Episodic Neurological Conditions

Question 1

define an episodic neurologic condition.

Answer 1

The condition occurs periodically and/or repeatedly, but not continuously.

Question 2

Name examples of episodic neurologic conditions.

Answer 2

-Headaches
-dizziness and vertigo
-epilepsy/seizures

Question 3

Can drivers with chronic headaches be certified?

Answer 3

-Sometimes, but not always
-must thoroughly examine degree, intensity, and duration of the headaches; it may be severe enough to prevent certification
-must also consider side effects of medications used to prevent or control headache pain, and disqualify patient if these medicines interfere with safe driving
-also consider whether the main effects of treatments interfere with safe driving
-disqualify for associated symptoms that may lead to unsafe driving, such as visual disturbances or severe mood swings

Question 4

Name some medicines are commonly used to treat headaches which would disqualify a patient from driving for as long as a using these medications.

Answer 4

Benzodiazepines and other sedatives
Barbiturates (e.g. phenobarbital, Barbital)
Codeine
Propoxyphene
analgesics that combine sedatives antihistamines
narcotics
phenothiazines such as chlorpromazine or promethazine

decongestants are not disqualifying.
Antihistamine usage is evaluated on a case-by-case basis; antihistamine use is not immediately disqualifying.

Question 5

When must you deny certification to a pt with chronic headaches?

Answer 5

Do not certify until and unless the following conditions are met:
-etiology is confirmed
-treatment is shown to be safe and effective
-nature and severity do not interfere with safe driving

Question 6

If a patient has chronic headaches is certified, what is the maximum duration of time for which they can be certified?

Answer 6

-Certification is for maximum of two years
-obtain additional tests when indicated
-must have medical exam at least once every two years

Question 7

Can patients with dizziness and vertigo be certified? What are dizziness and vertigo?

Answer 7

Dizziness = lightheadedness, swaying, floating, spinning
Vertigo = feeling of movement when no actual movement is present

Qualify or disqualify based on:
-meds used for treatment
-severity of individual symptoms; driver might need specialty evaluation

Question 8

Which medications used for treating dizziness and vertigo would disqualify patient from certification?

Answer 8

Benzodiazepines and phenothiazines are disqualifying.

use of antihistamines requires evaluation side effects

Question 9

Suppose a driver is diagnosed with benign positional vertigo or acute or chronic peripheral vestibulopathy. Under what circumstances can you certify this driver?

Answer 9

all the following criteria must be met:
-Patient is asymptomatic two months after diagnosis
-nature and severity don’t interfere with safe driving
-treatment is safe and effective

Remember: benzodiazepines and phenothiazines are disqualifying; antihistamines require evaluation for side effects

Question 10

Suppose a driver suffers from vertigo or dizziness. Under what circumstances are you unable to certify this driver?

Answer 10

-Symptomatic within the previous two months after being diagnosed with benign positional vertigo or acute or chronic peripheral vestibulopathy
-nature and severity of the diagnosis interfere with safe driving
-driver has been diagnosed with Ménière’s disease, labyrinthine fistula, and or nonfunctioning labyrinths
-use of benzodiazepines or phenothiazines

Question 11

If a driver with dizziness or vertigo is certified, was the maximum certification period you can give?

Answer 11

Certify for maximum of two years; if driver requires special evaluation or screening, then only certify for one year

Driver must be examined at least once every two years

Question 12

What factors affect risk for future seizures in a pt who has epilepsy?

Answer 12

-length of time sz free and off anticonvulsants
-underlying cause of szs
-area of brain affected

Question 13

Define the term seizure.

Answer 13

Clinical manifestation of an abnormal electrical discharge involving a set of cortical neurons.

Question 14

Can a person who sustained a single, unprovoked seizure be certified?

Answer 14

Yes
-reqs person to be sz free and off anticonvulsants for five years
-person also needs clearance from a neurologist
-certify for a maximum of one year
-must have a medical exam at least once every two yrs

Question 15

Is a provoked seizure disqualifying?

Answer 15

No.
A provoked seizure results from a specific cause, such as anesthesia induced seizures, febrile seizures, systemic metabolic illness, seizure due to hypoglycemia, medication side effects, etc.

Question 16

Under what circumstances can a driver who has a history of seizures limited to childhood febrile seizures be certified?

Answer 16

These drivers can almost always be certified. The general rule about withholding certification if the nature and severity pose a risk to safety really does apply here, because children don’t drive big trucks.

Question 17

What is the maximum certification period for a driver who reports a history of seizures limited to childhood febrile seizures, or who suffered a provoked seizure due to an identified cause?

Answer 17

Certify for maximum of two years
-additional testing can be done on a case-by-case basis we needed
-driver must have a biennial medical exam

Question 18

Suppose the driver has a seizure due to structural insult to the brain. During what time period is the driver at highest risk for having another seizure?

Answer 18

Greatest risk of seizure is in the first two years after the insult

Question 19

For a driver who has been accused seizure due to structural insult to the brain, what factors affect likelihood of recurrence of seizure?

Answer 19

-Location and severity of the insult
-timing of first seizure after the insult, except with occlusive vascular insults

Best predictor for seizures is the time driver he seizure free and off anticonvulsants.

Question 20

Embolic and thrombotic cerebral infarctions are the most common forms of cardiovascular disease. Risk for complicating seizures is associated with the ______________________.

Answer 20

location of the lesions

• Cerebellum and brainstem vascular lesions are not associated with an increased risk for seizures.
• Cortical and subcortical deficits are associated with an increased risk for seizures.
• Evaluation by a neurologist is necessary to confirm the area of involvement.

Question 21

Drivers with embolic or thrombotic cerebral infarctions will have residual intellectual or physical impairments. Fatigue, prolonged work, and stress may exaggerate the neurological residuals from a stroke. Most recovery from a stroke will occur within _______ of the event.

Answer 21

1 year

Question 22

If a driver has suffered an embolic or thrombotic stroke, what is the minimum waiting period before they can be considered for certification?

Answer 22

Minimum — 1 year if not at risk for seizures (cerebellum or brainstem vascular lesions)

Minimum — 5 years if at risk for seizures (cortical or subcortical deficits)

Question 23

What is the maximum certification period you can give to a driver who has had an embolic or thrombotic cerebral infarction?

Answer 23

Maximum certification — 1 year

Recommend to certify if: The driver with a history of stroke has:
* Completed the appropriate waiting period.
* Normal physical examination, neurological examination including neuro-ophthalmological evaluation, and neuropsychological testing.
* No neurological residuals or, if present, residuals of a severity that does not interfere with ability to operate a commercial motor vehicle.
* Clearance from a neurologist who understands the functions and demands of commercial driving.

The driver should have an annual medical examination.

Question 24

When is it recommended to not certify the driver who has sustained an embolic or thrombotic stroke?

Answer 24

Recommend not to certify if:
The driver:
* Has not completed the appropriate waiting period.
* Uses oral anticoagulant therapy because of the risks associated with excessive bleeding.
* Uses any other drug or combination of drugs that have potentially high rates of complications (e.g., depressing effects on the nervous system).
* Has residual intellectual or physical impairments that interfere with commercial driving.
* Does not have clearance from a neurologist who understands the functions and demands of commercial driving

Question 25

Intracerebral hemorrhage results from bleeding into the substance of the brain and subarachnoid hemorrhage reflects bleeding primarily into the spaces around the brain. What kind of deficits can result from brain bleeds?

Answer 25

Subarachnoid and intracerebral hemorrhages can cause serious residual neurological deficits in:
* Cognitive abilities.
* Judgment.
* Attention.
* Physical skills

Question 26

The risk for seizures following intracerebral and subarachnoid hemorrhages is associated with the location of the hemorrhage.
-Hemorrhages in what part of the brain are not associated with increased risk for seizures?
-Hemorrhages in what part of the brain are associated with increased risk for seizures?

Answer 26

• Cerebellum and brainstem vascular hemorrhages are not associated with an increased risk for seizures.
• Cortical and subcortical hemorrhages are associated with an increased risk for seizures.
• Appropriate evaluation by a neurologist is required to confirm the area of involvement

Question 27

What’s the waiting period for certification after a driver has sustained either an intracerebral or subarachnoid hemorrhage?

Answer 27

Minimum — 1 year if not at risk for seizures (cerebellum or brainstem vascular lesions) Minimum — 5 years if at risk for seizures (cortical or subcortical deficits)

Question 28

What would lead you to certify a driver who has sustained either an intracerebral or subarachnoid hemorrhage?

Answer 28

Recommend to certify if: The driver with a history of intracranial or subarachnoid hemorrhage has:
* Completed the appropriate waiting period.
* Normal physical examination, neurological examination including neuro-ophthalmological evaluation, and neuropsychological testing.
* No neurological residuals or, if present, residuals of a severity that do not interfere with the ability to operate a commercial motor vehicle.
* Clearance from a neurologist who understands the functions and demands of commercial driving.

Driver must have an annual exam.

Question 29

What would lead you to be unable to certify a driver who has sustained either an intracerebral or subarachnoid hemorrhage?

Answer 29

The driver:
* Has not completed the appropriate waiting period
* Uses any other drug or drug combination with a potentially high rate of complications (e.g., depressing effects on the nervous system).
* Has residual intellectual or physical impairments that interfere with commercial driving.
* Does not have clearance from a neurologist who understands the functions and demands of commercial driving.

Question 30

TBI is classified by depth of dural penetration and duration of loss of consciousness. What are the three classes of traumatic brain injury?

Answer 30

• Severe head injury - penetrates the dura and causes a loss of consciousness lasting longer than 24 hours. There is a high risk for unprovoked seizures, and the risk does not diminish over time.
• Moderate head injury -does not penetrate the dura but causes a loss of consciousness lasting longer than 30 minutes, but less than 24 hours.
• Mild head injury - has no dural penetration or loss of consciousness and lasts for fewer than 30 minutes. Be sure to distinguish between mild TBI with versus without early seizures.

Question 31

What is waiting period for drivers who have sustained any of the following:
*stroke without increased risk for seizures
Note: cerebellum or brainstem vascular lesions do not have increased risk of sz; cortical and subcortical deficits are associated with an increased risk for seizures
*intracerebral or subarachnoid hemorrhage without increased risk for seizure
Note: cerebellum or brainstem vascular lesions are not assoc with incr risk of sz; cortical or subcortical deficits are assoc with incr risk of sz
*mild traumatic brain injury without early seizure

Answer 31

For all these conditions, the minimum waiting period is one year. Patient must been the full year seizure free and off anticoagulants.

Maximum possible certification period for mild TBI without early seizures is TWO years.

Maximum possible certification period for the other situations is one year. They can have the one your certification if they meet the following criteria:
* Completed the appropriate waiting period.
* Normal physical examination, neurological examination including neuro-ophthalmological evaluation, and neuropsychological testing.
* No neurological residuals or, if present, residuals of a severity that do not interfere with the ability to operate a commercial motor vehicle.
* Clearance from a neurologist who understands the functions and demands of commercial driving.

Question 32

What is waiting period for drivers who have sustained any of the following:
*mild traumatic brain injury with early seizures
*moderate traumatic brain injury without early seizures
* surgically removed supratentorial or spinal tumor

Answer 32

Minimum — 2 years seizure free and off anticonvulsant medication

Question 33

What is waiting period for drivers who have sustained moderate traumatic brain injury with early seizures?

Answer 33

Minimum — 5 years seizure free and off anticonvulsant medication

Question 34

What is the waiting period for drivers who have sustained stroke with risk for seizures, or they have sustained intracerebral or subarachnoid hemorrhage with risk for seizures?
(events involving cortical or subcortical deficits/hemorrhages have increased sz risk)

Answer 34

Minimum — 5 years if at risk for seizures

Question 35

For what conditions is there a minimum 10 year waiting period during which the driver must be seizure free and off anticonvulsant medications?

Answer 35

-History of epilepsy
-viral encephalitis with early seizure

Once the driver meets the ten year requirement of being seizure free without taking any anticonvulsants during that 10 years, there is no specific guideline for how long you can certify the driver. Request additional testing on a case-by-case basis.

The driver must have an annual medical exam.

Question 36

For what conditions is there a minimum 5 year waiting period during which the driver must be seizure free and off anticonvulsant medications?

Answer 36

-Single unprovoked seizure, no identified acute change
-bacterial meningitis and early seizures

Question 37

What is the required waiting period for a driver who sustained acute seizure with acute systemic or metabolic illness?

Answer 37

There is not a specific time period; waiting period is based on the risk of recurrence of the primary condition.

Question 38

What is the required waiting period for a driver who sustained TIA, stroke, or intracerebral or subarachnoid hemorrhage with no increased risk for seizure?

Answer 38

One year

Question 39

What is the required waiting period for a driver who sustained a surgically repaired AV malformation or aneurysm with no risk for seizure?

Answer 39

One year

Question 40

What is the required waiting period for a driver who sustained surgically removed infratentorial meningiomas, acoustic neuromas, pituitary adenoma’s, and benign spinal tumors or other benign extra-axial tumors with no risk for seizure?

Answer 40

One year

Question 41

What is the required waiting period for a driver who sustained infections of the central nervous system, such as bacterial meningitis or viral encephalitis, without early seizures?