Post-Stroke Targeted Evaluation. Jon Van Doren, Ph.D. Arizona Neuropsychology, PC Scottsdale, AZ

Transcription

1 Post-Stroke Targeted Evaluation Jon Van Doren, Ph.D. Arizona Neuropsychology, PC Scottsdale, AZ

2 Proximal Medical Issue 60-year-old Caucasian man. Sudden onset of right hemiparesis, diaphoresis, generalized weakness. Symptoms resolved in minutes. Arrived at ER about 2 hours after onset. MRI showed multiple tiny infarcts in left MCA territory.

3 Proximal Medical Issue CTA of head/neck showed 90% occlusion of left ICA, with complex ulcerated plaque. Uncomplicated left carotid endarterectomy. He has had no further symptoms. Annual carotid ultrasounds have been stable. He believes he is back to pre-stroke baseline.

4 He allowed his 3 rd class pilot license to lapse the year after his stroke. Now that he has been stable for several years, he is re-applying for medical certification.

5 Code of Federal Regulations Title 14: Aeronautics and Space Chapter 1: Federal Aviation Administration Subchapter D: Airmen Part 67: Medical Standards and Certification Subpart D: Third-Class Airman Medical Certificate» Section 309: Neurologic ios or Android apps are available, < $10/year Search for Pilot FAR

6 FAR Part 67, section 309 a) No established medical history or clinical diagnosis of any of the following: 1) Epilepsy; 2) A disturbance of consciousness without satisfactory medical explanation of the cause; or 3) A transient loss of control of nervous system function(s) without satisfactory medical explanation of the cause.

7 FAR Part 67, section 309 b) No other seizure disorder, disturbance of consciousness, or neurologic condition that the Federal Air Surgeon, based on the case history and appropriate, qualified medical judgment relating to the condition involved, finds

8 FAR Part 67, section 309 1) Makes the person unable to safely perform the duties or exercise the privileges of the airman certificate applied for or held; or 2) May reasonably be expected, for the maximum duration of the airman medical certificate applied for or held, to make the person unable to perform those duties or exercise those privileges.

9 Medical Certification not denied He was never denied medical certification, so was not seeking Special Issuance. But FAA wanted clarification of his status. A letter was sent to the Airman, outlining the required information

10 FAA Letter #1 Due to your history of a stroke, you must provide the following information for the Aerospace Medical Certification Division s review: 1.A current history and clinical examination from your treating neurologist regarding your history of stroke and carotid disease. This report should include a complete history and symptoms, neurologic examination, neurocognitive testing using a mini-mental status exam such as the MoCA test (Montreal Cognitive Assessment), specific comments on results of your most recent imaging of the brain and carotid arteries, diagnosis, treatment plan, prognosis, and plans for follow-up. Include copies of any pertinent medical/treatment records and the results of any current studies deemed clinically appropriate by your physician to document stability. 2.The results of a current CogScreen- Aeromedical Edition (AE). Following review of the above, additional information may be required by the FAA.

11 Standard Protocol: Report Standard protocol for neuropsychological evaluation for potential neurocognitive impairment can be found at: /avs/offices/aam/ame/guide/media/npevalspecs.pdf

12 Standard Protocol: Report Must include: 1)Review of all available records 2)Thorough clinical interview 3)Mental status exam 4)Interpretation of testing including but not limited to the core battery, and 5)An integrated summary of findings.

13 Standard Protocol: Core Battery CogScreen-AE WAIS-IV Trail Making Test Executive function tests (Category Test or WCST, and Stroop Test) PASAT Continuous performance test Test of verbal memory (WMS-IV subtests, Rey AVLT, or CVLT-II) Test of visual memory (WMS-IV subtests, BVMT-R, or Rey-O Language measures (Boston Naming, fluency to letter and category) Psychomotor measures including (Finger Tapping and Grooved or Purdue Pegboard Personality testing to include MMPI-2 (not MMPI-2-RF).

14 Background Male Age 64 years Born/raised in Portales, NM Lived/worked on family cattle ranch Normal social/developmental history

15 Background Repeated 1 st grade ( played all the time ). B student in mainstream classes. No further educational issues or delays. Enlisted in Navy out of high school (age 19). Assigned to flight deck of helicopter carrier during Vietnam conflict. After 4 years of service, honorable discharge as petty officer 3 rd class.

16 Background Worked in oil fields Supervised oil-fracking crew for last 3 years. Laid off due to downturn in industry, so enrolled in college to collect on GI Bill. Did not expect to graduate- just needed $. Earned BA in Accounting from Eastern NM University in 1987, at age 34.

17 Background Worked as IRS Revenue Agent for 2 years- hated it. Described that as his only white collar job. Quit IRS job, moved to a rural residential airpark. Worked at Bureau of Reclamation as heavy equipment operator until retiring in 2014 at age 60.

18 Background He and his wife now provide landscape maintenance to their HOA, hours per month, even in triple-digit temperatures. No change in ADLs since stroke. Presentation at the time of initial evaluation appeared highly nervous.

19 Initial Test Results MoCA = 27/30 (-1 for incorrect cube orientations, -2 for sentence repetition) CogScreen LRPV = (elevated by standard criteria, but at the 25 th percentile for GA norms) The Attribute Identification Taylor Factor score was deficient, at the 3 rd percentile. 3 of the 4 scores contributing to this factor were WNL for same-age major carrier pilots. All were WNL for GA pilots. Base rate analysis for scores 5 th percentile: Major Carrier General Aviation Speed 3/19 (10 th %ile) 1/19 Accuracy 3/19 (7.5 th %ile) 3/19 Thruput 4/16 (5 th %ile) 0/16 Process 2/10 (10 th %ile) 1/10

20 CogScreen Results: The Weeds MC T GA T SATDIACC Shifting Attention Discovery, accuracy SATDIFAI Shifting Attention Discovery, set loss SATDIPER Shifting Attention Discovery, persev error SATDIRUL Shifting Attention Discovery, rule shifts 42 45

21 FAA Letter #2 Due to your history of stroke, you must provide the following information for the Aerospace Medical Certification Division s review: 1.In-flight instructor pilot evaluation of operational flight experience (emergency procedures, communication with air traffic control, safely manipulate aircraft controls). Please provide a copy of your in-flight instructor pilot evaluation to your neuropsychologist. 2.The results of additional neuropsychological testing to include a Wisconsin Card Sorting Test, Iowa Gambling Test, Trails A and B Tests. Following review of the above, additional information may be required by the FAA.

22 Follow-up Test Results Hopkins Adult Reading Test, form B: 13/35 words pronounced correctly. Estimated premorbid IQ = 95. Adding demographics, estimated IQ = 104. Trail Making Test percentiles employing 3 normative databases: Heaton CNNS Kay (2002) Trails A Trails B Wisconsin Card Sorting Test: 6 categories in 74 trials, 8 errors (81 st %ile for age/education), 1 loss of set, 6 perseverative errors (68 th %ile). Iowa Gambling: Total Net Score = 52 (88 th %ile), raw net scores produced a (+) slope (6, 2, 14, 14, 16). FAS: 16 th %ile, Animals: 42 nd %ile.

23 In Conclusion Be prepared for atypical requests/situations. If uncomfortable with a request for specific testing, call the referring party. The top priority is maintaining aviation safety. Be aware of the potential influence of confounding factors (e.g., fatigue, anxiety).