Okay, I'd like to introduce Tara Sharma, D. O. M. S. She will be talking about applying considerations after concussion and symptom recovery. She had did her fellowship at the Cleveland Clinic. I'm sorry her residency at the Cleveland Clinic and fellowship at UCLA. She's a board certified neurologist and one of the country's few fellowship trained sports neurologists. As a sports neurologist, she treats patients with both sport and non sport related traumatic brain injuries. She believes a multidisciplinary approach with collaboration between other healthcare providers and disciplines is essential to improving quality of life for patients with various neurological conditions. She also takes a holistic approach to evaluating and treating patients as she believes emotional, physical, psychosocial and lifestyle stressors could affect the course of disease. Dr. Sharma's clinical and research interests include managing post traumatic headache, sports related concussion and analyzing factors that influence concussion recovery. For her personal interest, she likes running, hiking, skiing, figure skating and going to the park with her family during her free time. She has nothing to disclose. So I'm going to talk about air travel after TBI. I'm focusing probably more on the mild traumatic brain injury and concussion side of things. So no disclosures and I do not plan to discuss off label use of drugs or products during this presentation. So it's also a little outline of the presentation. First, we're going to discuss the effect of air travel and so how air travel affects concussion or TBI recovery and symptoms severity. Then we're going to go over the Federal Aviation Administration guidelines for concussion and TBI and then kind of go over how it differs from our clinical practice guidelines for concussion and TBI. And then we're going to describe the role of neuropsych testing and how neuropsych testing determines recovery of TBI and the ability to return to fly in pilots. And then we're also going to discuss some research involving neurological sequelae. I'll probably mainly just discuss seizures and epilepsy since that's the most common complication we see after TBI. And then I'll discuss factors that might exacerbate flying in pilots and how concussion and TBI might exacerbate their symptoms. So how does flying affect your body? Well, an aeromedical evacuation, so for example, in the military when they evacuate people after TBI, there is a development of hypoxia. And that hypoxia provides decreased or inadequate blood flow to the tissues. So the other organs, brain, lungs, things like that. And so they recommend correcting an EMAN patient. So if any one patient with a hemoglobin of less than 8 should be corrected and giving supplemental oxygen during flight if the SbO2 is less than 92% or if they have a TBI or hypoventilation from narcotic use. And so there's a study done in the military by John Eman, which showed that 90% of the 61 military combat casualties had one drop in SbO2, less than 90% during the flight. And these people had a variety of different injuries, orthopedic injuries, pneumothorax, TBI of varying degrees, usually more on the severe spectrum of TBI. So people that had brain bleeds and things. So there's also some other studies that have been done way in the past, one by Langdon in 1961, actually showed there's minimal symptoms during flight. And people with a variety of different head injury severities and mainly people with contusions and cerebral hemorrhages. Yes, they had 17 concussions in their study, but not all of them were severe. But they found that people had mild symptoms, maybe mild headache in one case or in some cases, nausea. No one really died or decompensated significantly during flight. That being said, I think one person did die afterwards, but all these people too had other injuries like pneumothorax, lung injuries, orthopedic injuries, as well as a brain injury. There's also another study by Strickland and Rafferty that showed also in 16,000 cases, again, this is a military study with people with different various different types of head injuries and other injuries too, as well, that the in-flight symptoms were actually minimal and did not significantly differ from the general population. I don't know why it's too late. Oh, I see. I see what it is now. I'm sorry. Okay. We're on this one, right? Yeah. Did you want to do... Sorry, guys. Here we go. I got it. Is that good? Yeah. But it won't let me do the presentation. I guess, can you present from this? Yeah. Will they see the slides when I click? Let me check. Okay. So, basically, so return to learn was pretty similar between the groups. Also, to return to symptom resolution, so return to when their symptoms are back to their baseline symptoms, according to the SCAT score, was similar. And also, too, we found that total symptom severity using the SCAT, again, was pretty similar between groups. And basically, the SCAT in this case was taken about 48 hours after they flew. So, basically, overall, no significant differences between groups. And so, this could reassure athletic trainers, clinicians, patients, and coaches that flying after concussion is relatively safe. There's no change in the recovery. However, the study, we really didn't look at long-haul flights. A lot of our athletes, they flew within two to three hours. So, that would probably be, like, a future study looking at long-haul flights or earlier flight times as well. Did they make any distinction between what they pulled out, the difference in altitude? I mean, it was one thing for somebody to be, in fact, let's say, 800 or 1,000 feet ASL in NOM versus 3,000 versus going to 8,000 pressurized aircraft at 20 or more feet altitude flying. And if you have somebody like the Air Force Academy where they're looking at not quite 1,000 in ASL. So, yeah. So, like, a lot of the military studies are at 8,000 feet. And our study really didn't know, but a lot of the times they were commercial air flights, which are about 6,000 feet, pressurized to 6,000 feet. But yeah, most of them were basically flying to and from games. And so, they were flying commercial flights, not really. And even our military were basically, were all athletes. So, they're all NCAA athletes or non-NCAA athletes for the most part. I think a few, which I'll come to in a little bit, in the Air Force Academy, did fly gliders too. So, which I'm really, I'm not sure exactly what that's pressurized to, maybe 8,000 or zero. I don't know. Okay. Okay. But yeah, about like three, I think, very small number flew gliders afterwards. Now, this thing's not moving. Let's see. If you click on the screen, you should pick it back up. Click on the screen? Click on the screen. Look at your picture. Position, what's happening. It's not advanced. Slides aren't advanced? Yeah. Well, I'm clicking on this. Sorry. Sorry, I'm not very technically savvy. Okay. Is that where you're trying to get to? Yeah. Perfect. Now, your clicker should work. It should work. That goes back. Okay. Thanks. Okay. So, I also took a smaller sample of the Air Force Academy cadets, those that suffered concussion and did not travel by airplane, those that did. And again, I just only looked at return to academics, and it shows that there's, again, not really much significant difference between groups in terms of returning to full school or full academics. About, they all flew about within 20 hours of injury. So, the median was about 20 hours. Range was from, or the interquartile range was from 5 to 41, 3 to 5. So, there's some limitations. So, even with the Air Force Academy cadets, like I mentioned, a lot of them were flying to and from games. So, they weren't flying back to the actual planes themselves. Probably only three that I knew of in the data set, and that I spoke to the Air Force Academy officer on the ground. They said that probably three flew gliders. One actually got a concussion while he was flying in the glider, interestingly enough. So, it was not enough, though, to kind of see if they had symptoms during flight or even after the flight. And so, we also really didn't evaluate if anyone had symptoms during the flight. However, in the data set, they do have a measure that shows if their symptoms did worsen during flight. And about 33.8% of the athletes actually did have worse than symptoms during the flight, while they were flying. And we had no control to compare it to, so we couldn't compare it to people that did not suffer TBI and flu. But however, there's other studies that have been done out there that have shown, especially this one by MUM in 2007, showed that 7.4% of healthy participants did suffer acute mountain sickness with air travel, but that's significantly lower, it looks like, than the 33.8% our data said. So, therefore, it's possible that air travel might temporarily exacerbate symptoms, especially if you haven't completely recovered from a concussion. But it does not really affect overall recovery. So, the recovery measures seem like they're still kind of recovered the same as people that didn't fly. So, now we're going to go to return to flight after TBI. How is that determined for pilots? I have a question. The return, okay, I know there's protocols. I would wonder if their return to recovery is that kind of people just plug them in and at this time they should be going back to work. Or are they really returning according to symptoms? So, the symptoms resolution, you mean the symptom resolution measure? Well, the return should approach from recovery. That end point that we're actually testing, is it influenced by their symptoms? Or is it just they all get back at the same time because we follow a protocol? So, that's true. So, they do follow a protocol. But they do have to be asymptomatic before they start the return to flight protocol. So, the symptom resolution actually is time to asymptomatic. So, time to when they don't have symptoms. So, they're cleared to start the return to flight protocol. And then the return to flight start is basically just when they were able to start it. So, of course, sometimes the neuropsych test, I'm Warren Silverman. So, sometimes the neuropsych testing, you know, they think they're normal and they get the neuropsych testing and they're not. Right. We'll go into that. Yeah. Yeah. Especially the ones with more severe TBIs too. And sometimes they're not honest about their symptoms. Which happens a lot. Okay. So, we're going to the Federal Aviation Administration Guidelines. So, their definition of concussion. So, this is their definition of concussion. So, mild head injury with loss of consciousness, alteration of consciousness, or post-traumatic amnesia for less than an hour, no seizure, or if they have an immediate impact seizure. So, basically, if they have an injury and then have a seizure immediately after. And so, after a six-month recovery period, they evaluate them to return to flight. Must include in the reports any evidence of seizure, any confusion, or post-traumatic amnesia that occurred, any post-concussive symptoms. So, headache, dizziness, brain fog, attention difficulties, things like that should be included. Usually, they should get imaging too, CT head, especially if there's any focal deficit. So, any deficits in vision, blurry vision, double vision, which is actually relatively common during concussion, but especially if they have a visual field cut or if they have weakness on one side of the body and things like that. That usually, if they have weakness on one side of the body, kind of prompts you to do more than a CT, to do an MRI if you don't see anything in the CT. So, basically, so I got this actually from the CAA website to the UK guidelines. So, an applicant with a history of mild traumatic brain injury is considered as having a condition that's not aeromedically significant. So, that means they're okay if they have a detailed history that supports a diagnosis of a concussion based on loss of consciousness and amnesia. Review of the CT scan. So, the CT head does not show any overt bleed. Again, kind of like what I mentioned in my prior lecture, concussion, there's usually no—there's no overt bleed on the CT scan. Applicant is asymptomatic. So, there's no cognitive or mood deficits or cognitive sequelae. And the full neurological exam is normal. And so, they say that three months or more has elapsed since the injury before they could be cleared to return to fly again. And so, this goes into the FAA definition of moderate TBI. So, this is a little bit more severe than the mild people. So, loss of consciousness, alteration of consciousness, or actually, I was supposed to say post-traumatic amnesia—that's a typo there—between 1 to 24 hours or nondispersed skull fracture or seizure more than 24 hours after TBI or multiple seizures. Again, that a lot of times indicates that there's usually a bleed in the brain in those cases. Or small parafalsine subdural hematomas. So, parafalsine basically is in the phalx, in the middle of the brain. And usually, those bleeds are pretty, pretty small, and they resolve around three months or so. I'm doing that. And so, with this, after a 12-month recovery period, so after a year, then they could be evaluated to return to flying. So, basically, this involves a detailed neurological exam as well as a neuropsychological exam. So, it's very, very important in these people with moderate TBIs, especially with bleeds—most people with moderate TBIs have bleeds—to make sure that everything seems cognitively intact, even if they feel like they're normal and they feel like they're cognitively back to their baseline. E.g., only if a seizure has occurred. Not really that necessary. I agree if a seizure has not occurred. MRI brain, yes, I agree. So, most of these people should get MRI brains and with contrast. And the reason why being with contrast is because some people with injuries could have leaks, especially if they have subdurals or spinal leaks. And with the contrast, you'll see if there's any leptomeningeal or pachymeningeal enhancement indicative of a leak or sagging of the brain. And so, kind of like what I mentioned before, small para-phalcine hematomas. Again, if they are asymptomatic, return to their baseline. Neuropsychological exam is good. And they may be considered after six months. Also, too, they have to have a repeat MRI, just showing that the hematoma has resolved. So, in moderate TBI, people with moderate head injuries should be considered having a condition that's of aeromedical significance unless they have a CT head that doesn't show any evidence of any abnormality. Like I said, that's pretty rare for moderate TBI. I mean, I probably had only one case that that was the case. And in that case, it was kind of unclear if that person actually suffered a head injury or not because he had some other things going on. So, like I said, that's pretty rare. Good clinical recovery. No cognitive or mood sequelae. Again, full neurological exam is normal. Neuropsychological—that includes a neuropsychological evaluation—concludes there's an absence of sequelae or elevated risk of seizure. And we'll kind of go into that in a little bit, the risk of seizure of the various degrees of TBI. And then two or more years have elapsed since the moderate head injury. So, basically, they have to be pretty far out from their injury. So, now we're going to go to severe TBI. So, this is the FAA definition of—their definition of what they consider a severe TBI. So, basically, anyone with a bleed in the brain or a subdural hematoma or diffuse axonal injury, brain contusions—so, basically, any intracranial process. Or if they have a loss of consciousness, alteration of consciousness, post-traumatic amnesia for 24 hours or more, or a depressed skull fracture or penetrating head injury. So, basically, open head injury. And so, with evaluation of this, after a five-year period, they submit for review. And it has to include the MRI and EEG. MRI, CTA, I'm assuming probably because of ruling out dissections and things like that which could occur. And so, basically, any time during their recovery process that these things should be submitted. So, basically, for people with severe TBI, they have a condition that is considered of aeromedical significance unless it's more than 10 years has elapsed since their injury. They're neurocognitively intact, close to their baseline. Again, I rarely see this for severe TBI. They usually, even if they feel like they're cognitively intact, they usually have some mild deficits, usually a memory or attention. And that's mainly in the younger people, too. I keep saying close to baseline. How do we know what the baseline is that we've never met? Right. So, they have actually norms. So, based on age, based on sex, based on demographic information. So, everyone compared to their peers in that level. Personal baseline. So, they don't have to have a personal baseline. So, basically, they just compare it. Now, if you don't have a baseline, they compare it to everyone in your age group and see if you kind of fall within that range of everyone in your age group. And usually, these people, too, have to have a full neuropsychological evaluation. So, not the brief test, but the full test. And all the full neuropsychological tests, they have the averages and things like that of everyone in their age group. So, anyone with a documented structural brain injury will not be considered to return until after 5 to 10 years or probably even more time has elapsed. Okay. So, that's their classification of traumatic brain injury. And this is our clinical classification. So, in the clinic nowadays, we're kind of veering away from the loss of consciousness, post-traumatic amnesia kind of definition because it tends to be kind of all over the place. And people have different definitions of that. And so, now we're going to standardize it a little bit more to be based on Glasgow's Coma Scale. So, mild, moderate, severe TBI is based primarily on the Glasgow's Coma Scale. So, that's a primary measure that we use. So, 3 to 8 are those with severe TBI, 9-12 are moderate TBI, and 13-15 are mild TBI. Measured when? Huh? Measured when? So, for mild TBI, it's measured approximately 30 minutes, and for the more severe TBI, probably 6 hours. Approximately 6 hours after their injury. So, if you guys don't know about the Glasgow Coma Scale, so it's based on three different things. Eye opening, verbal response, and motor response. So, the higher you score on it, that means the better you are. So, basically, we're all 15s here. Alert, oriented, obeys commands. Hopefully. Sure. Sure. You're up for that? Okay. So, the worse that you are, so people that are not doing very well, basically, the lower you are. So, people that are doing nothing are 3. The lowest score you could score pretty much is a 3. Yes. So, that's that. So, that's basically. Did I skip a slide? So, for neuropsych testing after TBI. So, neuropsych testing is super, super important, especially in those with the moderate to severe TBIs, and even those with mild complicated TBIs. I really didn't go into mild complicated TBI, but those basically are people that scored within the 13 to 15 on the GCS and have evidence of brain injury, structural brain injury. On the MRI or CT scan. And so, basically, it determines what areas are affected or impacted by their injury, too. So, like I said, people could feel like they're walking, that they have no symptoms, no headache, no dizziness, no cognitive fog. This is actually pretty common with neuroathletes. Yet, they could score poorly, more impulsivity, score high on the impulsivity portion of the neuropsych testing, and stuff like that. It also takes into account other factors, such as depression, anxiety, sleep difficulties. People that have a history of ADHD, ADD tend to have a little bit more attention deficit after injuries, especially people with persistent symptoms after concussion. Neuropsych testing is important because it kind of determines—oh, sorry. It kind of points us into what's prolonging their symptoms, whether it's depression, sleep difficulties, headaches, things like that. And so, afterwards, they came up with a report of recommendations of things or deficits that might impact their ability to return to flight. So, these are some studies that have been done on neuropsych testing. So, most neuropsychological recovery occurs the first year after injury. So, no matter what injury you have—moderate TBI, severe TBI, usually people with the brain bleeds mainly—in the first year, they have most of their neuropsychological recovery. So, their study actually showed that they did evaluations one year and even five years after injury, and there was not very much change in what they scored poorly on between those two time points. So, there's some variability, but it's not clinically significant, they felt like. People ranged from having no deficits, and usually those were more people in the mild, like mild-complicated TBI spectrum, the milder spectrum. Most of the people on the moderate to severe spectrum did have deficits in memory, attention, and processing speed. And some of them had actually pretty severe deficits, too, in some of those areas. It's really important, too, to try to have a neuropsychologist that kind of knows a little bit about TBIs and recovery from TBIs and things like that. So, what is the risk for post-traumatic epilepsy? So, this is actually good to know for people, especially ones that have more severe injuries. So, prevalence of epilepsy in the general population. So, prevalence of epilepsy is defined as basically having two or more unprovoked seizures more than 24 hours apart. So, it's 0.5% to 2%. And the cumulative incidence of PTA ranges from 2% to 50%, depending on injury severity. So, 50% is usually those people with the open head injuries with neural penetration. And so, epilepsy after TBI. So, this is how we define it. So, immediate seizures are seizures that occur within 24 hours of injury. Early seizures, 24 hours to 1 week. And in some cases, we give them prophylactic AEDs in people that have—or antiepileptics, I should say—in people that have subdurals and subarachnoids, just because their risk is a little bit higher for developing early seizures. Late seizures—it's also called late post-traumatic seizures—occurs more than 1 week after injury. Again, the definitions kind of vary depending on the literature. Some people say it's 30 days after injury. But we usually, in the clinical setting, as TBI specialists, use the week after injury as a point. If they have one late post-traumatic seizure, their risk of having another one is really, really, really high. So, 70%. And so, with these people, I usually start them on AEDs anyways, or antiepileptic treatment, just because their risk is high of having another one. And so, some people say that even if you have one late post-traumatic seizure, it still classifies as post-traumatic epilepsy. And so, this is just a review article kind of looking at different brain pathologies and risk of developing epilepsy. And so, as you see, the mild TBI folks have the lowest risk. Moderate, slightly higher—4. And severe has the highest in the TBI group—29. This is actually kind of a very, very small graph, so it's hard to see what the lines represent. But basically, the turquoise line here is anyone with focal brain injury. So, anyone with a post-traumatic injury, brain injury, or head injury, TBI, that had a brain bleed. So, as you can see, their risk for developing epilepsy is pretty high, around 12%, maybe. The yellow line represents diffuse brain injury. So, basically, people that have diffuse axonal injury. So, shearing—a lot of times, diffuse axonal injury is shearing in the white matter. So, you have damage to the white matter tracts, the subcortical tracts. On the MRI, it sometimes shows microbleeds also, too, white matter changes, things like that. And then the orange line is extracerebral injury. So, basically, subdural hematomas, epidural hematomas. So, things that are not inside the parenchyma of the brain, but a little bit outside. And the blue line is fractures. So, anyone with a fracture—it doesn't really specify what kind of fracture. I'm assuming mostly depressed fractures or skull fractures. But anyone with a fracture, their risk is also still a little bit elevated. It looks like it's close to, like, 4%, maybe, 3%. And then the red line is a mild TBI group. Dr. Sharma, so, the one that's 12% is your MRI is showing brain bleed. Right. Not subdural or anything. They do the MRI after the injury, and it's just showing— So, blood inside the brachial membrane of the brain, yeah. So, that's the highest. And then the blue line is just, like, the control group. So, people in the normal population that don't have TBIs. Yeah. If someone has a tumor, a pituitary, and they don't want to take it out, how is that? So, like, a craniotomy? Yeah. So, like, about 11% of a risk. So, still pretty elevated. And usually that's more elevated immediately after the surgery. Not sure about pituitary specifically, but more super-tentorial craniotomies tend to have a higher risk. So, basically, people that have cerebellar stuff have less of a risk. That's probably, like, more like 3% to 4%. People that have super-tentorial is a little bit higher. Just because there's edema, swelling, things like that that occur during craniotomies, which could cause seizures. Okay. And so, I like this because it kind of shows, too, not only the degree of TBI, but, like, the type of injury, too, in the brain that could cause epilepsy and the risk for epilepsy. And so, this is just a table kind of going through the same thing. And so, this is another study that showed, based on TBI severity, what their overall risk is. And so, as you see here, the top line is severe TBI. So, people with severe TBI have a significantly higher risk than everyone else. The risk in this study was about approaching 15%. And as you can see here, it doesn't kind of plateau until about, like, 20 years. So, basically, the risk remains elevated until about 20 years—15 to 20 years. A moderate TBI—so, the moderate TBI folks are the ones in the middle here with the triangle—upside-down triangles. And their risk kind of plateaus around 10. So, it kind of is 4%, and it kind of plateaus at that point, so it kind of reaches the general population around 10 years. It kind of stays there. And then the people with mild TBIs, again, kind of similar to the overall population, maybe a little bit elevated. In their study, they said that the risk kind of plateaus around 4 years. So, right here. So, this is neat, because it kind of shows a probability of seizures or epilepsy depending on the years since injury. So, up to 30 years. The severe should say 20 years instead of 10. Yeah, yeah, sorry, yeah. So, that's a typo. Yeah, so, it's actually—they did say greater than 10 years, but I'm not sure. Yeah, yeah, sorry, yeah. So, that's a typo. Yeah, so, it's actually—they did say greater than 10 years in the article, but looking at the graphs, I think it looks more like—and they said 10 to 15 years, but looking at the graphs, I feel like it looks more like 15 to 20 years. So, concussions. So, now we're going to the mildest spectrum of injury, the concussions. So, the other studies really lumped the mild TBI folks together, the complicated and uncomplicated. So, we're not really sure. Some might have had bleeds. Some might have not had bleeds. It's hard to tell. But is concussion a risk factor for epilepsy? Well, in the past, we actually thought there was twice as high of a risk as the general population of having epilepsy after concussion. Now, there's this recent article that came out, or study that came out, that showed actually the risk. So, they looked at 300, about 330 patients that suffered concussions, and they actually had an epileptologist look at their semiology for their seizures. And they found that these people, like eight of the people, had documented seizures, but the seizures were actually not really seizures. They're more non-epileptic events. So, we can, like numbness, one person had numbness on one side of the body. One person didn't have seizures, semiology, that classified as epilepsy, things like that. So, basically, they found that the risk for epilepsy is no greater than the general population of people with concussion, which is really interesting. So, basically, it shows that there's evidence now that there is no increased risk compared to the general population of people with concussions. It's complicated by a high frequency of non-epileptic seizures. And so, like a lot of the studies didn't really kind of go into what the semiology of the seizure was. I see in clinical practice that people with concussions tend to do have—a lot of them do have non-epileptic events, seizure-like events. And so, it's good to kind of classify to see, oh, these are really seizures, or these are just non-epileptic seizures. Especially people with migraines, too, they tend to have a high frequency, too, of non-epileptic events, too. So, what factors can increase the risk of posttraumatic epilepsy? Well, in the studies, they've shown that basically any of these factors—so, intracranial hematoma, kind of like we saw, definitely increases risk. Early seizures increases risk, so that means seizures within the first week. Posttraumatic amnesia, greater than 24 hours. At least one non-reactive pupil. I'm assuming that they mean probably somebody that's herniating or close to herniating. Depressed skull fracture. Neuropenetration. So, neuropenetration basically is the people with the open-head injuries where there's something that's actually penetrating the dura to the brain. Anyone after the—injury after 16 years of age. Interesting. Usually, it's more 65. They tend to have a higher risk. Glasgow Coma Scale of 3 to 8. So, basically, the severe TBI spectrum have a higher risk. Anyone also with focal neurological deficits. Also, I think they found if they have parietal lesions on CT. So, again, this is just an overview of the risk of posttraumatic epilepsy within the general population. Like I mentioned, it's from 0.5 to 2%. It is correlated to the severity of the head injuries. The more severe your head injury, the more likely you'll be able to develop epilepsy or the risk is higher. So, basically, in the study that we looked at, 30 years after TBI, it's 2% for the mild injuries, 4% for the moderate, and 15% for the severe. It depends on the study. Some say 16% for the severe injuries. If there's cortical injuries—so, again, if there's open-head injury, if the dura is penetrated, it's 50%. It's pretty high. It's very high. Late seizures. Late seizures. So, most people I've seen, too, in clinical practice develop their posttraumatic epilepsy within the first two years. So, actually, developing posttraumatic epilepsy is the highest in the first two years, and that kind of gradually decreases after that. In the severe TBI cases, in that study, one study that we looked at, 10 to 15 years, probably even more than that. Looking at the curves, probably it looks like closer to 20 years. So, what to do if a pilot has posttraumatic epilepsy. So, the FAA really didn't have clear guidelines, but I found guidelines on people that have epilepsy and whether it's okay to fly or not. So, in their guidelines, they say over 10 years, off anticonvulsant medications for the last 3 years. Possibly also need to have an EEG, and I usually always like to get EEGs on people, even when I'm about to take them off. Just to make sure there's no increased risk of having seizures in the future. And also, to neurological exam, EEG, probably also neuropsych exam, too. Imaging as well, yeah. So, air travel and epilepsy. So, there's only one study that's been done on air travel and people with epilepsy. So, looking at if air travel is safe in people with seizures or history of seizures. It actually shows that these people have frequent seizures. So, they're not pretty much uncontrolled seizures or not adequately controlled. I think there's about like 37-something subjects, so it's a very small number of subjects. But they found that these people actually had an increase in their seizure burden the week after a flight. But nobody had a seizure on the flight. Everything. Yeah. so it's actually relatively safe for people with epilepsy to fly, but they do have increased seizure burden, tend to have it after the flight. And a lot of the times it's probably because of jet lag, fatigue, time change. Usually people going—they found for people going westward in direction, or sorry, eastward in direction, tend to have more frequent seizures after the flight, too. So sleep deprivation does play a role, and I see this, too, in a lot of my patients with post-traumatic epilepsy after they've taken a flight. So should people with epilepsy fly pains? Well, risk for epilepsy and moderate TBI. So like in one of the slides prior, they said that it has to be no greater than the general population. Well, moderate TBI is increased for up to 10 years. So basically 10 years is the time where it reaches the general population. The risk is no longer increased. Severe TBIs with post-traumatic epilepsy have no cognitive deficits. I feel like this is very rare. Usually they do have some sort of deficit. It should be considered greater than 10 years or even at all. Usually people with post-traumatic epilepsy with severe TBIs, they are pretty impacted. So I would probably not be safe for training these kind of people to fly. So basically kind of agree with the current recommendations with flight. Obviously these people have to be neurocognitively intact. Their neuropsych exam has to be close to their baseline, close to the baseline of their peers. So hypoxia and flying. So how does hypoxia affect a pilot's performance? So there is a study done in, again, pilots in the Air Force. So basically they exposed them to a partial pressure, equivalent partial pressure of being 18,000 feet above sea level. And they found that their air control, their speed control, their altitude and speed control degraded by 53%. And a lot of them also had other symptoms, lightheadedness, physical tiredness, headaches, things like that, respiratory symptoms. In one study they found 64%, so a pretty high number had these symptoms. Again, you know, 18,000 feet is pretty high up in the air. And so also they found that 56.6 had memory confusion, judgment impairment, and 45 had psychomotor impairment too. So problems with dexterity, slowing with dexterity. So in this study, again, the study where they were exposed to partial pressures equivalent to that, being 18,000 feet above the air. Bless you. So 14 pilots, for a pretty small sample size actually, were given a flight task. So the flight task is basically holding a constant airspeed of 70 knots, altitude of being constant at 3,000 feet, and the heading was 180 degrees, and to kind of have a slower speed than the minimal aircraft drag speed. And these are the performance scores. So basically room air is prior to the task. This is under hypoxic conditions, so when they're 18,000 feet, simulated 18,000 feet in the air. And then the bottom here is back to room air, so post the task. As you can see here, there is a lot of variability in their ability to accomplish the task. Oh, sorry. There's a lot of variability here. And also, too, their airspeed and altitude and everything was higher. So they were supposed to keep a constant low altitude and airspeed, and theirs was significantly higher during when they were exposed to the hypoxic conditions as opposed to when they were room air. And so that was that study. This is another study, too, about oxygen saturation. So this is not really – this is not in pilots. This is more in athletes. And this study showed that athletes that were exposed to basically – I think it was about 8,000 feet had three hours after the flight, so they basically flew three hours. Their mean oxygen saturation decreased about 4%, so significantly from pre-flight. And when they reached their destination, again, their oxygen saturation kind of returned to baseline, but at three and seven hours, it significantly decreased. So basically, it's like – usually the oxygen dip or the hypoxia encountered during flight is temporary. So other effects of air travel that might influence performance and might influence their symptoms, especially people that suffer from concussion or more severe TBIs – jet lag, sleep disorder, especially with going westward – or eastward, I mean. Sorry. Dehydration, reduced quality of air in the cabin, noises, too, in the cabin, things like that. Pressure changes. So how does flying influence pilots who have suffered from a concussion? Well, no study has been done on that yet, on the performance of pilots who are suffering a concussion. But it's possible that during the flight travel, that hypoxia could compound their effects of concussion. So basically, concussion, we know there's decreased blood flow increase followed by a decrease in cerebral blood flow. Hypoxia could potentially increase the inflammation, decrease the blood flow even further, things like that. It could also lead to more worsening psychomotor slowing as well during the flight. So in terms of returning to flying after a concussion, well – so concussion convulsions, going back to the impact seizures. So early seizures – not really early seizures, but I would say more impact seizures. So seizures when they fall or after they fall, immediately after they fall or hit their head. So these actually are found to be non-epileptic. We don't know what the exact pathophysiology of that is, but they're actually not actually epileptic. So basically, the risk of having epilepsy, even in people with concussive convulsions, is not higher. It doesn't confer an increased risk of epilepsy, in other words. So it's not higher than the general population. And so now we know that possibly, too, neither do concussions confer an increased risk of epilepsy. So also, too, much of the pathophysiology resolves around four weeks. So the studies that I showed in my last lecture, there's a lot of the blood flow, the glutamate, the energy crisis that occurs during concussion kind of dips down and dies down around three to four weeks, give or take. And it depends on the study. So if there's no neurological sequelae, CT is normal, exam looks normal, psychological exam is normal, and you could even do the impact test or a brief screening, too, in a clinic, then it should be okay to return to flying. Those obviously with persistent symptoms should get a neuropsych evaluation just to see if there's anything else playing around with those symptoms and if they should be treated for any other factors like ADHD or sleep disorder or things like that. A lot of, especially younger people that have suffered a concussion, tends to unlock a migraine. So they have a concussion, they resolve from their concussion, their initial injury, and then they have symptoms, what they feel like is their concussion symptoms returning again. And a lot of times in those cases, it's just a migraine. They're basically getting migraines. And so that concussion has unlocked their predisposition to getting migraines. And so migraines is a chronic disorder. It comes and goes depending on stressors, depending on lack of sleep and things like that. And so frequent migraines do impair your ability to fly. So even in these folks, they should have migraines that are pretty well controlled with medication. Obviously, taking their board of medication when they're able to as well if they develop a migraine. So some risk factors for people with a concussion that might have migraine years in the future is basically family history of migraines, personal history of car sickness as a kid, things like that. And so I think that's pretty much it. The rest are cases which we could look at later. Any questions? Yeah. Compressive convulsions. Does that mean most of them will have normal EEGs? Yeah. So I usually don't get EEGs on those unless there's like a fracture or something. Or if there's something that you suspect there might be not compressive convulsion, something more. But, yeah, I usually don't get EEGs on those folks. Usually it's – and a lot of times the EEGs tend to be normal even in people with epilepsy just because if you're not capturing them in the event or immediately after the event, it's hard to see anything or know where the seizure is coming from. I have a question for you and Dr. Silberman. A little bit off of it, but we look at the EPILEPY exam and the bus driver exam. We tend to – apparently it's the FAA that we tend to, at the ultimate, are looking to as helping guide. There is a, I think, relatively new procedure. For example, I had a bus driver with familial tension or tremors. Very bad tremors. And the neurologist, they put a wire into the site. PBS? To decrease those tremors. But it pierced the nerve. They pierced. So I then took that. One of our rules, like for bus drivers, is that if they pierce, if you have a penetrating trauma, you cannot drive or whatever. So would that, if you got that in a pilot that had a procedure done like that, where they put a wire through, would that limit their ability to pull? Well, if they yield, there's not many, we'll yield Parkinson's and do them the deeps and keep brainy. They have led guides like that twice since way back. A lot of them still do well. I mean, if they start filling on multiple beds that are unacceptable, then they're gone. But I did a study. They asked me to do a study, I think during the government shutdown a bunch of years ago. And there was only a couple. Some of them, like one, there was two in all. I did 50 cases, random, of Parkinson's. And, you know, one got, was accepted. One got, eventually got grounded. You never know what happens. The governments, you know, are weird. They don't let us, let the government do surveys after a person, you know, gets lost or follow up, you know. If they stop flying, lots of times you don't know why. Right. And also, too, the surgical procedure is still a little different than if you have like a rod or something sticking out. That's like really piercing the dura. I think they're very more, like kind of, they're more exact with it. So a lot of times it does resolve over time. I'm not sure how long. But the DBS, yeah, there's not very many complications with the DBS procedure. But I know of course. What I'm asking is, you know, I kind of am a guru, like, especially for the bus driver. And what you can say, it does penetrate and that's kind of one of the rules. So to know, so you're saying out of 50, 48 weren't allowed to fly. No, out of 50, only about two of them had a deep brain stimulation. Okay. And I seem to recall that one of the fellows continued to fly and one of them got grounded. Yeah. And I know it's more exact, but so it could be considered to be that. Yeah, it's more exact. To be honest, I don't know. I don't know if the studies have been done on surgical procedures that actually pierce the dura. It's not like it's spiked. Right. And I'm sure there's going to be someone spying on them. Let me see if there's a chat going on and invite our presenters to uh any any I'm gonna uh temporarily allow folks to uh to unmute or if you raise your hand or type a question in for the uh into the chat. Okay you're now allowed to unmute yourself. Play play for the interior. They're the ones that feel as unique as they can be. What I call ultra mild. Yeah and I'm not I was going to ask Dr. Sharp. Any questions from our audience? She thought about because I thought that was used to be like you used to let the miles back like almost right away. Now it's six months and they all want. Six months and a huge workaround. And they want the biotech and they want six months. It's a huge workout because you're going to want to pay for these death and childhood. Right that's what. Just so you know this all these cases uh all these cases that were in that chart they all go to window. And so there's a bunch of paramedical neurologists and it was now they have one cardiologist because they ate in stuff. Uh look at these cases and and you know and argue about it. And but it's six months. Yeah six months. I normally keep my mouth shut because I I have a tendency not to. But you know I don't know that I agree with the six six shots for a very mild you know knock on the head and the guy's fine. And now he's down for six months. Right yeah I I agree. I think because like I said the pathophysiology resolves you know in four weeks. Give or take. Maybe even sooner than that. The CAA goes three. You know. Yeah. So yeah. I mean I the vast majority of my FAA adults are young people. Like people starting training. Right. That's a that's more or less just shooting around. Right. And so what it may be is all these kids when they were 14 they had some athletic event. And they and they tell me about it. When that puts it I mean and they they went back to school like the next day. And they you know they they got it you know 1700 of the rest. My answer is I would just explain it and don't do a workup. They want to and tell them that you know they become very conservative and they but I doubt that they're going to do. I find it. No they they won't stop. Oh you're kidding. Oh no it's like what is what is he like doing the guy like that after he's for six months. I mean he's not going to keep trying. They put him on this you know disability if they have it. The problem too with that. Oh yeah. So the problem with that too is if they're not doing anything. So they also have to probably be able to do exercise right. Without symptoms and things like that. Kind of like our athletes. We're not doing anything. Then sometimes that could make symptoms worse too. So it's kind of you have to find a sweet spot. Yeah. It's not too long yet not too short. Perhaps Dr. Sherman will be around a little longer and might answer any questions informally. But that'll have to be the end of our time.

traumatic brain injury

TBI recovery

air travel impact

concussion

FAA guidelines

neuropsychological testing

seizures and epilepsy

hypoxia

individualized care