Patient: The President

To physicians talking among themselves, anything that suddenly goes wrong with the blood vessels in the brain is a "C.V.A."--cerebral vascular accident. To physicians talking with patients or other laymen, any C.V.A. is a stroke. President Eisenhower had an accident in one of the blood vessels of his brain; therefore he had a stroke. The White House tried to sidestep the word stroke in Ike's case, on the ground that it suggests paralysis or brain hemorrhage to the layman, but the word actually covers all kinds of C.V.A.s and all degrees of severity, with or without paralysis.

Strokes can have at least three causes, possibly four. The confirmed causes:

1) HEMORRHAGE in the brain caused by the bursting of a blood vessel (this type is usually severe, with paralysis).

2) THROMBOSIS (clotting), when an occlusion (shutdown) is caused by a blood clot forming in the artery affected.

3) EMBOLISM, when the shutdown is caused by a clot which has formed elsewhere in the body and traveled through the arteries to the brain.

Neurologists who examined the President are satisfied that he had no hemorrhage, probably no embolism.

Specialists are divided about fifty-fifty as to whether a fourth type of stroke exists, caused by SPASM of an artery (involving contraction, and therefore closing). Among the authorities who argue for its reality are those at the National Heart Institute, who include spasm in their official list of causes of strokes. Equally eminent experts point out that patients whose strokes were originally attributed to spasm have shown marked freedom from recurrences when maintained on anti-clotting drugs. These drugs, they argue, could have no effect on spasm, would be useful only in cases where there is a tendency to thrombosis; therefore these patients must really have had a thrombosis.

The Trigger. Whatever the cause of a stroke, the immediate effect is always to cut down drastically or to shut off completely the flow of blood to the part of the brain served by the artery affected. If it is a major artery branch, the effects will be more extensive; the longer the shutdown lasts, the greater the danger that the damage to the brain will be permanent. Although the idea of a stroke (associated with a picture of severe paralysis, usually on one side of the body) fills the layman with dread, physicians have long been convinced that many, if not most, aging individuals suffer a succession of "little strokes," so slight that the victims are unaware of them; such strokes can be detected only at post-mortem examination of the brain.

The trigger mechanisms that set off strokes are unknown in the vast majority of cases. As in the case of a heart attack (coronary occlusion), a clot (thrombus) can form at any time, often when the victim is at rest, though some medical men think that severe physical or mental stress may precipitate either type of occlusion. If arterial spasm is accepted as a cause of stroke, severe chilling such as President Eisenhower underwent at Washington's National Airport might bring it on.

Arteriosclerosis. Far more likely than the problematical spasm as the cause of Eisenhower's stroke is a thrombus. The President has been taking anti-clotting drugs of the coumarin family six days a week ever since his 1955 heart attack. They have been shown to be highly effective in cutting down recurrence of clots caused by embolism (TIME, Feb. 4), but it is not yet certain that they prevent thrombosis.

One medical opinion (as relayed by Press Secretary James Hagerty) to the contrary, many physicians hold that it is 95% certain that the President has arteriosclerosis; otherwise it is most improbable that he would have had a heart attack in the first place. And in elderly patients who have heart attacks, there is usually simultaneous involvement of the brain's arteries, so that parts of them are inelastic and narrowed, offering points of resistance that invite clot formation.

Strokes, no matter how caused, have varying effects, depending on how large an area of the brain is affected; they range from instant death through complete or partial paralysis to temporary impairments of speech or other functions. In the President's case, doctors first noticed a slurring of his speech and some difficulty forming words. They made the diagnosis almost instantly: there had evidently been an interruption of the blood supply to the brain's speech center, which is on the left in a righthanded man like Ike (it would be on the right side in a lefthanded individual, since the two hemispheres of the brain control opposite sides of the body). What other consequences had resulted from the stroke? None, apparently, because, beyond this "mild aphasia" (literally, lack of utterance), Eisenhower's doctors could find no other symptoms. The President's blood pressure was good (130/80), his pulse 64 and regular; he "had no headache, nausea, vomiting, impairment of consciousness or breathing, convulsions, stiffness of the neck, paralysis or abnormal reflexes."

The Site. These negative findings pinpointed the site of the damage: "the area of Broca"* (see diagram), which controls many components of the complex processes that result in speech. Like most of the brain lying near the surface, Broca's area gets its blood supply from one of the countless branches of the middle cerebral artery. The particular branch supplying Broca's area is not much thicker than the lead in a pencil, and if in Ike's case this was already narrowed by arteriosclerosis, a tiny clot would be enough to shut down the flow. That a bigger artery branch was not involved was shown by Ike's keeping full command of functions controlled by adjacent brain areas.

If a total shutdown to Broca's area had lasted six minutes or more, Eisenhower would have lost the power of coherent speech; at normal blood heat, brain cells cannot survive longer than that without oxygen-bearing blood. Evidently the shutdown was incomplete or for a shorter period because, although the cells in Broca's area had been damaged, the damage was not severe: overnight the doctors observed improvement in the President's speech. Adequate blood flow to the oxygen-starved cells had been restored.

Treatment and Recurrence. There was never any dramatic sign that this C.V.A. was taking place. The President could not tell just when he had his stroke. Neither could the four neurologists who examined him next day--Georgetown University's Francis M. Forster, the Army's Lieut. Colonel Roy E. Clausen, Columbia University's Houston H. Merritt and James F. Hammill--though they confirmed the findings of Ike's regular doctors. As for treatment, all they could advise was wait and see, combined with a stress-free routine. They prescribed plenty of rest for Ike, but not the total inertia that was, until recently, standard for victims of strokes, however mild. The only medication that the President got, even in the first stages of his illness, was a mild sedative. Beyond that, he is expected to stay on anticoagulants. In the case of a mild stroke such as Ike's, recovery is apt to take place--barring a new stroke--simply because the clot has dissolved. Even in more serious cases, when brain cells are damaged or destroyed, partial recovery is possible, as neighboring brain cells take over the function of damaged cells and other blood vessels take over to supply the damaged area with blood.

The near completeness of Ike's immediate recovery was evident in his activities, including his trip to church and his motor journey to Gettysburg. The long-term outlook is less clear. After one stroke there is always danger of recurrences. That danger is greatest in the first year. If Ike can go twelve months without a second stroke, it will give added reason for hope that he can serve out his term with faculties unimpaired.

* So named for Pierre Paul Broca, who described it in 1861.

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