| Abstrakt: |
INTRODUCTION: This case describes a young flight instructor who suffered an embolic ischemic stroke with punctate lesions in his right motor and superior parietal cortex. Investigations revealed a small patent foramen ovale (PFO). BACKGROUND: Stroke in young patients is frequently associated with a PFO. Controversy exists over whether the PFO is a cause, a risk factor, or an incidental finding in these cases. Estimating the individualised risk of stroke recurrence is difficult to ascertain. This has implications for medical certification for pilots following recovery. CASE PRESENTATION: A 28-year-old male recreational flight instructor held a Commercial Pilot Licence with approximately 2000 hours of flight experience. He presented to the hospital with sudden onset left-sided facial paraesthesia, left hand weakness and blurred vision, accompanied by gradual onset, moderate severity, bilateral headache. The cranial symptoms resolved within 30 minutes. The left hand weakness persisted for three days. MRI revealed two punctate ischemic foci in the right precentral gyrus and superior parietal lobe. Vasculitis and thrombophilia screen, CT angiography, lower limb Doppler, 7-day Holter monitoring, and stress echocardiogram were normal. Transesophageal echocardiogram revealed a PFO with small bidirectional shunt. The cardiologist and neurologist opined that the PFO was unlikely to have caused his stroke and estimated an annual recurrence rate of <1.8%. The pilot was placed on life-long aspirin and atorvastatin. He was offered PFO closure but declined. Under Recreational Aviation Australia rules, he was able to return to flying light sport aircraft. However, an enduring co-pilot restriction for general aviation activities was placed on his Class 1 and 2 Aviation Medical by the Australian Civil Aviation Safety Authority. Following a review two years later, the restriction was upheld despite no stroke recurrence. DISCUSSION: This case highlights the difficulty in determining individualised risk for pilots recovering from a stroke associated with a small PFO. Whilst treatment with aspirin and a statin or PFO closure reduces the risk of stroke recurrence, these treatments carry a risk of side effects. Further evidence is required to better individualise risk for stroke patients with a small PFO to determine optimal treatment options and to stratify their suitability for medical aviation re-certification. Learning Objectives 1. Understand the relevance of the finding of a patent foramen ovale following ischemic stroke in young patients. 2. Appreciate the current difficulties in stratifying and individualising stroke recurrence risk in patients with patent foramen ovale and the implications this has on aeromedical re-certification following recovery. 3. Develop an awareness of different aeromedical certification standards based on activity type and jurisdiction. [ABSTRACT FROM AUTHOR] |
