Introduction
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German Society of Neuroscientific Assessment (DGNB)
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German Society of Neurology (DGN)
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German Society of Neurosurgery (DGNC)
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German Society of Neurorehabilitation (DGNR)
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German Stroke Society (DSG)
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Society for Neuropsychology (GNP)
Legal requirements
Annex 4 of the FeV and Annex 4 of the evaluation guidelines for driving ability (BGL)
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Are there any physical or mental functional limitations that permanently impair driving ability? If so, are there any ways of compensating for these functional limitations, such as making driving fitness subject to conditions or restrictions?
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How high is the risk potential of a sudden loss of control as a result of another stroke or cardiovascular event while driving?
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Are there deficiencies in self-control or attitudes contrary to safe behavior?
Evaluation of physical and mental dysfunctions
Recommendation Patients suffering from any form of cerebrovascular disease with substantial initial disability (modified Rankin Scale, mRS > 2) should be evaluated for their driving fitness during the rehabilitation process. A detailed summary should be included in the final discharge documents. |
Neurocognitive impairments
Recommendation If minimum cognitive requirements, as defined in the German Evaluation Guidelines for Driving Ability (BGL), are not met, but the patient still wishes to drive, an on-road driving test with a neuropsychologist should be recommended to the patient. The same applies in the case of changes to emotional control, awareness, or personality, all of which may result in unsafe driving. In individual cases, risk can be reduced to an acceptable level by, for example, limiting driving to certain vehicle types (e.g., automatic transmission), familiar surroundings, or daytime only. |
Neglect
Recommendation Group 1 If the visual neglect without additional visual field loss has improved to such an extent that it can no longer be observed by others (e.g., therapists or family members) an on-road driving test of at least 60 min should be considered. The driving evaluation should be done in such a way that the neglect is specifically evaluated (e.g., in inner city traffic at rush hour). This test should be carried out together with a neuropsychologist. Group 2 As a rule, safe driving of group 2 vehicles (e.g., trucks) cannot be expected because of the additional demands on cognitive resources (e.g., sustained attention over long periods of time) even if the neglect has improved and cannot be observed by others. In rare cases, a driving evaluation can be carried out with appropriate vehicles and for longer time periods to test the stability of functioning. |
Language impairments
Recommendation Group 1 In general, an on-road driving evaluation is recommended for aphasic patients, if possible accompanied by a neuropsychologist. In this context, it should also be assessed whether comprehension of traffic signs is impaired. Group 2 The on-road driving test should be carried out with an appropriate group 2 vehicle and for longer time periods to test the stability of functioning (minimum driving duration 60 min). |
Vascular dementia
Visual disturbances
Recommendation In addition to the regulations of Annex 6 of the FeV, examination of the useful field of vision is recommended to assess the compensatory use of saccadic eye movements after visual field loss. |
Motor impairments
Recommendation Limitation or loss of limb function as a result of a central or peripheral nervous system disorder requires regular neurological evaluations. Compensatory options (e.g., modifications of the vehicle) must be checked within the framework of an on-road driving test. |
Balance disorders
Evaluation of the risk potential for sudden loss of control in cerebrovascular disease
General hazard risk from motor vehicles
Group 1 | Vehicle population | Accidents involving personal injury | Risk per vehicle |
Passenger cars | 45,803,560 | 287,710 | 0.0063 |
Trucks up to 3.5 tons | 2,383,394 | 12,865 | 0.0054 |
Passenger cars plus LKW bis 3.5 tons | 48,186,954 | 300,575 | 0.0062 |
Group 2 | Vehicle population | Accidents with personal injury | Risk per vehicle |
Busses | 78,949 | 3503 | 0.044 |
Trucks > 3.5 tons | 528,449 | 5904 | 0.011 |
Busses + trucks > 3.5 tons | 607,398 | 9407 | 0.0155 |
Assessment of the risk for a loss of control while driving due to a further stroke or cardiovascular event (SCI)
Risk of damage to persons from an accident resulting from a sudden loss of control (ac)
Assessment of the risk potential after stroke according to the risk of harm formula adapted for the traffic conditions in Germany
Prognosis prediction after different types of stroke
Transitory ischemic attacks (TIA)
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TIA 7.1%
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Brain infarct 5.1%
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Death 1.8%
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Acute coronary syndrome 1.1%
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Intracerebral hemorrhage 0.4%
Brain infarction
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7.9% recurrences for macroangiopathic infarcts
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6.5% for cardioembolic infarcts
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6.5% for microangiopathic infarcts.
Intracerebral hemorrhage
Subarachnoid hemorrhages
Non-ruptured aneurysms
Arteriovenous malformations (AVM)
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a bleeding has occurred already
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the location of the AVM is deep in the brain or brain stem
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the venous drainage is via deep veins
Intracerebral cavernomas
Arteriovenous (AV) fistulas
Cerebral venous or sinus thrombosis
Assessment of driving ability in specific cerebrovascular diseases
Driving ability in cerebrovascular disease | ||
Transitory ischemic attacks (TIA) | Group 1 | Group 2 |
Low risk profile, cause treated | Yes | Yes |
Waiting period | 1 month | 3 months |
High risk profile (ABCD2 > 6) | ||
Waiting period | 3 month | 6 months |
Intracranial stenoses and occlusions of large cerebral arteries | Yes | No |
Waiting period | 6 months | _ |
Extracranial stenosis and occlusion s. brain infarcts with carotid stenosis | ||
Brain infarcts | Group 1 | Group 2 |
Intracranial stenoses and occlusions of large cerebral arteries | Yes | No |
Waiting period | 6 months | – |
Severe carotid stenosis after successful desobliteration | Yes | Yes |
Waiting period | 1 month | 3 months |
Severe carotid stenosis, conservatively treated | Yes | Yes |
Waiting period | 3 months | 6 months |
Unknown cause / low risk profile | Yes | Yes |
Waiting period | 1 month | 3 months |
Unknown cause / high risk profile | Yes | Yes |
Waiting period | 3 month | 6 months |
Dissection of the large brain-supplying arteries | Yes | Yes |
Waiting period | 3 month | 6 months |
Cardio-embolic CHA2DS2-VASC up to 5, anticoagulated | Yes | Yes |
Waiting period | 1 month | 3 months |
Cardio-embolic CHA2DS2-VASC up to 5, not anticoagulated | Yes | No |
Waiting period | 6 month | – |
Cardio-embolic CHA2DS2-VASC > 5, anticoagulated | Yes | Yes |
Waiting period | 1 month | 3 months |
Cardio-embolic CHA2DS2-VASC > 5, not anticoagulated | No | No |
Waiting period | – | – |
Microangiopathic | Yes | Yes |
Waiting period | 1 month | 3 months |
Cerebral vasculitis | Group 1 | Group 2 |
Giant cell arteritis, untreated | No | No |
Waiting period | – | – |
Giant cell arteritis, treated ESR and CRP normalised for 4 weeks | Yes | Yes |
Waiting period | None | None |
Other cerebral vasculitis, if under treatment controlled | Yes | Yes |
Waiting period depending on the prognosis of the disease | 3–12 month | 6–12 months |
Brain hemorrhage | Group 1 | Group 2 |
Amyloid angiopathy / symptomatic bleeding + more than 5 asymptomatic bleedings or superficial siderosis | No | No |
Waiting period | – | – |
Single hypertensive bleeding / blood pressure within normal range | Yes | Yes |
Waiting period | 1 month | 3 months |
Single hypertensive bleeding / blood pressure not within normal range | No | No |
Waiting period | – | – |
More than 2 hypertensive bleedings within 5 years | No | No |
Waiting period | – | – |
Subarachnoid hemorrhage | Group 1 | Group 2 |
Non-aneurysmatic perimesencephalic/prepontine/convexity | Yes | Yes |
Waiting period | 2 weeks | 2 weeks |
Aneurysm occluded | Yes | Yes |
Waiting period | 1 month | 1 month |
Aneurysm not occluded | No | No |
Waiting period | – | – |
Asymptomatic, unruptured aneurysm | Group 1 | Group 2 |
Bleeding risk up to 4%/year | Yes | Yes |
Waiting period | None | None |
Bleeding risk > 4%/year | No | No |
Waiting period | – | – |
Aneurysm occluded | Yes | Yes |
Waiting period | 1 month | 1 month |
Arterio-venous malformations | Group 1 | Group 2 |
Not ruptured, without deep or brainstem involvement and without deep venous drainage (accidental finding) | Yes | Yes |
Waiting period | None | None |
Ruptured, untreated | Yes | Yes |
Waiting period | 3 years | 5 years |
Ruptured, completely removed | Yes | Yes |
Waiting period | None | None |
Ruptured, treatment not yet completed | Yes | Yes |
Waiting period | 3 years | 5 years |
Cavernoma | Group 1 | Group 2 |
Accidental finding, no bleeding, not located in the brain stem | Yes | Yes |
Waiting period | None | None |
Accidental finding, no bleeding, located in the brain stem | Yes | No |
Waiting period | None | – |
Surgically removed | Yes | Yes |
Waiting period | 3 months | 3 months |
Bled, not removed, not located in the brain stem | Yes | Yes |
Waiting period | 2 years | 2 years |
Bled, not removed, located in the brain stem | Yes | No |
Waiting period | 2 years | – |
Arterio-venous fistulae | Group 1 | Group 2 |
Asymptomatic | Yes | Yes |
Waiting period | None | None |
Symptomatic, high risk (type Boden 2 and 3, Cognard 2b-5) | No | No |
Waiting period | – | – |
Completely removed | Yes | Yes |
Waiting period | 1 week | 1 week |
Cerebral venous or sinus thrombosis | Group 1 | Group 2 |
Without congenital coagulation defects | Yes | Yes |
Waiting period | None | None |
With congenital coagulation defects, anticoagulated | Yes | Yes |
Waiting period | 1 month | 1 month |