency mixed in with politics? has your name all over it!

    if you're working tonight, may this storm not cause too many horrendous issues.

  6. Dana, thanks. So far the storm (and the football game) have kept most folks out of the ED -- which is why I have time to write this.

    Anon 3:43
    Um, thanks for reading, I guess. I will say that unless Johnson dies, the seat is not vacant and he cannot be replaced. There are ample historical precedents for senators being incapacitated for months and even years, yet continuing to hold their seats. I'm glad to hear that you're not a Republican, though. It would be pretty hard to live with that sort of shame. But it apparently does make it easier to revel in the prospect of a good man's death. Odd people, these conservatives.


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