Neurology guidance material GM

1. Applicants with clinical diagnosis or a documented medical history of any of the following medical conditions shall be assessed as unfit:
   1. Epilepsy, except in the cases referred to in points (1) and (2) of point (b);
   2. Recurring episodes of disturbance of consciousness of uncertain cause.
2. Applicants with clinical diagnosis or a documented medical history of any of the following medical conditions shall undergo further evaluation before they may be assessed as fit:
   1. Epilepsy without recurrence after age 5.
   2. Epilepsy without recurrence and off all treatment for more than 10 years.
   3. Epileptiform EEG abnormalities and focal slow waves.
   4. Progressive or non-progressive disease of the nervous system.
   5. Inflammatory disease of the central or peripheral nervous system.
   6. Migraine.
   7. A single episode of disturbance of consciousness of uncertain cause.
   8. Loss of consciousness after head injury.
   9. Penetrating brain injury;.
   10.   Spinal or peripheral nerve injury.
   11.   Disorders of the nervous system due to vascular deficiencies including haemorrhagic and ischaemic events.

Applicants for a class 1 medical certificate shall be referred to the medical assessor of the licensing authority. The fitness of applicants for a class 2 medical certificate shall be assessed in consultation with the medical assessor of the licensing authority.

CLASS 1 - AMC1 MED.B.065

(a) Epilepsy

(1) Applicants with a diagnosis of epilepsy should be assessed as unfit 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 should lead to unfitness. 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 evaluation.

(2) Applicants may be assessed as fit with an OML if:

(i) there is a history of a single afebrile epileptiform seizure;

(ii) there has been no recurrence after at least 10 years off treatment;

(iii) there is no evidence of continuing predisposition to epilepsy.

CLASS 2 - AMC2 MED.B.065

(a) Epilepsy

Applicants 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; and

(3) there is no evidence of continuing predisposition to epilepsy.

CLASS 1 - AMC1 MED.B.065

(b) EEG

(1) Electroencephalography is required when indicated by the applicant’s history or on clinical grounds.

(2) Applicants with epileptiform paroxysmal EEG abnormalities and focal slow waves should be assessed as unfit.

CLASS 1 - AMC1 MED.B.065

(c) Neurological disease

Applicants with any disease of the nervous system which is likely to cause a hazard to flight safety should be assessed as unfit. However, in certain cases, including cases of minor functional losses associated with stable disease, a fit assessment may be considered after full evaluation which should include a medical flight test which may be conducted in a flight simulation training device.

CLASS 2 - AMC2 MED.B.065

(b) Neurological disease

Applicants with any disease of the nervous system which is likely to cause a hazard to flight safety should be assessed as unfit. However, in certain cases, including cases of functional loss associated with stable disease, a fit assessment may be considered after full evaluation which should include a medical flight test which may be conducted in a flight simulation training device.

CLASS 1 - AMC1 MED.B.065

(d) Migraine

Applicants with an established diagnosis of migraine or other severe periodic headaches likely to cause a hazard to flight safety should be assessed as unfit. A fit assessment may be considered after full evaluation. The evaluation should take into account at least the following: auras, visual field loss, frequency, severity, therapy. Appropriate limitation(s) may apply.

CLASS 2 - AMC2 MED.B.065

(c) Migraine

Applicants with an established diagnosis of migraine or other severe periodic headaches likely to cause a hazard to flight safety should be assessed as unfit. A fit assessment may be considered after full evaluation. The evaluation should take into account at least the following: auras, visual field loss, frequency, severity, therapy. Appropriate limitation(s) may apply.

CLASS 1 - AMC1 MED.B.065

(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 applicants experiencing a recurrence should be assessed as unfit.

CLASS 1 - AMC1 MED.B.065

(f) Head injury

Applicants with a head injury which was severe enough to cause loss of consciousness or is associated with penetrating brain injury should be evaluated by a neurologist. A fit assessment may be considered if there has been a full recovery and the risk of epilepsy is sufficiently low.

CLASS 2 - AMC2 MED.B.065

(d) Head injury

Applicants 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. An evaluation by a neurologist may be required depending on the staging of the original injury.

CLASS 1 - AMC1 MED.B.065

(g) Spinal or peripheral nerve injury

Applicants with a history or diagnosis of spinal or peripheral nerve injury or a disorder of the nervous system due to a traumatic injury should be assessed as unfit. A fit assessment may be considered if neurological evaluation is satisfactory and the conditions of AMC1 MED.B.050 are satisfied.

CLASS 2 - AMC2 MED.B.065

(e) Spinal or peripheral nerve injury

Applicants with a history or diagnosis of spinal or peripheral nerve injury or a disorder of the nervous system due to a traumatic injury should be assessed as unfit. A fit assessment may be considered if neurological evaluation is satisfactory and the conditions of AMC2 MED.B.050 are satisfied.

CLASS 1 - AMC1 MED.B.065

(h) Vascular deficiencies

Applicants with a disorder of the nervous system due to vascular deficiencies including haemorrhagic and ischaemic events should be assessed as unfit. A fit assessment may be considered if neurological evaluation is satisfactory and the conditions of AMC1 MED.B.050 are satisfied. A cardiological evaluation and medical flight test should be undertaken for applicants with residual deficiencies.

CLASS 2 - AMC2 MED.B.065

(f) Vascular deficiencies

Applicants with a disorder of the nervous system due to vascular deficiencies including haemorrhagic and ischaemic events should be assessed as unfit. A fit assessment may be considered if neurological evaluation is satisfactory and the provisions of AMC2 MED.B.050 are met. A cardiological evaluation and medical flight test should be undertaken for applicants with residual deficiencies.

There is guidance available on Centrally Acting Medication.

Epilepsy

Epileptiform seizures 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. The Alcohol and Substance Misuse guidance and the Head Injury guidance offers further information.

Neonatal and febrile convulsions occurring under five years of age are not disqualifying.

A single unprovoked seizure does not constitute epilepsy. About 50% of single seizures in adult life recur but from an aeromedical perspective the risk remains high for up to 10 years.

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

Please note each of MED.B.065 (c) (1-8) 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.

Clinical electroencephalogram (EEG) abnormalities

If an EEG has been undertaken for clinical reasons, for example, a single afebrile seizure, a “provoked” seizure, head injury, post neurosurgery or infection the report should be available for the Aeromedical Examiner (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. Civil Aviation Authority (CAA) Medical advice should be sought.

Please note each of MED.B.065 (b) (1-11) 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.

There is guidance available on Encephalitis/Meningitis/brain abscess.

Multiple Sclerosis

The Multiple Sclerosis flow chart offers information and guidance.

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 may be mild cognitive dysfunction, even in the early stages, especially in those patients where tremor is not the presenting symptom. There is also a high incidence of anxiety and depression. Bradykinesia and tremor may present a flight safety hazard.

Pilots with a diagnosis of Parkinson’s disease will be made unfit pending a neurology review. For commercial pilots this will include a review with a CAA neurologist. Most medications used to treat Parkinson’s disease are unacceptable for certification due to their side-effects. A low dose of L-DOPA / Sinemet (maximum 25/100 mg three times daily) may be considered on a case-by-case basis.

Class 1 certification with an Operational Multi-pilot Limitation (OML) or Class 3 with standard ATCO Proximity Condition (APC) may be considered in the very early stages, subject to a satisfactory functional assessment / simulator check. The disease process is slowly progressive, which makes it difficult to predict cognitive and physical function with passage of time, and so six-monthly assessments with a CAA neurologist may be necessary.

Class 2 / LAPL applicants may regain certification, which may be subject to an Operational Safety Pilot Limitation (OSL), once a satisfactory report is obtained from a consultant neurologist, in consultation with a CAA medical assessor.

Please note each of MED.B.065 (c) (1-8) 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.

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 several simple tests of cognition that can be used by the AME, these are unlikely to pick up mild cognitive impairment. Asking older pilots about their flying and how well they manage certain situations may expose any risk in particular read-back of information and the acquisition of new skills such as 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 CAA Medical for a simulator assessment with a Type Rated Examiner (for Class 1) may be required, specifically to test decision-making skills and conditional tasks.

Please note each of MED.B.065 (b) (1-11) 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.

Migraine

The Migraine flow chart offers information and guidance. A specification for migraine reports is also available.

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

In exceptional circumstances low dose propranolol (10mg 3 times daily or 80mg sustained release once daily) may be considered for Class 1, on referral to CAA Medical, or for Class 2 in consultation with CAA Medical. 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.

Please note each of MED.B.065 (b) (1-11) 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.

Episode of disturbance of consciousness

There is guidance available on certification following a Stroke, including Transient Ischaemic Attack (TIA).

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.

The Neuro-cardiogenic Syncope flow chart offers guidance on certification following an episode or episodes of syncope.

Please note each of MED.B.065 (b) (1-11) 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.

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.
There is further guidance for Head Injury and Medical reports - Head Injury. 

Please note each of MED.B.065 (b) (1-11) 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.

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. 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.

The Certification of Pilots with a Disability offers further guidance for certification following a permanent spinal injury. 

There is additional information in the Musculoskeletal section, Musculoskeletal - GM MED.B.050 guidance material. 

Please note each of MED.B.065 (b) (1-11) 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.

Cerebral aneurysm, Sub-Arachnoid haemorrhage including coiling

Three factors influence aeromedical safety:

• Any neurological damage from the bleed or subsequent surgery.
• The risk of epilepsy (which may be modified by surgery).
• 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 CAA Medical and Class 2 cases managed by AMEs in consultation with CAA Medical.

Cerebral amyloid angiopathy and transient focal neurological episodes

Applicants with cerebral amyloid angiopathy (CAA), discovered as either as a chance finding or following transient focal neurological episodes (TFNE), should be assessed as unfit.

TFNE manifests as recurrent, brief, and often stereotyped spells of weakness, numbness, paraesthesia, or other cortical symptoms that can spread smoothly over contiguous body parts over several minutes. TFNE needs to be differentiated from other transient neurologic attacks such as transient ischemic attacks (TIAs), seizures, and migraine auras. Brain MRI, vascular imaging and possibly EEG can help with this. There is an increased risk of sudden disablement occurring following such episodes, either because of intra-cerebral haemorrhage or further TFNE episodes.

In general, applicants found to have CAA / TFNE will be assessed as unfit for Class 1, 2 and 3 medical certification. In some circumstances the Authority may consider restricted LAPL certification following a neurological assessment.