What are the guidelines for clearing someone to drive or fly after a hemorrhagic stroke?

Guidelines for Returning to Drive or Fly After Hemorrhagic Stroke

Patients who have experienced a hemorrhagic stroke should wait at least 4 weeks before resuming driving or flying, with clearance dependent on comprehensive neurological assessment and absence of significant deficits. 1, 2

Initial Assessment Timeline

• Patients should not drive during the acute phase of hemorrhagic stroke (first 4 weeks) due to significantly increased risk of driving errors and impaired performance 2
• Formal assessment for fitness to drive or fly should begin only after medical stability has been achieved, typically 4-6 weeks post-stroke 1, 3
• Early mobilization within 24 hours of stroke onset is not recommended and may reduce the odds of a favorable outcome at 3 months 1

Driving Assessment Process

• A comprehensive driving evaluation should be conducted by an occupational therapist with expertise in driving assessment 3, 4
• The Occupational Therapy - Driver Off Road Assessment Battery has good predictive validity for determining fitness-to-drive after stroke, with cognitive subtests being particularly important 4
• Patients with acute mild stroke commit significantly more driving errors than healthy controls, particularly during complex tasks like left turns with traffic 2
• Driving simulation testing can help identify specific deficits that may not be apparent during basic driving tasks 2, 5

Medical Criteria for Clearance

• Before clearance for driving or flying, patients must be assessed for:

  • Resolution of acute neurological deficits 1, 6
  • Absence of significant cognitive impairment 4
  • Adequate visual fields and visual acuity 5
  • Sufficient motor control for vehicle operation 4
  • Absence of seizures (if seizures occurred, additional restrictions may apply) 1, 6

• Patients with persistent neurological deficits should undergo formal driving assessment with both off-road and on-road components 3, 4

Special Considerations for Flying

• Commercial air travel involves exposure to altitude changes and potential pressure differences that may impact recent hemorrhagic stroke patients 1
• Medical stability, including well-controlled blood pressure, is essential before air travel 1
• For flying clearance, consider:
  • Complete resolution of increased intracranial pressure 1, 6
  • Stability of any residual hematoma on follow-up imaging 1, 7
  • Risk of venous thromboembolism during prolonged flights 1

Risk Stratification

• Higher risk patients requiring more extensive evaluation before clearance include those with:
  • Large volume hemorrhage or multiple hemorrhages 1, 7
  • Significant residual neurological deficits 6, 4
  • Cognitive impairment affecting judgment or reaction time 5, 4
  • Visual field deficits or visual neglect 5
  • History of seizures post-stroke 1, 6

Common Pitfalls to Avoid

• Clearing patients too early (within first 4 weeks) when risk of driving errors is highest 2, 3
• Relying solely on patient self-reporting of symptoms or abilities 3, 5
• Failing to consider the impact of medications (particularly anticonvulsants or sedating medications) on driving performance 6, 5
• Not providing clear written documentation of driving/flying restrictions and when reassessment should occur 3
• Overlooking the need for specialized driving rehabilitation for patients with persistent but potentially correctable deficits 5, 4

Follow-up Recommendations

• Patients cleared to drive should initially be restricted to familiar routes, daylight hours, and good weather conditions 3
• Regular reassessment is recommended, particularly if there are changes in neurological status or medication regimen 3, 4
• Patients and families should be educated about warning signs that would necessitate driving cessation and reevaluation 3