Post-Stroke Targeted EvaluationJon Van Doren, Ph.D.Arizona Neuropsychology, PCScottsdale, AZvandoren@azn.us

Proximal Medical Issue• 60-year-old Caucasian man.• Sudden onset of right hemiparesis,

diaphoresis, generalized weakness.• Symptoms resolved in 15-30 minutes.• Arrived at ER about 2 hours after onset.• MRI showed multiple tiny infarcts in left

MCA territory.

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.

• He allowed his 3rd 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.

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…

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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.

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–

FAR Part 67, section 3091) 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.

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…

FAA Letter #1Due to your history of a stroke, you must provide the followinginformation for the Aerospace Medical Certification Division’s review:1.A current history and clinical examination from your treatingneurologist regarding your history of stroke and carotid disease. Thisreport should include a complete history and symptoms, neurologicexamination, neurocognitive testing using a mini-mental status examsuch as the MoCA test (Montreal Cognitive Assessment), specificcomments on results of your most recent imaging of the brain andcarotid arteries, diagnosis, treatment plan, prognosis, and plans forfollow-up. Include copies of any pertinent medical/treatment recordsand the results of any current studies deemed clinically appropriate byyour physician to document stability.2.The results of a current CogScreen- Aeromedical Edition (AE).Following review of the above, additional information may berequired by the FAA.

Standard Protocol: ReportStandard protocol for neuropsychological evaluation for potential neurocognitive impairment can be found at:

https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/media/npevalspecs.pdf

Standard Protocol: Report

Must include:

1)Review of all available records2)Thorough clinical interview3)Mental status exam4)Interpretation of testing including but not limited to the “core battery,” and5)An integrated summary of findings.

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).

Background

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

Background

• Repeated 1st 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 3rd class.

Background

• Worked in oil fields 1976-1983. 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.

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.

Background

• He and his wife now provide landscape maintenance to their HOA, 50-100 hours per month, even in triple-digit temperatures.

• No change in ADLs since stroke.• Presentation at the time of initial

evaluation appeared highly nervous.

Initial Test Results• MoCA = 27/30 (-1 for incorrect cube orientations, -2 for sentence

repetition)• CogScreen LRPV = 0.9244 (elevated by standard criteria, but at the

25th percentile for GA norms)• The Attribute Identification Taylor Factor score was deficient, at the

3rd 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 ≤ 5th percentile:

Major Carrier General AviationSpeed 3/19 (10th %ile) 1/19Accuracy 3/19 (7.5th %ile) 3/19Thruput 4/16 (5th %ile) 0/16Process 2/10 (10th %ile) 1/10

CogScreen Results: The Weeds

MC T GA T

SATDIACC Shifting Attention Discovery, accuracy 41 42

SATDIFAI Shifting Attention Discovery, set loss 53 59

SATDIPER Shifting Attention Discovery, persev error 31 42

SATDIRUL Shifting Attention Discovery, rule shifts 42 45

FAA Letter #2Due to your history of stroke, you must provide the followinginformation 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, safelymanipulate aircraft controls). Please provide a copy of your in-flightinstructor pilot evaluation to your neuropsychologist.2.The results of additional neuropsychological testing… …to include aWisconsin Card Sorting Test, Iowa Gambling Test, Trails A and B Tests.Following review of the above, additional information may berequired by the FAA.

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:

• Wisconsin Card Sorting Test: 6 categories in 74 trials, 8 errors (81st%ile for age/education), 1 loss of set, 6 perseverative errors (68th%ile).

• Iowa Gambling: Total Net Score = 52 (88th %ile), raw net scores produced a (+) slope (6, 2, 14, 14, 16).

• FAS: 16th %ile, Animals: 42nd %ile.

Heaton CNNS Kay (2002)Trails A 42 58 12Trails B 69 88 11

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).

Post-Stroke Targeted EvaluationProximal Medical IssueProximal Medical IssueSlide Number 4Code of Federal RegulationsFAR Part 67, section 309FAR Part 67, section 309FAR Part 67, section 309Medical Certification not deniedFAA Letter #1Standard Protocol: ReportStandard Protocol: ReportStandard Protocol: Core BatteryBackgroundBackgroundBackgroundBackgroundBackgroundInitial Test ResultsCogScreen Results: The WeedsFAA Letter #2Follow-up Test ResultsIn Conclusion