Migraine History and Outcomes in Military Pilots and Flight Surgeons.

BACKGROUND: Migraine is a common disorder with significant aeromedical implications. The variability and unpredictable nature of occurrences hampers accurate assessment of future risk. This uncertainty results in a necessarily conservative approach to aeromedical recommendations, which unfortunately may lead to over-restrictive dispositions. Limited long-term follow up information is available on migraine outcomes in pilots, particularly assessing for impact of potential modifiable aggravating factors.Methods: This retrospective study reviewed 159 U.S. Air Force pilots with migraine who had been granted aeromedical waivers. As a comparison group, 44 U.S. Air Force flight surgeons with migraine who had been granted aeromedical waivers were reviewed.Results: Migraine with aura and isolated migraine aura without headache accounted for the majority of migraine subtypes in both male and female subjects. Self-identified triggering factors were identified by 62% of subjects. The most commonly reported triggers were dietary factors, sleep disturbances, stress, caffeine intake, and hormonal factors. Sleep disturbances, stress, hormonal factors, and ethanol triggers were more frequently noted in female subjects. Self-reported positive response to trigger factor modification was noted in 54% of subjects. Subjects reported an average of only 3 migraine attacks in the previous year. Long-term follow up indicated continued aeromedical waiver in 91% of subjects.Discussion: The majority of subjects had migraine with aura or isolated migraine aura. Significant salutary response to modification of commonly-reported triggering factors was noted. These findings can be incorporated into individualized aeromedically-compatible management strategies to clarify symptom impact on aviation safety, improve symptom control, and increase the possibility of safe return to fly recommendations.Hesselbrock RR, Haynes JT. Migraine history and outcomes in military pilots and flight surgeons. Aerosp Med Hum Perform. 2022; 93(1):26-31.

Vitamin B12 Deficiency Related Syncope in a Young Military Pilot.

BACKGROUND: Syncope and near-syncope are commonly encountered symptoms. Many cases are situationally specific or otherwise benign, with no adverse aeromedical implications. Autonomic dysfunction can produce orthostatic intolerance with resultant symptoms and is aeromedically concerning for potential occurrence in flight. Vitamin B12 deficiency is an insidious condition with protean manifestations, which can present with autonomic dysfunction. Neurological abnormalities are often reversible following adequate replacement.CASE REPORT: We describe a case of vitamin B12 deficiency in a pilot with atypical syncope and abnormal tilt-table testing who had progressively abnormal hematologic findings on review. He was also discovered to have intrinsic factor antibodies. After B12 replacement, he had normal cardiovascular response to exercise stress testing and an unremarkable centrifuge assessment.DISCUSSION: This case highlights the importance of recognizing subtle laboratory findings and serial laboratory data review in cases of atypical syncope to identify potential reversible etiologies.Hesselbrock RR, Palileo EV, Davenport ED. Vitamin B12 deficiency related syncope in a young military pilot. Aerosp Med Hum Perform. 2020; 91(9):746748.

Migraine History and Recurrence in Military Pilot Applicants.

BACKGROUND: Migraine is a common condition with features that can adversely impact aviation activities. The diagnosis of migraine is often compatible with civil aviation training, but is much more concerning for military pilot applicants. A history of migraine headache traditionally medically excluded potential military pilot applicants due to unpredictability of occurrence and potential for operational distraction or incapacitation. Medical standards and policy applications have been quite variable, ranging from total exclusion for even one headache occurrence to as low as a 1-yr migraine-free period before consideration. In many instances, policy application has been subjective and not based on objective evidence. This presents a challenge to waiver authorities and also potentially sends a mixed message to command authorities. There is essentially no current literature evidence applicable to the aviation population on migraine occurrence risk.METHODS: This study reviewed 71 U.S. Air Force pilot applicants who were diagnosed with migraine and had been granted waivers to assess any predictive factors for migraine recurrence and its aeromedical impact.RESULTS: Only three applicants had recurrence after waiver was granted, with two of these occurring within 2 yr of their last reported migraine event, and all recurrences noted within 3 yr.DISCUSSION: Data indicated favorable risk with suitable migraine-free observation before military pilot training, which could be incorporated into aeromedical standards and policies.Hesselbrock RR, Haynes JT. Migraine history and recurrence in military pilot applicants. Aerosp Med Hum Perform. 2020; 91(1):37-40.

Cerebellar Infarction Presenting with Acute Vestibular Syndrome in Two U.S. Air Force Pilots.

BACKGROUND: Cerebellar infarction is an uncommon but serious cause of isolated acute vestibular symptoms, particularly in young, healthy individuals, and can easily be overlooked. We present two cases of cerebellar infarction in U.S. Air Force pilots, one of which occurred during flight. CASE REPORTS: A 41-yr-old man developed acute vertigo, disequilibrium, nausea, and headache, with progressive slow symptomatic improvement, and presented to medical attention 4 d after symptom onset. Brain magnetic resonance imaging showed right inferomedial cerebellar infarction. Echocardiography discovered patent foramen ovale and atrial septal aneurysm. A 40-yr-old man developed severe vertigo, nausea, and vomiting during initial aircraft descent. Head computed tomography scan was performed acutely and was normal. Initial assessment was benign paroxysmal positional vertigo. Brain magnetic resonance imaging 1 mo after symptom onset showed a small right inferior cerebellar infarction. Patent foramen ovale and bilateral atrial enlargement were seen on echocardiography. Both pilots made full neurological recoveries and were eventually returned to flight status. DISCUSSION: Central causes of isolated acute vestibular symptoms are uncommon and are often not considered in otherwise healthy individuals. Cerebellar infarction is one of these uncommon but increasingly recognized causes of acute vestibular symptoms. As evaluation and management of central causes are much different from peripheral conditions, prompt localization confirmation is paramount. Accurate evidence-based bedside screening methods are available for rapid localization. Awareness of the possibility of central etiologies and careful clinical evaluation with application of bedside screening methods in patients with acute vestibular symptoms will reduce the number of inaccurate diagnoses.Hesselbrock RR. Cerebellar infarction presenting with acute vestibular syndrome in two U.S. Air Force pilots. Aerosp Med Hum Perform. 2017; 88(9):880-883.

Developing an outline for teleneurology curriculum: AAN Telemedicine Work Group recommendations.

The emerging field of teleneurology is delivering quality care to neurologic patients in increasingly numerous technologies and configurations. Teleneurology is well-positioned to address many of the logistical issues neurologists and their patients encounter today. However, formalized medical training has not caught up with this developing field, and there is a lack of formal education concentrating on the specific opportunities and challenges of teleneurology. Considering this, the American Academy of Neurology Telemedicine Work Group identified equivalencies with which any practitioner of teleneurology should be familiar. The purpose of this curriculum is not to define teleneurology or mandate where its use is appropriate, but rather to provide guidance on basic equivalencies that students, residents, and practitioners should know while practicing teleneurology. Comprehensive training in clinical bedside neurology is necessary to safely practice teleneurology and the components of this curriculum are an extension of that training. In this article, we offer a detailed discussion on the rationale for the contents of this curriculum and conclude by providing a model curriculum and an outline for evaluating residents in teleneurology.

Outcomes from a US military neurology and traumatic brain injury telemedicine program.

OBJECTIVE: This study evaluated usage of the Army Knowledge Online (AKO) Telemedicine Consultation Program for neurology and traumatic brain injury (TBI) cases in remote overseas areas with limited access to subspecialists. We performed a descriptive analysis of quantity of consults, response times, sites where consults originated, military branches that benefitted, anatomic locations of problems, and diagnoses. METHODS: This was a retrospective analysis that searched electronic databases for neurology consults from October 2006 to December 2010 and TBI consults from March 2008 to December 2010. RESULTS: A total of 508 consults were received for neurology, and 131 consults involved TBI. For the most part, quantity of consults increased over the years. Meanwhile, response times decreased, with a mean response time of 8 hours, 14 minutes for neurology consults and 2 hours, 44 minutes for TBI consults. Most neurology consults originated in Iraq (67.59%) followed by Afghanistan (16.84%), whereas TBI consults mainly originated from Afghanistan (40.87%) followed by Iraq (33.91%). The most common consultant diagnoses were headaches, including migraines (52.1%), for neurology cases and mild TBI/concussion (52.3%) for TBI cases. In the majority of cases, consultants recommended in-theater management. After receipt of consultant's recommendation, 84 known neurology evacuations were facilitated, and 3 known neurology evacuations were prevented. CONCLUSIONS: E-mail-based neurology and TBI subspecialty teleconsultation is a viable method for overseas providers in remote locations to receive expert recommendations for a range of neurologic conditions. These recommendations can facilitate medically necessary patient evacuations or prevent evacuations for which on-site care is preferable.