Aeromedical Implications of Cerebral Cavernomas.

BACKGROUND: Cavernomas, cavernous angiomas, or cerebral cavernous malformations are clusters of endothelium-lined blood vessels usually found in the brain. With the increasing use of radiological imaging, these are being detected incidentally in asymptomatic aircrew. The UK Civil Aviation Authority (CAA) experience of cavernomas is described and the aeromedical concerns, that is, the risk of epilepsy, hemorrhage, and the development of a neurological deficit, are considered.METHODS: A search of the CAA database between 1990 and 2020 was performed for the term cavernoma. The gender, age at diagnosis, class of certification held, clinical presentation, location, and size of the lesion were noted. A PubMed literature review for papers with complications of cavernoma was performed.RESULTS: Six cases of cavernoma have been declared to the CAA: five professional pilots and one private pilot. Five were men and one was a woman. The age range was between 38 and 60 yr, with a mean of 48 yr. Two cases presented with clinical symptoms and four were asymptomatic. Complication rates for seizure and hemorrhage were extracted from the published literature together with the significance of other factors such as cavernoma size, family history, multiplicity, and the development of new lesions.DISCUSSION: A policy for the medical certification of aircrew with cavernomas that have presented with clinical symptoms and those that are detected incidentally is proposed.Jagathesan T, OBrien M. Aeromedical implications of cerebral cavernomas. Aerosp Med Hum Perform. 2021; 92(2):120123.

Certification of a Pilot with Charcot-Marie-Tooth Disease.

BACKGROUND: Charcot-Marie-Tooth disease (CMT) is a rare hereditary motor and sensory neuropathy. This is a report of a pilot with this condition with a discussion of the challenges for the regulator in the assessment for medical certification of pilots with a neurological disability.CASE REPORT: A pilot with CMTX1 declared his condition to the United Kingdom Civil Aviation Authority when his brother was diagnosed with the same condition. Apart from high arched feet and some difficulty playing sports, he had no problems until his mid-forties, when he very slowly developed increasing weakness with foot dorsiflexion and later wasting and weakness of the small hand muscles. He reported no problems with any flying activity. On clinical examination, it seemed likely that the disability would have an impact on his ability to undertake all the flying tasks of a commercial pilot, including those required in emergencies.DISCUSSION: A modified Medical Flight Test (MFT) specifically tailored by the regulator to test areas of functional impairment allowed the successful certificatory assessment of a pilot with this condition; an approach which could apply to any pilot with a rare neurological disability.Jagathesan T, OBrien M, Rattray A. Certification of a pilot with Charcot-Marie-Tooth disease. Aerosp Med Hum Perform. 2021; 92(2):124126.

Aeromedical Certification Following Mechanical Aortic and Mitral Valve Implants in the United Kingdom.

BACKGROUND: For many years, anticoagulant therapy had been deemed unacceptable for civilian pilot medical certification in the United Kingdom under the Joint Aviation Authorities Requirements and, therefore, mechanical valve implants were disqualifying. In 2012, this restriction was removed by implementation of the European Union requirements. This study was undertaken to assess the medical evidence available to develop a certificatory policy following mechanical valve implants in the United Kingdom. METHODS: A literature review was performed for complication rates following the implantation of mechanical aortic and mitral valves. This study was confined to the three major types of valve commonly used in current clinical practice: the ATS, the Carbomedics, and the St. Jude Medical valves. RESULTS: We identified 28 papers on aortic valve replacements and 22 papers on mitral valve replacements. Data were extracted for the late complication rates for endocarditis, paravalvular leak, thromboembolism, hemorrhage, and structural valve dysfunction. The total calculated incidence of a late complication was 3.8% per annum for aortic valves over a mean follow-up period of 57 mo and 5.2% per annum for mitral valves over a mean follow-up period of 61 mo. Both of these exceed the maximum 1% per annum medical incapacitation risk considered acceptable for professional multicrew pilot operations. CONCLUSION: Confounders and sources of error in estimating the risks and methods to mitigate these are considered. A certificatory policy is proposed and the UK experience of mechanical valve replacements is described.Jagathesan T, O'Nunain S, O'Brien M. Aeromedical certification following mechanical aortic and mitral valve implants in the United Kingdom. Aerosp Med Hum Perform. 2018; 89(10):912-917.

Myasthenia Gravis and Its Aeromedical Implications.

BACKGROUND: Myasthenia gravis is an autoimmune condition where antibodies form against the acetylcholine receptors at the neuromuscular junction, eventually causing damage to the motor end plate. The clinical features include muscle fatigability as well as ocular, bulbar, and limb weakness, which can have implications on the role of a pilot or air traffic controller. This retrospective study reviewed the United Kingdom Civil Aviation Authority (UK CAA) experience of myasthenia gravis. METHODS: A search of the United Kingdom Civil Aviation Authority medical records database from 1990 to 2016 identified 11 individuals with a diagnosis of myasthenia gravis. Data were extracted for the class of medical certificate, age at diagnosis, symptoms, acetylcholine receptor antibody status, treatment, the time from diagnosis to loss of medical certification, and the reasons for loss of certification. RESULTS: There were two Class 1 certificate holders (for professional flying) and six Class 2 certificate holders (for private pilot flying) and three air traffic controllers. The mean and median ages at diagnosis were 53 and 57 yr, respectively, with a range of 28-67 yr. The mean and median intervals from diagnosis to loss of certification were 22 and 11 mo, respectively, with a range of 0 to 108 mo. CONCLUSION: The aeromedical implications of myasthenia gravis, including complications, types of treatment, and functional impact, are considered. A policy for medical certification following a diagnosis of myasthenia gravis is proposed.Jagathesan T, O'Brien MD. Myasthenia gravis and its aeromedical implications. Aerosp Med Hum Perform. 2017; 88(1):30-33.

Lesson of the month 1: Post-malaria neurological syndromes.

There are three neurological syndromes that may follow -malarial infection after recovery and at a time when the patient is aparasitaemic. An acute disseminated encephalopathy; a cerebellar syndrome; and an acute demyelinating polyneuropathy. This paper reports a 42-year-old male patient who developed encephalopathy.

The Aeromedical Implications of Parkinson's Disease.

BACKGROUND: Parkinson's disease is a progressive neurodegenerative disorder which is encountered in the pilot population and has clinical features that can impact on the flying role. This retrospective study reviewed the United Kingdom Civil Aviation Authority (UK CAA) experience of Parkinson's disease. The aeromedical implications of the condition are discussed and the UK CAA policy for the certificatory assessment of pilots with Parkinson's disease is described. METHODS: A search of the UK CAA medical records database from 1990 to 2015 identified 34 pilots with a diagnosis of Parkinson's disease. Data was extracted for the class of medical certificate, time from first symptoms to diagnosis, age at diagnosis, the time from diagnosis to loss of certification and the reasons for loss of certification. RESULTS: Of 15 professional (Class 1) and 19 private (Class 2) pilots, the mean time from onset of symptoms to diagnosis was 36 and 19 mo, respectively. The mean ages at diagnosis were 55 and 59 yr, respectively. The mean interval from diagnosis to loss of certification was 21 (0-93) and 37 (0-84) mo, respectively. The reasons for loss of certification are considered. CONCLUSION: In the UK, pilots diagnosed with Parkinson's disease may be granted medical certification depending on their functional ability and the side effect profile of medication. The aeromedical implications of Parkinson's disease and the UK CAA policy for the certification of pilots with Parkinson's disease are discussed.

Transient global amnesia and its aeromedical implications.

INTRODUCTION: Transient global amnesia (TGA) is an episode of severe anterograde amnesia of sudden onset, characteristically lasting 4 to 6 h. Patients become disorientated in time and place, but not in person. Automated motor tasks are preserved; however, the retention of new information is impaired, with clear implications to a pilot's fitness to fly. This study examines the United Kingdom Civil Aviation Authority (UK CAA) experience of pilots with TGA and compares it to the medical literature. METHODS: The UK CAA medical records database was searched for subjects who had reported a history of TGA between the years 1990 and 2010. Subject age and gender, the frequency and duration of episodes, the follow-up period, precipitants, and associated features were recorded. A literature search for papers with similar information was undertaken. RESULTS: The UK CAA database showed 29 subjects who had held a UK CAA medical certificate with a history of TGA. There were 28 male individuals and 1 female. The mean age was 59 yr. The mean follow-up period was 3.4 yr. The average duration of an episode was 2.8 h. Activity, stress, or exposure to cold water were reported as possible precipitants by 16 subjects (55%). There were 6 subjects (21%) who had a history of migraine and 10 (34%) who had a history of hypertension. From the literature, 10 papers were reviewed and compared to our study group. DISCUSSION: The aeromedical implications of TGA, including its etiology, associations, misdiagnosis, and recurrence risk are considered. A policy for the certification of pilots following TGA is proposed.

Axillary vein thrombosis and congenital dysfibrinogenemia in a commercial pilot: a case report.

A 34-yr-old male commercial pilot developed a painful swollen right upper arm following an episode of trauma. Venography confirmed the clinical diagnosis of a right axillary deep venous thrombosis. Magnetic resonance imaging suggested the presence of a fibrous tissue band overlying the junction of the right subclavian and innominate veins, potentially creating a thoracic outlet syndrome. A thrombophilia screen revealed an abnormal fibrinogen variant consistent with a diagnosis of congenital dysfibrinogenemia. The pilot was treated with anticoagulant therapy for 4 mo. There were diagnostic difficulties in determining the definitive etiology of the axillary vein thrombosis. Congenital dysfibrinogenemia is a rare condition, which is asymptomatic in the majority, but may manifest with hemorrhage or thrombosis in up to 45% of cases. The clinical management of the pilot and the aeromedical implications of the diagnosis are discussed.