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Cerebrovascular Accident

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Aeromedical Implications

Effect of aviation on condition

• Lowering of seizure threshold by relative hypoxia

Effect of condition on aviation

• Neuropsychological impairment e.g. impaired attention, concentration, memory
• Functional impairment due to permanent neurological injury
• Co-morbidities e.g. CVD, diabetes, AF etc.
• Overt incapacitation from event
  • Neurological incapacitation
  • Sudden death

Effect of treatment on aviation

• Impaired 'g' tolerance secondary to drug therapy
• Antiplatelet agents - haemorrhagic risk

Approach to medical certification

Based on the condition

• Confirmed diagnosis of cerebrovascular accident
• Exclusion of significant vascular pathology in other organs eg heart
• Estimate of seizure risk
• Estimate of CVA recurrence risk
• Estimate of cardiac event risk
• Satisfactory neuropsychological profile
• Adequate functional capacity

Based on treatment

• Acceptable, stable treatment without significant side effects
• Management of co-morbidities e.g. cardiovascular disease, diabetes, hypertension etc.

Demonstrated stability

• Nil recurrence of neurological episode(s) during 12 month period of surveillance from time of diagnosis

Risk assessment protocol - Information required

New cases

On being diagnosed with a CVA please provide the following reports to CASA as a bundle as soon as they become available

• Hospital admission notes
• Results of Brain imaging
• Results of blood tests
• Hospital discharge letter
• Initial Neurologist assessment

In many cases CASA will be able to make a preliminary assessment of the prospects for future certification on the basis of these reports and before the mandatory 12 month grounding period is complete.

In cases where the prognosis is less certain a follow up Neurologist report after the completion of the 12 month grounding period may be required.

A Cardiologist report may also be required after the completion of the mandatory 12 month grounding period.

Renewal (if applicable)

Where CASA is able to issue a medical certificate, at renewal, it requires a report from the Neurologist / Physician monitoring the applicant’s CVA. The specialists report should detail:

• Clinical status
  • Progress
  • any neurological episodes in the preceding 12 months
  • any cardiac episodes in the preceding 12 months

• Investigations conducted o results of a recent (within the last 3 months) stress test

• ANY relevant investigations undertaken in the interim

• Management

• control of cardiovascular risk factors
• side-effects

• Proposed monitoring and follow-up plan
• CHA₂DS₂VASC score (if relevant)
• Prognosis including annualised percentage risk of:

• recurrence of CVA
• myocardial Infarction
• references for opinion

Indicative outcomes

• Grounding required immediately and notification to CASA
• Because of risk of seizure and recurrence of TIA or CVA, a minimum period of 12 months grounding after CVA will be required before risk assessment by CASA
• Functional assessment may be required depending on nature and extent of neurological injury
• Applicants with residual impairment, unacceptable recurrence risk and/or risk of myocardial infarction may not meet the required standard for medical certification
• If a certificate can be issued, permanent annual requirement for cerebrovascular and cardiovascular risk assessment may be required
• If a certificate can be issued, permanent Multi-crew (Class 1) or Safety Pilot (Class 2) restriction may be required

Favourable:

• Successful treatment of reversible cause of CVA in the absence of other significant risk factors and co-morbidities
• Artery dissection CVA
• Relative young age (18 to 50 years of age)

Unfavourable:

• Unacceptable risk of future vascular events associated with combined history of CVA and co-morbidities
• Permanent and significant functional impairment due to neurological injury
• Significant coronary artery disease - see coronary artery disease advice
• Co-morbid conditions:
  • Diabetes
  • Uncontrolled hypertension
  • Coronary artery disease
  • Atrial fibrillation
  • Anticoagulation o Heart failure
  • Previous TIA
  • Underlying coagulation defects if associated with an increased risk of spontaneous bleeding or thrombosis.

Pilot and Controller Information

• CVA (Stroke) is an aero-medically significant medical condition.
• It is a significant risk factor for further strokes and heart attacks.
• Pilots and controllers who have had a CVA are required to ground themselves and notify this condition to their DAME or CASA.

Disclaimer

The Clinical Practice Guideline is provided by way of guidance only and subject to the Clinical practice guidelines disclaimer