Biden once nearly died of an aneurysm. Risky surgery changed his life.

Instead of heading to an emergency room, Biden flew home with an aide to Wilmington, Del., where he tried to get some sleep. Awakened hours later by even greater pain, he rushed to St. Francis Hospital. It wasn’t a pinched nerve. Doctors found blood in his spinal fluid, and then a dangerous balloon-shaped bulge — an aneurysm — on an artery wall at the base of the brain. Even worse, Biden’s aneurysm had already burst, leaking blood around the base of his brain.

The danger was immense: If the aneurysm burst again and sent blood coursing into his brain, it could mentally and physically disable him — or be fatal.

A priest was called to his bedside to deliver last rites, but Jill Biden, who had been ordered to stay out of the room, burst in, yelling at him to leave. “You’re not giving him the last rites. He’s not going to die,” she said, according to an account by Biden’s sister, Valerie.

Now there was only one hope, the doctors concluded: Biden needed immediate, risky surgery.

The race was on to save Biden’s life.

The story of how Biden survived the aneurysm — as well as a second one and a blood clot — is one of the most revealing if little understood episodes in the life of the 81-year-old president.

A review of the events, as described by the president, his family and his associates, in books and other forums, as well as Washington Post interviews with a surgeon who operated on Biden, provides a nearly moment-by-moment account that reveals new details about how close Biden came to incapacitation or death — and how those events shape him to this day.

The near-fatal experience highlights the depth of Biden’s resilience, which had already guided him to political success even after the deaths of his first wife and young daughter. But it also underscores how he initially played down a serious health issue for fear of the political consequences and, as he later acknowledged, sometimes failed to heed the advice of his doctors.

As Biden now seeks reelection amid voter concerns about his health and age, his opponent — 77-year-old Donald Trump — has alleged without medical evidence that Biden is “cognitively impaired,” an allegation dismissed by the surgeon who operated on Biden. Doctors who treated Biden say he fully recovered and suffered no brain damage. And while some people who have had aneurysm surgery do experience longer-term health repercussions, experts say, there is no evidence that Biden has suffered such consequences — though he has said it significantly changed his outlook on life.

In those early moments in a Wilmington hospital room, though, the idea that Biden would fully recover, much less become president and seek reelection, seemed remote.

‘A fifty-fifty chance’

Sixteen years earlier, Biden had rushed to the same Delaware hospital where he now lay on a table with doctors hovering nearby. On that night, shortly after his 1972 election to the Senate, his first wife, Neilia, and 18-month-old daughter, Naomi, who was known as Amy, had been killed when an 18-wheeler crashed into their car. His sons, Beau and Hunter, had been seriously injured in the accident and Joe had visited them at St. Francis.

In the years since, he had become a leading Democrat in the Senate and had launched a presidential bid in 1987. But that effort had fizzled months earlier amid a plagiarism scandal.

Now it was Biden’s second wife, Jill, who agreed with his political team on a perilous plan. The family believed the Delaware hospital was not equipped to save his life. So Biden would have to be taken to Walter Reed Army Medical Center in Washington. If the aneurysm burst during the trip, Biden wrote in his memoir, “Promises to Keep,” there was nothing those traveling with him could do to save him.

Outside, though, conditions were deteriorating — foggy with wet snow that stung his face as firefighters wheeled him on a gurney to the ambulance. President Ronald Reagan, briefed on the emergency, had offered a helicopter. But the weather was too dire, and doctors worried that the change in air pressure could kill Biden.

So an ambulance team with a police escort began driving Biden more than 100 miles south on Interstate 95 toward Washington; Delaware police stopped at the state line, with Maryland officers taking over, Biden wrote.

At Walter Reed, Biden was given a more thorough test by the institution’s neurosurgeon, Eugene George. He not only confirmed the aneurysm that had bled on the left side of Biden’s brain but also found a smaller one on the right that had not burst.

The left one needed to be operated on immediately, Biden wrote. (George could not be reached for comment.)

The previous misdiagnosis of Biden’s condition had put the family on edge. Biden’s brother James “demanded” a second opinion, according to Biden, and narrowed his search to one surgeon: Neal Kassell, a legendary figure in the world of neurosurgery and particularly in the treatment of aneurysms.

Born with near-blindness in his left eye, Kassell had decided at age 10 that he wanted to be a neurosurgeon. As a high school sophomore in Philadelphia in 1964, he worked as a neurosurgeon’s assistant, during a period when he has said he was so poor he ate the food given to laboratory monkeys.

One day, Kassell observed an operation on a young mother who had an aneurysm bleeding at the base of her brain — similar to what he would encounter with Biden decades later. After what seemed to be a successful treatment, the woman died of a complication called a vasospasm, a persistent narrowing of arteries that restricts blood flow.

That experience would haunt Kassell for much of his career as he became one of the nation’s top neurosurgeons, he later said.

When Biden’s family reached out to the 41-year-old specialist, it wasn’t clear he would be available in time. He practiced at the medical center of the University of Virginia in Charlottesville, nearly a three-hour drive from Washington.

As it happened, though, Kassell was minutes away, attending a conference. George agreed to consult with Kassell, who had written numerous medical articles on cerebral aneurysms, which affect an estimated 6.8 million Americans — many of whom live a normal life if the aneurysm never ruptures. But for the 30,000 people annually who suffer a rupture, it proves fatal about half the time, according to the Brain Aneurysm Foundation. Fifteen percent die before they get to a hospital, it said. And 66 percent of survivors have some permanent neurological damage.

Kassell was initially reluctant to get involved. He had performed almost all such surgeries with his team in Charlottesville.

“The success of aneurysm surgery is not only surgical virtuosity but, more importantly, the ability to orchestrate a whole team,” Kassell said in one of several interviews with The Washington Post conducted mainly in 2020. (Kassell told The Post recently that he stood by his earlier statements and had no further comment.) “Obviously, I didn’t have my team there.”

Nonetheless, Kassell agreed and determined that Biden needed immediate attention on two fronts: to secure the aneurysm from the risk of new bleeding, and then to do everything possible to prevent the potentially deadly complication of the artery-tightening vasospasm.

The standard practice for treating an aneurysm at that time was a brute-force method: drilling a hole in the head and then moving the brain slightly to operate on the aneurysm.

In his memoir, Biden wrote that he discussed the risks with George. “As I heard it, my chances of surviving the surgery were certainly better than fifty-fifty. But the chances of waking up with serious deficits to my mental faculties were more significant.”

Jill Biden wrote in her autobiography that a doctor told her there was “a fifty-fifty chance Joe wouldn’t survive surgery.” She wrote that she was told “it was even more likely Joe would have permanent brain damage if he survived. And if any part of his brain would be adversely affected, it would be the area that governed speech.”

In September 2020, Biden put the risk in even more dire terms, saying a neurosurgeon told him that he had “a relatively small chance of making it after it was all over.”

Biden was told he should prepare to talk with his family, in case he died on the operating table. He wrote that he worried that his sons would lose a parent for the second time, and that his 6-year-old daughter, Ashley, would have to be told he wasn’t returning home, just as he had once told Hunter and Beau that their mother wasn’t coming back.

“I’m so proud of you,” Biden said he told his sons. “So I know you’ll live up to your obligations. I know you’ll take great care of your mother and your sister.”

“Don’t say that, Dad,” responded Beau, who had recently turned 19. “You’re not going anywhere.”

Biden was wheeled into an airy operating room, where doctors and nurses in scrubs were busily lining up equipment. An anesthesiologist put a mask over his face.

Biden wrote that he wasn’t frightened and had “no real fear of dying,” but that, as he lay on the operating table, he felt like he was “floating gently in a wide-open sea,” with his life in the hands of the surgeons.

Biden’s skull was readied to be cut open.

A mass of blood

Kassell had performed this surgery at least 1,500 times. Still, the three-to-five-hour procedure could be fraught, especially if the aneurysm burst, which happened about 10 percent of the time.

Kassell, who stressed in the interviews that George was a crucial partner, said they started by drilling a two-inch hole in Biden’s head, precisely cut so that the “lid” could be removed. “You break off a piece of the skull, like removing the top of a cookie jar,” Kassell said. As delicate as it sounded, Kassell said, that was the easy part, “like carpentry.”

A cantilevered arm holding a microscope was swung over Biden to give Kassell a detailed view as the dura — the outer layer of tissue over the brain — was opened. With his one good eye, Kassell peered through the microscope. He elevated Biden’s brain from the base of the skull and saw the aneurysm on the left side. It was “like a balloon with a neck that came off the wall of the artery. … It was certainly dangerous,” Kassell said.

He prepared to put a tiny metal clip around it, which would deflate the aneurysm and begin healing the artery.

Suddenly, Kassell’s field of vision flooded with a mass of blood that was about the size of a quarter — a large amount in his microscope’s view.

The aneurysm had burst. The risk now was exponentially greater that the blood could leak into the brain, which could be fatal.

Kassell uttered a four-letter expletive.

Yet he also felt a sense of calm, he later said. He had encountered this numerous times and knew precisely what to do. He controlled the bleeding, preventing it from damaging the brain, and sealed the aneurysm with the clip.

The rupture on the operating table was not widely known, apparently not even to Biden at the time or years later. Biden never mentioned it in his autobiography.

Kassell’s account was confirmed by Ted Kaufman, Biden’s Senate chief of staff, who said he remembered Kassell describing the incident at the time.

To Kassell’s relief, Biden did not suffer a vasospasm, the complication that Kassell had seen kill other patients. Kassell said Biden was fortunate that he was in good physical condition before the surgery. “The blood did not bleed into his brain — it bled around his brain,” Kassell said. “So he had no brain damage whatsoever.”

Still, there were more surgeries, and more risks, to come.

Only the beginning

“Am I alive?” Biden recalled asking Jill after the operation.

His shaved skull had been stapled back together, and his head looked like “a misshapen baseball that had just had its cover nearly knocked off,” Biden wrote in his autobiography.

“You’re alive,” Jill responded.

Jill believed that Biden’s withdrawal from the presidential race had saved his life, according to the Bidens’ accounts. It had been humiliating to end his bid, but he might have continued disregarding the pain if he’d stayed on the trail. He also might have refused a trip to the hospital, which could have been politically damaging.

The aneurysm on the left side had been successfully treated, but that was only the beginning. He was hooked up to an array of monitors that measured his vital signs and, he would later write, was having trouble breathing — “I almost quit the fight.” He stayed at the hospital for 10 days, resting in preparation for surgery to treat the aneurysm on the right side, and then was sent home to wait.

The doctors had warned Biden that he would have a long recovery and needed to be extraordinarily careful. He was forbidden to climb stairs, for example. Jill soon caught Biden ignoring that order.

“I was so sure I was making a remarkable recovery, so intent on proving my health, that I took chances,” Biden wrote.

Then, Biden said, he got permission to go to a friend’s condo at Bethany Beach, Del. After arriving, he felt as if something was rattling in his head and the room was spinning, an experience he was told was normal. After returning to Wilmington, he wrote, he was extra careful, but found that he could not get out of bed. He felt a knifelike pain in his chest and abdomen, even worse than his headache months earlier.

Jill called the doctor who had misdiagnosed his aneurysm as a pinched nerve, and this time, the doctor diagnosed his new pain as “a gas bubble.” Biden wrote that “my neighborhood doctor was wrong again.” He did not name the doctor.

Biden agreed to be rushed to the hospital, where he was diagnosed with a blood clot in his lung, which Biden wrote probably came from spending so much time in bed recovering from surgery. His doctors worried that this and possibly other clots would kill or disable him. Once again, Biden went to Walter Reed, where specialists successfully inserted a titanium filter on the sides of an artery to prevent clots from reaching his lungs or heart, he wrote in his memoir. (Such devices are actually implanted in veins, a medical expert told The Post.) He was also given a drug to prevent clots from causing an embolism, or artery blockage, that could kill him. After 10 days of treatment, he returned home.

Three months after the initial aneurysm surgery, it was time to deal with the right side. Twenty percent of people with one aneurysm have a second one, Kassell said. Biden again went to Walter Reed, where Kassell once again was on the surgery team.

As Kassell entered the operating room, Biden said, “Doc, do a good job, because someday I’m going to be president,” according to Kassell.

This time, the aneurysm didn’t rupture. The surgery was successful, but the risks were still so great that Biden was required to stay at the hospital for much of May 1988, he would write. Kaufman said he watched his boss “very carefully” afterward and saw no sign of any change.

In all, Biden was largely absent from public life for six months after the first surgery. Under doctor’s orders, he didn’t go to his office, cast a vote or deliver a speech.

After Biden was released from Walter Reed, reporters found him in the parking garage. No news conference had been arranged, but Biden was ready with a joke: “I’ve asked you all to come today because I’ve decided to announce that I am reentering the race for president.”

Defying the odds

For years, Biden’s triumph over the aneurysms was the subject of bipartisan applause. But during the 2020 campaign, Trump began raising doubts about Biden’s mental acuity. Trump’s son Don Jr. tweeted that it is “strange they never talk about Joe Biden’s TWO brain aneurysms and brain surgeries.” He added mockingly: “That has nothing to do with why he can’t remember where he is most days.”

On Oct. 11, 2020, Fox Business Network host Maria Bartiromo told Trump during an interview that her “medical sources have told me that Joe Biden had two brain aneurysms, not one, but two brain aneurysms. I pray to God it isn’t true, but my medical sources are solid on this. … Do you believe he should be disclosing that?”

Trump responded that “he should certainly come clean, and he should — he should say something about that. Absolutely. If that’s the case.”

In fact, Biden had disclosed both of his aneurysms when they were discovered in 1988.

During the current campaign, Trump has alleged that his Democratic opponent is “cognitively impaired.” Biden’s doctors have said there is no evidence that he has any such issues, and Biden’s supporters note that Trump has made a series of confused statements, such as when he mixed up former speaker of the House Nancy Pelosi with former South Carolina governor Nikki Haley.

Voters have said in polls that the physical and mental state of the candidates is one of their greatest concerns. Biden has released a six-page letter with specific details about his blood tests, conditions and medication, while Trump, whose father died of conditions related to Alzheimer’s disease, has issued a vague three-paragraph letter from his doctor that says he is in excellent health and has “exceptional” cognitive ability.

Biden has long said surviving the aneurysms affected him in personal ways, citing how close he came to death as a reckoning. While the episode was a humbling one of frailty, he has said the recovery was a lesson in resilience.

Biden said that dropping out of the 1988 presidential campaign “saved my life. My doctors told me point-blank that I would not be alive today had I stayed in the race.” He said his medical emergency had made him “a little wiser … and more serene.” Had he done what doctors told him, he wrote, he might have avoided the blood clot in his lung. The lesson, he wrote, was that seeking the presidency “could wait. There would be another time if I really wanted it.” Surviving the aneurysms, he wrote, was “my second chance in life.”

In the years after the surgery, Biden called Kassell on the anniversary to thank him. As Kassell got to know Biden in a setting other than the operating room, he concluded that the experience had forever changed the future president.

“For a lot of people, it changes their perspective about what’s really important and how they use their time,” said Kassell, who now runs the Focused Ultrasound Foundation, a Charlottesville-based group that aims to use beams of sound waves to treat medical conditions including Parkinson’s disease and some cancers. “Biden’s the type of person that this did have an impact on him, how precious life is.”

The treatment of brain aneurysms, meanwhile, has changed dramatically since Biden’s operations, often making the recovery much quicker and easier. While many patients are still best served by removing part of their skull for surgery, the majority today are treated by inserting a tube through the wrist or groin, with a coil instead of a clip used on a burst aneurysm, specialists said.

In Biden’s case, the clips remain and are expected to last the rest of his life. (Biden took medication aimed at preventing further blood clots for a few months; today, he takes the anticoagulant Eliquis to mitigate stroke risk from atrial fibrillation, which in Biden’s case is stable, according to his medical reports.) Christine Buckley, executive director of the Brain Aneurysm Foundation, said she knows of no concerns that such clips could fail. Biden released a medical report in 2014 saying that a scan showed there had been no recurrence of aneurysms.

As for the long-term impact of such surgery, Biden and Kassell have both said Biden completely recovered with no ill effects.

Biden, Jill, and his siblings Valerie and James all declined to comment for this story. White House spokesman Andrew Bates said in an emailed statement that “President Biden is grateful that he received high quality care and support from his family that enabled a full recovery. The experience is one of many reasons that he’s fighting for every American to have access to affordable health care.”

For some patients, the aftereffects of such surgery can be long-lasting. A 2016 study published in the Journal of NeuroInterventional Surgery concluded that “many patients with ruptured cerebral aneurysms … struggle with a poor quality of life,” including issues with memory loss and depression.

Erwin Mangubat, a co-author of the study and chief of neurosurgery at Prisma Health in South Carolina, said in an interview that having a ruptured aneurysm “can be very life-changing” but that many patients “continue to live pretty normal, active and functional lives despite a very scary event.”

Biden’s outcome — defying the odds of death or disability despite an initial misdiagnosis — makes him an extraordinary success story, according to Tom Tinlin, who also survived two aneurysm surgeries and is now chairman of the Brain Aneurysm Foundation. The former Massachusetts highway administrator said such stories are all too rare, with far too few aneurysms being diagnosed. He said a bill in Congress to increase funding for aneurysm research by $10 million annually for five years has long been stalled.

He said there is no reason to think the aneurysm surgeries have had any mental or physical impact on Biden. The president is particularly fortunate, Tinlin said, because blood did not leak into the brain.

“I look at Joe Biden as the person — to those of us in the brain aneurysm community — that we all strive to be: very high-functioning and productive,” Tinlin said.

Alice Crites contributed to this report