This is medical, actually

This may be overly provocative, but it is a legitimate question: Has John McCain had a recent stroke?

This question has been danced around at lot recently -- McCain's age and physical health. He has been quite sparing with his medical records, but other than the melanoma (other than that!) he is reportedly reasonably healthy for a man of his age. He is, however, at risk for a stroke, based on his age and history of high cholesterol and long-term tobacco abuse.

Watch this video, and in particular watch the movements of McCain's left eyelid, brow and forehead muscles.


There is, to my eye, a clear and discernible droop of the left eyebrow and eyelid. There is a small lag when he blinks, there is smoothing of the forehead wrinkles on the left, and the eyebrow does not elevate symmetrically.

Are these clearly visible neurologic deficits consistent with a stroke? Well, sort of but not exactly. There does not appear to be any motor abnormality of the lower part of the face, and his speech is quite clear. Updated: On closer viewing, I think there is some asymmetry of the lower face, with slight smoothing of the nasolabial fold, and reduced excursion of the mouth. It is subtle, and McCain's face is asymmetric at baseline, so it's hard to say whether it is significant. If the impairment were caused by a central lesion (i.e. in the brain), I would generally expect those areas to be affected also, since the motor cortex that controls that area is not usually broken down quite so discretely. But weird stuff can happen in neurology, so it's certainly not conclusive, and a cerebrovascular accident is by no means excluded as a possible cause.

The alternative is that this is a peripheral lesion. The facial muscles are innervated by the Seventh Cranial Nerve, the facial nerve (yellow in this diagram):
The most common cause of facial nerve paralysis is Bell's Palsy, in which the nerve is compressed as it exits the bony skull. Bell's palsy, however, usually affects the entire face, and as I mentioned, there is no evident impairment of the midface and mouth. I might guess that the lesion is confined to the temporal branch of the facial nerve: I believe that McCain had a melanoma lesion removed some years ago from his left temple. Is this deficit related to that surgery? Has it always been present? If so, why are we just noticing it now? It does not seem evident in his convention acceptance speech, only three weeks ago.

What other things can cause this deficit? Ptosis, drooping of the eyelid, can be caused by a lesion of the third cranial nerve, but that should not affect the forehead muscles. There are a large number of things that can cause acquired ptosis, but many are bilateral, which McCain does not have, and I would argue that these are all quite unlikely due to the involvement of the forehead musculature. Ptosis is generally a phenomenon of the eyelid alone.

Bottom line: This looks to my eye like a peripheral injury to the facial nerve, but a stroke cannot be excluded based on what I have seen. Given John McCain's age and the office he seeks, and the patent incompetence of his running mate, he owes the American voters answers to these questions:

• Has he sought medical treatment for this condition?
• If not, why not?
• If so, what evaluation was performed, and what diagnosis was rendered?
• Has he had screening studies for cerebrovascular disease, and what were the results?

General social politeness requires that when you interact with someone with an obvious abnormality like this, you discreetly pretend not to notice. When you are running for the office of the most powerful man in the world, the voters must have all information available to make the best choice for the country. Someone needs to ask John McCain these questions.

[Update: More relevant information posted here.]