Section 3: Cerebrovascular Diseases

  1. Post intracranial surgery
  2. Stroke
  3. Subarachnoid hemorrhage
  4. Syncope
  5. Transient ischemic attacks (TIA)
  6. Vascular malformation

Strokes and other insults to the cerebral vascular system may cause a wide variety of symptoms, including sensory deficits, motor deficits, and cognitive impairment. These symptoms range from mild to severe and may resolve almost immediately or persist for years. Because each patient is affected uniquely, the physician must take into account the individual patient’s constellation of symptoms, severity of symptoms, course of recovery, and baseline function when making recommendations concerning driving.

Driving should always be addressed prior to the patient’s discharge from the hospital or rehabilitation center. Patients with residual deficits who wish to resume driving should be referred to a driver rehabilitation specialist (DRS) whenever possible. Upon stabilization of symptoms, the DRS assesses the patient for fitness to drive through clinical and on-road evaluations. After assessment, the DRS may recommend adaptive techniques or adaptive devices (eg, wide-angle rear view mirror, spinner knob for the steering wheel, left foot accelerator) and provide training for their proper use. Even patients with mild deficits should undergo driver evaluation prior to resuming driving, if possible. Research indicates that a post-stroke determination of driving safety made on a medical basis alone may be inadequate.10

For the patient whose symptoms clearly preclude driving, it should not be assumed that the patient is aware that he/she should not drive. In such cases, the physician should counsel the patient on driving cessation.


Section 3: Cerebrovascular Diseases


Post intracranial surgery

The patient should not drive until stabilization or resolution of disease and surgery symptoms. See also stroke recommendations below.

Stroke

Patients with acute motor, sensory, or cognitive deficits should not drive. Depending on the severity of residual symptoms and the degree of recovery, this restriction may be permanent or temporary.

Upon the patient’s discharge from the hospital or rehabilitation center, the physician may recommend temporary driving cessation until further neurological recovery has occurred. Once neurological symptoms have stabilized, physicians should refer patients with residual sensory loss, cognitive impairment, visual field deficits, and/or motor deficits to a driver rehabilitation specialist, if available, for driver assessment and rehabilitation. The specialist may prescribe vehicle adaptive devices and train the patient in their use.

Patients with neglect or inattention should be counseled not to drive until symptoms have resolved and safe driving ability has been demonstrated through assessment by a driver rehabilitation specialist.

All patients with moderate to severe residual hemiparesis should undergo driver assessment before resumption of driving. Even if symptoms improve to the extent that they are mild or completely resolved, patients should still undergo driver assessment, as reaction time may continue to be affected.

Patients with aphasia who demonstrate safe driving ability may fail in their efforts to renew their license due to difficulties with the written exam. In these cases, the physician should urge the licensing authority to make reasonable accommodations for the patient’s language deficit.

Patients with residual cognitive deficits should be assessed and managed as described under the dementia recommendations in Section 4. Periodic reevaluation of these patients is recommended, as some patients may recover sufficiently over time to permit safe driving.

Subarachnoid hemorrhage Patients should not drive until symptoms have stabilized or resolved. Driving may resume following medical assessment and, if deemed necessary by the physician, driver evaluation (including on-road assessment) performed by a driver rehabilitation specialist.

Syncope Syncope may result from various cardiovascular and non-cardiovascular causes, and it is recurrent in up to 1/3 of cases. Cardiac arrhythmias are the most common cause of syncope.11 (See Section 2 for causes of cardiac syncope.)

Driving restrictions for neurally-mediated syncope should be based on the severity of the presenting event. No driving restrictions are necessary for infrequent syncope that occurs with warning and with clear precipitating causes. Patients with severe syncope may resume driving after adequate control of the arrhythmia has been documented and/or pacemaker follow-up criteria have been met (see Section 2).12 For patients who continue to experience unpredictable symptoms after treatment with medications and pacemaker insertion, driving cessation is recommended.

Transient ischemic attacks (TIA) Patients who have experienced a single TIA or recurrent TIAs should refrain from driving until they have undergone medical assessment and appropriate treatment.

Vascular malformation Following the detection of a brain aneurysm or arterio-venous (AV) malformation, the patient should not drive until he/she has been assessed by a neurosurgeon. The patient may resume driving if the risk of a bleed is small, an embolization procedure has been successfully completed, and/or the patient is free of other medical contraindications to driving, such as uncontrolled seizures or significant perceptual or cognitive impairments.

10 Wilson T, Smith T. Driving after stroke. International Rehabilitation Medicine. 1983;5(4):170-177.

11 Syncope. In: Beers MH, Berkow R (eds.). The Merck Manual of Diagnosis and Therapy, 17th ed. Merck and Co., Inc., 1999. Available at: http://www.merck.com/pubs/ mmanual/ section16/chapter200/200b.htm Accessed January 9, 2003.

12 North American Society of Pacing and Electrophysiology/American Heart Association. Personal and public safety issues related to arrhythmias that may affect consciousness: Implications for regulation and physician recommendations (Part 3 of 4). September 1, 1996. Available at: http://naspe.org/naspe_in_ action/position_statements/view/?id=8505. Accessed January 9, 2003.


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