Stroke and antiplatelet therapy

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Stroke and antiplatelet therapy

Post by Dion234 » Thu Mar 12, 2020 2:43 pm

61-year-old male 5 months post-stroke just had a re-exam with his neurologist today. Onset included left-sided weakness and slurred speech. Symptoms cleared up within hours and never returned. Imaging revealed a focal Pontine infarct with no ischemic changes. Head magnetic resonance angiographic imaging was negative. Ultrasound of both carotids revealed less than 50% stenosis. He was prescribed amlodipine, atorvastatin and Plavix. A neurologist says the Plavix will be life long. He has cleared the driver for CDL work. But because he would not discontinue the antiplatelet therapy I am considering the driver to be a significant risk and disqualifying him since he is not one year out from the stroke. Except for this, he passes his CDL physical.

Would you agree with my conclusion? The driver and neurologist don't.

Thanks for your input.

Robert Swotinsky MD
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Re: Stroke and antiplatelet therapy

Post by Robert Swotinsky MD » Fri Mar 13, 2020 1:20 pm

You are likely already familiar with the FMCSA Medical Examiner Handbook text from 7-1-19:
Individuals with embolic or thrombotic cerebral infarctions will have residual intellectual or physical impairments. Fatigue, prolonged work, and stress may exaggerate the neurological residuals from a stroke. Most recover from a stroke will occur within 1 year of the event.

The neurological examination should include assessment of:
• Cognitive abilities
• Judgment
• Attention
• Concentration
• Vision
• Physical strength and agility
• Reaction time
Key points to aid a medical examiner’s decision on safe driving ability include using best practice methodology through experience and research to ensure driver and public safety:
• A waiting period of 1 year if the driver is not at risk for seizures (cerebellum or brainstem vascular lesions)
• A waiting period of 5 years if the driver is not at risk for seizures (cortical or subcortical deficits)
• Assess if there are any neurological residuals or, if present, residuals of a severity that does not interfere with ability to operate a commercial motor vehicle
• Assess the drug regimen for side effects that could impair a driver’s ability to operate a CMV safely
• Medical clearance from a neurologist should be obtained
In your case, the neurologist has provided medical clearance. There was likley a neurologic exam during the DOT physical. The waiting period of 1 year has not been completed.

The driver understandably wants to be cleared. We presume that is why he presented for his DOT physical. Your post says the neurologist has cleared the driver. FMCSA guidelines are not rules. And, if the treating neurologist can offer an individualized, evidence-based rationale as to why this particular examinee is safe to drive at 6 months instead of waiting the 1 year that FMCSA recommends, that could be informative. Its possible the treating neurologist is not familiar with the FMCSA guidance and FMCSA's neurology expert reports, which are posted on FMCSA web pages?

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