Class 1/2 Certification after Stroke (including TIA)

When there is no doubt about a diagnosis of Transient Ischaemic Attack (TIA) or Stroke and the cause is likely to be of atherosclerotic origin, no form of initial certification is possible and recertification is unlikely.  This is because the epidemiological studies show that the risk of a future atherosclerotic event will always exceed 1% per annum, usually by a considerable margin.  Certification after a stroke due to a spontaneous cerebral haemorrhage will not usually be possible for the same reasons.  In young patients (under 45 years) where no atherosclerotic disease can be shown there may be circumstances in the absence of generalised arterial disease, for example carotid or vertebral arterial dissection where some form of certification may be possible after a period of 6 to 12 months grounding if the risk of recurrence is acceptably low.  

Re-certification following a TIA is subject to the absence of certain underlying abnormalities and disease and demonstrated control of specified risk factors.  An age limit has been set because of the importance of age as a prognostic factor.

Unacceptable co-existing conditions:-

• Diabetes
• Uncontrolled hypertension
• Coronary artery disease
• Atrial fibrillation
• Anticoagulation
• Heart failure
• Previous TIA
• Age >70 
• Underlying coagulation defects if associated with an increased risk of spontaneous bleeding or thrombosis.

Demonstrated Control of the Following Risk Factors:-

• Blood pressure (ideally <140/85; maximum acceptable level is 150/90)
• Cessation of smoking
• Discontinuation of the oral contraceptive pill
• Should be on aspirin or other anti-platelet agent if aspirin intolerant
• Dyslipidaemia and consideration should be given to taking a statin
• Advice should be given to take regular exercise, lose weight if appropriate, minimise salt intake and eat healthily.

Investigations That Shall be Required:-

• Exercise stress test and Myocardial Perfusion Scanning or stress echocardiography (to confirm absence of reversible ischaemia) and/or angiogram to exclude associated coronary artery disease (criteria as per coronary artery disease flow chart) if the cause was likely to have been atheromatous or there are any symptoms suggestive of peripheral vascular disease, carotid or coronary artery disease
• Transoesophageal echocardiogram or a transthoracic echocardiogram with bubble contrast
• 24 hour ECG recording
• Thrombophilia screening if indicated in accordance with British Haematological guidelines

Investigations That May be Required:-

• Carotid artery doppler scan to exclude carotid artery disease
• Selective arterial angiogram to exclude arterial disease in the carotid or posterior cerebral circulations. 

Guidance for Certification

When all reports have been received Class 1 applicants should be referred to the AMS and Class 2 applicants shall be assessed in consultation with the AMS.  The following time periods are given for guidance.

Type of TIA	Class 1 unrestricted	Class 1/OML	Class 2 unrestricted	Class 2/OSL
A Fugax *	N/A	1 year	1 year	6 months
Non-recurrant **	2 years	1 year	1 year	6 months
Other ***	N/A	2 years	2 years	1 year

*      Amaurosis Fugax of Unidentified Cause
**    Other TIA With Identified Non-Recurrent Cause
***  Other TIA With Unidentified Cause or after Carotid Endarterectomy
N/A = Not Applicable

Follow Up

Annual cardiological review with exercise tolerance test.