Driving after a transient ischaemic attack or minor stroke

Increased Risk of Traffic Injury After a Cerebrovascular Event

Background and Purpose- We aimed to determine the long-term risks of a motor vehicle collision after a cerebrovascular event and whether the risks were similar after left- or right-hemispheric events. Methods- We used a population-based registry to identify patients diagnosed with a transient ischemic attack or stroke (hemorrhagic or ischemic) between 2003 and 2013 in Ontario, Canada. Hemispheric laterality was determined using radiological and clinical findings. We identified subsequent serious injuries involving the patient as a driver using linked administrative data. Secondary outcomes included serious injuries involving the patient as a pedestrian, as a passenger, or other traumatic events (fall, fracture, ankle sprain). We used proportional hazard models accounting for death as a competing risk to test the association of hemispheric laterality and outcomes with and without adjustment for age, sex, discharge modified Rankin Scale score, home location, and prior driving record. Patients were followed through to 2017. Results- Among 26 144 patients with hemispheric cerebrovascular events, 377 subsequent serious traffic injuries as a driver (2.2 per 1000 person-year) were identified over a median follow-up of 6.4 person-years. The rate did not differ by laterality (adjusted hazard ratio, 1.00; 95% CI, 0.82-1.23). The risk of a serious traffic injury as a pedestrian was significantly higher after a right-sided than left-sided event (adjusted hazard ratio, 1.27; 95% CI, 1.02-1.58). Subsequent risks for other traumatic injuries did not differ by laterality of cerebrovascular event. Conclusions- The risk of a serious traffic injury as a pedestrian is substantially higher after a right-hemispheric cerebrovascular event compared with a left-sided event. Walking should be promoted for exercise in survivors of a stroke or transient ischemic attack, but these vulnerable road users may benefit from additional poststroke rehabilitation to optimize safety.

A Case-Control Study Investigating Simulated Driving Errors in Ischemic Stroke and Subarachnoid Hemorrhage

Background

Stroke can affect a variety of cognitive, perceptual, and motor abilities that are important for safe driving. Results of studies assessing post-stroke driving ability are quite variable in the areas and degree of driving impairment among patients. This highlights the need to consider clinical characteristics, including stroke subtype, when assessing driving performance.

Methods

We compared the simulated driving performance of 30 chronic stroke patients (>3 months), including 15 patients with ischemic stroke (IS) and 15 patients with subarachnoid hemorrhage (SAH), and 20 age-matched controls. A preliminary analysis was performed, subdividing IS patients into right (n = 8) and left (n = 6) hemispheric lesions and SAH patients into middle cerebral artery (MCA, n = 5) and anterior communicating artery (n = 6) territory. A secondary analysis was conducted to investigate the cognitive correlates of driving.

Results

Nine patients (30%) exhibited impaired simulated driving performance, including four patients with IS (26.7%) and five patients with SAH (33.3%). Both patients with IS (2.3 vs. 0.3, U = 76, p < 0.05) and SAH (1.5 vs. 0.3, U = 45, p < 0.001) exhibited difficulty with lane maintenance (% distance out of lane) compared to controls. In addition, patients with IS exhibited difficulty with speed maintenance (% distance over speed limit; 8.9 vs. 4.1, U = 81, p < 0.05), whereas SAH patients exhibited difficulty with turning performance (total turning errors; 5.4 vs. 1.6, U = 39.5, p < 0.001). The Trail Making Test (TMT) and Useful Field of View test were significantly associated with lane maintenance among patients with IS (r_s > 0.6, p < 0.05). No cognitive tests showed utility among patients with SAH.

Conclusion

Both IS and SAH exhibited difficulty with lane maintenance. Patients with IS additionally exhibited difficulty with speed maintenance, whereas SAH patients exhibited difficulty with turning performance. Current results support the importance of differentiating between stroke subtypes and considering other important clinical characteristics (e.g., side of lesion, vascular territory) when assessing driving performance and reinforce the importance of physicians discussing driving safety with patients after stroke.

Driving in stroke survivors aged 18–65 years: The Psychosocial Outcomes In StrokE (POISE) Cohort Study

Background

There is limited information regarding return to driving after stroke.

Aims

To determine the frequency and predictors of return to driving within 1 month of acute stroke in younger (age 18–65 years) adults.

Methods

POISE (Psychosocial Outcomes In StrokE) was a cohort study conducted in Australia between October 2008 and June 2010. Consecutive patients (age 18–65 years) with a recent (≤28 days) acute stroke were recruited. Validated demographic, clinical, mental health, cognitive, and disability measures including return to driving were obtained. Multivariable logistic regression was used to determine factors associated with return to driving within 1 month of stroke.

Results

Among 359 participants who were legally able to drive before stroke, 96 (26.7%) returned to driving within 1 month. Compared to those without an early return to driving ( n = 263), drivers were more often male, the main income earner, in paid work before stroke and without symptoms of depression or fatigue. Independence in activities of daily living (odds ratio (OR) 30.05, 95% confidence interval (CI) 3.85–234.45), not recalling receiving advice on driving cessation (OR 5.55, 95% CI 2.86–11.11), and having returned to paid work (OR 3.93, 95% CI 1.94–7.96) were associated with early return to driving.

Conclusions

One in four young adults resumed driving within a month, contrary to guideline recommendations. These data reinforce the importance of deciding who is responsible for determining fitness to drive after stroke, when, and whether it is reasonable to enforce driving restrictions on those with minimal disability who are fit to return to work.

Registration

Australian New Zealand Clinical Trials Registry ANZCTRN 12608000459325.

Returning to driving after stroke: A systematic review of adherence to guidelines and legislation

Introduction

This systematic review aimed to determine whether stroke survivors routinely received return-to-driving education in the acute hospital setting prior to discharge home; and if education was provided, were the restrictions in driving guidelines adhered to.

Method

A systematic search was conducted of PubMed, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Web of Science, Scopus, Pedro and OTseeker databases for original research reporting findings on the adherence to return-to-driving legislation and clinical guidelines after stroke, and return-to-driving behaviours in stroke survivors up to 1 month post stroke.

Results

Three studies met the inclusion criteria and reported on a combined total of 252 stroke survivors living in the United Kingdom. Forty-eight per cent of stroke survivors received education on the 1 month driving restriction. A total of 61.4% of participants waited 1 month prior to returning to driving.

Conclusion

This review found that there is limited literature available on the management of return to driving following acute stroke but there is evidence that education may not be routinely provided in the acute hospital setting and that many stroke survivors could be returning to driving within the 1 month restriction.

The risk of motor vehicle crashes and traffic citations post stroke: a structured review

BACKGROUND

Stroke impacts the domains known to be important for driving and is a primary condition for driving evaluation referrals. Given the high prevalence of stroke, the objective was to summarize the evidence regarding risk of crashes and traffic citations post stroke.

METHODS

A structured review of six databases was conducted to retrieve studies that included stroke as a separate exposure from other disorders and measured crashes or traffic citations as an outcome.

RESULTS

Four cohort and three case-control studies met the inclusion criteria. Five of the seven studies found increased odds or risk ratios ranging from 1.9 to 7.7, while two found an association of 0.8. Only one result was statistically significant (RR=2.7). One study examined the outcome traffic citations and found no significant association.

CONCLUSION

There is cause for concern regarding increased risk of crashes post stroke. Future studies that examine the impact of stroke severity and sequelae will help health professionals, families, and those with stroke make informed decisions regarding driving post stroke. This review indicates that drivers with stroke have an increased risk of crashing compared to their counterparts without stroke, as demonstrated by increased risk estimates in five out of the seven studies that have examined this issue. This review also points to an urgent need for rigorous studies investigating the risk of crashes according to specific stroke sequelae: an understanding of crash risk based on stroke severity, impairments, and function will assist clinicians in making informed decisions regarding the need for comprehensive driving evaluation and the potential for driver retraining for specific subgroups.