An airman was not practicing good preventive health measures. He smoked a bit, had a nightcap most nights, and loved to eat junk food while watching TV. One night he awoke to get rid of the beer he drank earlier and fell smack on the floor! His wife heard the loud bang and got up, and noticed that he could not move his entire left side. When she asked him how he was doing, he mumbled some unintelligible gibberish. She called emergency services, and they took him to the hospital.
The paramedics notified the emergency room about their incoming patient so that a neurologist and an interventional radiologist would be present when he arrived. After they examined the fellow, obtained some lab results, and ran an electrocardiogram, they took him to their catheterization laboratory. There, the radiologist performed a cerebral arteriogram, injecting a substance known as tissue plasminogen activator (TPA), commonly referred to as a “clot buster,” a drug that can dissolve clots. Shortly after this was done, the airman's symptoms began to subside. They sent him to the intensive care unit for monitoring. By the next day, he was up, walking, and completely lucid.
This fellow suffered what we physicians call a “cerebrovascular accident” or “stroke.” The airman spent the next several days undergoing tests to determine the cause of this event. In the end, it was felt that it was caused by his poor “risk factor management” and inadequately controlled high blood pressure.
So, how does the FAA's medical certification folks look at airmen who have had a stroke? The current FAA policy denies medical certification for two-years after such an event. You have probably heard me speak and write about the 15 specifically disqualifying medical conditions. One of these conditions is a transient loss of nervous system function without adequate explanation. This is the terminology that the FAA uses to describe a stroke or transient ischemic attack (TIA).
A stroke or TIA is a vascular type of condition. In medicine, we observe a rule of thumb when evaluating a patient with stroke-like symptoms: When a person has a condition involving one blood vessel system, one should look at the other vascular systems to make sure they too are not affected. The other system we consider that could result in sudden incapacitation is the heart. For these reasons, the FAA will want to see the following tests:
1. MRI of the brain: This is done to show the area of the stroke and perhaps see if there is evidence of prior strokes.
2. Carotid ultrasound: This is a sonar test on the main blood vessels that supply the brain. These arteries can become obstructed with cholesterol plaques just like the heart arteries.
3. Echocardiogram: This test “bounces” sound waves off the heart and shows the cardiologist what the heart valve structures look like as well as the size and function of the heart.
4. A maximum stress test: This test is best performed with a radioactive substance that is injected into a vein in the arm. The data obtained from this study indicates to the cardiologist if there might be disease of the coronary arteries or even a previous heart attack.
5. Lipid panel and fasting blood sugar: This is done to identify risk factors for high cholesterol, triglycerides, and diabetes.
6. Neuropsychological testing: These days, aerospace specialists also require neuropsychological testing. This is a series of objective tests performed by a clinical psychologist to determine whether the stroke involved your memory and executive functioning, among other things. Many times these higher brain functions could have been affected and the person may not realize it, and it may not be picked up by the basic tests the neurologist performs in the office.
The airman can reapply for medical certification after two years and at that time must provide an evaluation by the treating neurologist attesting to no further events.