Neurological Conditions Guidance Material

Implementing Rules (IRs), Acceptable Means of Compliance (AMCs) and Guidance Material (GM) on neurological conditions

The following are the requirements for the medical certification of aircrew, including guidance material issued by the UK CAA Medical Department in relation to the neurological system.

Implementing Rules

Acceptable Means of Compliance

Guidance Material

MED.B.065 Neurology
(a) Applicants shall have no established medical history or clinical diagnosis of any neurological condition which is likely to interfere with the safe exercise of the privileges of the applicable licence(s).

Cerebral aneurysm, Sub-Arachnoid haemorrhage including coiling

Three factors influence aeromedical safety:

  1. Any neurological damage from the bleed or subsequent surgery
  2. The risk of epilepsy (which may be modified by surgery) and;
  3. The risk of future bleeding. 

A full neurological report must be obtained which gives information about these factors, the presentation, exact diagnosis, surgical treatment and post-operative course.  Information on post-operative medication, if any, must be obtained.

The site of the aneurysm and nature of the surgical treatment will determine the overall risk of epilepsy in the future and this will determine the certification decision that can be taken.

Once neurology reports and investigation results are available Class 1 cases should be referred to the AMS and Class 2 cases managed by AMEs in consultation with the AMS.

 
UK CAA Centrally Acting Medication  guidance.

(b) Applicants with an established history or clinical diagnosis of:
   (1) epilepsy;
   (2) recurring episodes of disturbance of consciousness of uncertain cause;
shall be assessed as unfit.

(c) Applicants with an established history or clinical diagnosis of:
   (1) epilepsy without recurrence after age 5;
   (2) epilepsy without recurrence and off all treatment for more than 10 years;
Class 1
(a) Epilepsy
   (1) A diagnosis of epilepsy is disqualifying, unless there is unequivocal evidence of a syndrome of benign childhood epilepsy associated with a very low risk of recurrence, and unless the applicant has been free of recurrence and off treatment for more than 10 years.  One or more convulsive episodes after the age of 5 are disqualifying.  In the case of an acute symptomatic seizure, which is considered to have a very low risk of recurrence, a fit assessment may be considered after neurological review.

   (2) An applicant may be assessed as fit with a multi-pilot limitation if:
      2.1 there is a history of a single afebrile epileptiform seizure;
      2.2 there has been no recurrence after at least 10 years off treatment;
      2.3 there is no evidence of continuing predisposition to epilepsy.


Epilepsy
Epileptiform seizures immediately occurring within 24 hours of a head injury may be acceptable, as may drug related or alcohol withdrawal seizures provided that the causation is certain and the predisposing causes have been acceptably managed.  Refer to the Alcohol and Substance Misuse guidance or the Head Injury guidance as appropriate.
 
Neonatal and febrile convulsions occurring under five years of age are not disqualifying.

A single unprovoked seizure does not constitute epilepsy.  About a third of single seizures in adult life recur. Recurrence is more common in the first three months after the first seizure than subsequently – so a significant seizure-free interval reduces the risk.

Two or more unprovoked seizures more than 24 hours apart fulfil the criteria for epilepsy.

 

Class 2
Epilepsy
An applicant may be assessed as fit if:
   (1) there is a history of a single afebrile epileptiform seizure, considered to have a very low risk of recurrence;
   (2) there has been no recurrence after at least 10 years off treatment;
   (3) there is no evidence of continuing predisposition to epilepsy.



Implementing Rules

Acceptable Means of Compliance

Guidance Material


   (3) epileptiform EEG abnormalities and focal slow waves;   
Class 1
(c) Clinical EEG abnormalities
   (1) Electroencephalography is required when indicated by the applicant’s history or on clinical grounds.
   (2) Epileptiform paroxysmal EEG abnormalities and focal slow waves normally are disqualifying.

Clinical EEG abnormalities
If an EEG has been undertaken for clinical reasons e.g. a single afebrile seizure, a “provoked” seizure, head injury, post neurosurgery or infection the report should be available for the AME to review.

Rarely, a first degree family history of epilepsy, especially if the mother is affected and if her epilepsy presented in childhood, and the applicant is young, an EEG may be warranted.  AMS advice should be sought.  


   (4) progressive or non-progressive disease of the nervous system;
Class 1
(d) Neurological disease
Any stationary or progressive disease of the nervous system which has caused or is likely to cause a significant disability is disqualifying.  However, in case of minor functional losses associated with stationary disease, a fit assessment may be considered after full evaluation.

Multiple Sclerosis
UK CAA Multiple Sclerosis flow chart.

Migraine
UK CAA Migraine flow chart

5HT1 agonists, ergot alkaloids and antidepressants are in general not permitted because of their side effect profiles.    
 

Class 2
(c) Neurological disease
Any stationary or progressive disease of the nervous system which has caused or is likely to cause a significant disability is disqualifying.  In case of minor functional loss associated with stationary disease, a fit assessment may be considered after full evaluation.


In exceptional circumstances low dose propranolol (10mg 3 times daily or slow release equivalent) may be considered for Class 1, on referral to the AMS, or for Class 2 in consultation with the AMS.  Simple analgesics or non-steroidal anti-inflammatory agents are permitted provided that they adequately control symptoms.  As with all medications, an adequate period of grounding must take place so that the effectiveness can be assessed and any side effects will become apparent.




Implementing Rules

Acceptable Means of Compliance

Guidance Material

Parkinson’s disease
A definitive diagnosis of Parkinson’s disease will not permit initial Class 1 or 2 certification.  Once the disease becomes clinically evident there is a high incidence of cognitive dysfunction which may progress to dementia.  There is also a high incidence of depression.  Bradykinesia and tremor may present a flight safety hazard.  Additionally the disease process is generally progressive which makes it difficult to predict the cognitive and physical function a few months ahead. 

Pilots with a diagnosis of Parkinson’s disease will be made unfit pending neurology review.  For commercial pilots this must be with a neurologist with a specialist interest in aviation.  Most medications used to treat Parkinson’s disease are unacceptable for certification due to their side-effects but amantadine and selegiline are acceptable.  Return to flying will be with an OML limitation and subject to a satisfactory simulator check.  Due to the progressive nature of the disease there must be an adequate process in place for regular clinical and functional review. 

Class 2 applicants may regain certification, which may be subject to an OSL, once a satisfactory report is obtained from a consultant neurologist, in consultation with the Authority Medical Section.  




Implementing Rules

Acceptable Means of Compliance

Guidance Material


   (5) a single episode of disturbance of consciousness of uncertain cause;
Class 1
(e) Episode of disturbance of consciousness
In the case of a single episode of disturbance of consciousness, which can be satisfactorily explained, a fit assessment may be considered, but a recurrence is normally disqualifying.

Episode of disturbance of consciousness

Stroke including TIA
UK CAA Stroke, including TIA guidance

Transient Global Amnesia (TGA)
A diagnosis of TGA should be confirmed by a neurologist.
Initial certification (Class 1 or 2) is not possible.
If investigations (EEG and appropriate scanning) are normal and if there has been no recurrence for 12 months then, for Class 1, a review should be undertaken by a CAA Consultant Advisor in Neurology.  If satisfactory Class 1/OML may be issued.
For Class 2 revalidation or renewal, recertification with an OSL may be considered. 

UK CAA Neuro-cardiogenic Syncope flow chart





   (6) loss of consciousness after head injury;

 

   (7) penetrating brain injury;

 

Class 1
(f) Head injury
An applicant with a head injury which was severe enough to cause loss of consciousness or is associated with penetrating brain injury should be reviewed by a consultant neurologist.  A fit assessment may be considered if there has been a full recovery and the risk of epilepsy is sufficiently low.

Class 2
(d) Head injury
An applicant with a head injury which was severe enough to cause loss of consciousness or is associated with penetrating brain injury may be assessed as fit if there has been a full recovery and the risk of epilepsy is sufficiently low.


Head Injury
History should include the date of the event, post-traumatic amnesia, duration of unconsciousness, any seizure, the presence or absence of skull fracture, and whether any scan or surgical procedure was performed, for example elevating a depressed fracture or removing a blood clot.

There may be associated facial or orbital trauma which may need additional assessment, for example formal visual field testing following orbital injury.

AMEs should consider Eustachian or sinus dysfunction following trauma.

Refer to Head Injury guidance. 

Medical reports - Head Injury




Implementing Rules

Acceptable Means of Compliance

Guidance Material


   (8) spinal or peripheral nerve injury;
shall undergo further evaluation before a fit assessment can be considered.  Applicants for a class 1 medical certificate shall be referred to the licensing authority.  Fitness of class 2 applicants shall be assessed in consultation with the licensing authority.

Class 1
(g) Spinal or peripheral nerve injury, myopathies
An applicant with a history or diagnosis of spinal or peripheral nerve injury or myopathy should be assessed as unfit.  A fit assessment may be considered if neurological review and musculoskeletal assessments are satisfactory.


Spinal or peripheral nerve injury
A pilot who suffers a peripheral nerve injury should be made unfit.  Once sufficient time for recovery has passed an assessment of function can be made.  Reports on the injury, its treatment and the recovery should be available.  For Class 1 applicants a Medical Flight Test should be performed in a relevant simulator or aircraft type with a Type Rated Examiner, to assess the ability of the applicant to perform all the checks, fly the aircraft and perform the emergency drills and evacuation procedures should be obtained.  This practical assessment will need to be repeated if there is a change in aircraft type.  For Class 2 applicants the AME should assess if recovery is complete.  If not, a Medical Flight Test report from a flying instructor should be obtained.

For certification following a permanent spinal injury refer to Guidance on the Certification of Pilots with a Disability.

Additional guidance is available in the Musculoskeletal section.




Class 1&2
(b) Conditions with a high propensity for cerebral dysfunction
An applicant with a condition with a high propensity for cerebral dysfunction should be assessed as unfit.  A fit assessment may be considered after full evaluation.


Dementia/Cognitive Impairment
Dementia (cognitive and behavioural problems severe enough to impair normal function) is incompatible with any form of certification.  Mild cognitive impairment does not interfere with normal daily activities but may represent a significant flight safety risk.  It is increasingly common with advancing age and may not be recognised by the pilot.  Although there are a number of simple tests of cognition that can be used by the AME these are unlikely to pick up mild cognitive impairment.  It is important to have an index of suspicion in elderly pilots and ask about their flying and how well they manage different situations, in particular read-back of information and the acquisition of new skills, for example a different communication layout on a different aircraft.  Presentation of a 4-digit number at the start of the medical for recall some time later may be useful.   A Medical Flight Test (for Class 2) or referral to the AMS for a simulator assessment with a Type Rated Examiner (for Class 1) may be required, specifically to test decision-making skills and conditional tasks.