Doctors following Ariel Sharon's condition from afar say his chances for recovery are probably slim, given his age and the fact that he required two brain operations after suffering a major hemorrhage Wednesday.
Many patients with his risk factors either die or have trouble walking, standing and talking again - let alone summoning the mental and physical faculties needed to run a nation, experts say.
"In general terms, you're so much better off if you have this problem when you're young," said Dr. E. Francois Aldrich, a neurosurgeon at the University of Maryland Medical Center. "With older people, the brain doesn't have the capacity to recover as well."
On Wednesday, the 77-year-old Israeli prime minister suffered a hemorrhagic stroke, a condition that arises when a blood vessel in the brain bursts and leaks into surrounding tissue.
Damage can occur in two ways. Leaking blood can destroy brain cells, and the clot that eventually forms can raise blood pressure and press against fragile brain structures. Either way, the damage can hinder patients' ability to speak or carry out activities of daily living - problems from which they might not recover.
Each year, about 700,000 people in the United States suffer strokes and about 160,000 die of the condition, according to the American Heart Association. Over two-thirds of stroke victims are over age 65, though the problem can also strike people in middle age or younger.
There are two kinds of stroke. Eighty percent are ischemic strokes, which happen when a blockage cuts off blood flow in an artery feeding certain parts of the brain. The rest are hemorrhagic.
Sharon's condition is complicated by the fact that he apparently had both kinds. On Dec. 18, Sharon suffered a mild ischemic stroke that doctors thought might have been caused by a tiny hole in his heart, a common defect that become a trap for blood clots that can then break off and flow to the brain.
His doctors reportedly placed him on a blood thinner to prevent further clots from forming, and they scheduled an operation for yesterday to seal the hole.
But Wednesday evening, the prime minister was placed in an ambulance after he complained of weakness and slight pain in his chest. The hemorrhage reportedly occurred during the hourlong ride from his ranch in the Negev desert to Hadassah-Ein Kerem hospital in Jerusalem.
Surgeons sought to remove the clot and control the bleeding during a seven-hour operation, but a short time later, he was sent back to the operating room when a CT scan revealed further problems, according to the hospital's director.
"They took him into surgery, then took him back again," Aldrich said. "That's not good. It spells danger and problems."
Doctors speculated that the blood thinners caused an artery in his brain to leak.
Dr. Daniel Hanley, a neurologist at the Johns Hopkins School of Medicine, said blood-thinners are commonly given to prevent ischemic strokes from recurring, though doctors face the possibility of setting off a hemorrhagic stroke in the process.
"There are things people are going to second-guess about that," Hanley said.
One is that it might have been safer to treat Sharon with aspirin. Some studies have shown that aspirin may be safer in this regard, though the question is far from settled, he said.
"But there's a long and very good, responsible and very reputable history of giving thinners when there are problems in the heart," Hanley said.
Though it's more a matter of academic interest in Sharon's case, surgery to close a tiny hole in the heart - a condition known as patent foramen ovale - is a subject of some controversy. Though the condition seems to increase a person's risk of a stroke, the patient may carry more serious risk factors that surgery cannot address.
In Sharon's case, these may include his age, obesity and apparent lack of exercise, Hanley said. And given those factors, it's also possible that he suffers from high blood pressure, which itself is a major contributor to strokes.
According to Aldrich, surgeons can prevent further injury but cannot do anything to reverse damage. "It's a case-by-case decision as to who is going to get surgery and who is not," Aldrich said.
To help him recover, doctors have used sedatives to place Sharon in a deep coma.
"It's to control the blood pressure and the intracranial pressure and to allow for a smoother recovery," Hanley said.
Nobody can reliably predict whether Sharon will survive and, if he does, how fully he might recover. But doctors agreed that the prospects are poor for patients like him.
Studies show that a third of patients have good outcomes after surgery for a hemorrhagic stroke, Hanley said. That means that two-thirds die or live with major deficits.
"There's a high likelihood that Mr. Sharon faces death, considering his age and the fact that he's gone into surgery twice already," Hanley said.
