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this condition. Brief lapses of awareness may occur with petit mal seizures (absence seizures),
commonly occurring in childhood.
ICAO Preliminary Unedited Version — October 2008 III-10-7
2. Partial Simple Seizures: Formerly known as focal seizures, partial simple seizures arise in a
discrete area of cerebral cortex, with seizure content depending on location. By definition
consciousness is preserved. Localized convulsive twitching of one hand might arise from a
neoplasm in the contra-lateral cerebral cortex.
3. Partial Complex Seizures: Formerly known as temporal lobe or psychomotor seizures, these
seizures are also focal (partial) in onset, but consciousness is impaired. An aura may occur such
as a déjà-vu experience, forced thought, or memory. Consciousness is impaired, and a dreamy
state may occur with non-responsiveness to the environment. Stereotyped movements (temporal
lobe automatism) may occur. The episode lasts a minute or two, with an element of post-ictal
confusion being common.
4. Partial Seizure with Secondary Generalization: Any partial seizure may spread to other cerebral
structures and evolve to a generalized tonic-clonic seizure. For example, a seizure may begin in
the hand and gradually spread to the limb and hemi-body (Jacksonian march3), then progress to a
generalized (grand mal or generalized tonic-clonic) seizure.
It is important to recognize a partial (focal) seizure, since this type of seizure implies a focal lesion. The
nature of the focal lesion (scar, haematoma, cavernous malformation, infarct, neoplasm, other) must be
determined. However, 60 per cent of all seizures are of unknown cause.
A generalized tonic-clonic (grand mal) seizure begins with a tonic phase lasting 15-20 seconds. Eyes
remain open and are deviated upward. Forced exhalation against partially closed vocal cords may lead to
a long, eerie, decrescendo “epileptic cry.” There is cyanosis, apnoea, and tonic extension of the limbs.
The tonic phase soon gives way to a clonic phase characterised by alternating clonic contractions and
relaxations. Relaxed intervals increase progressively until the seizure ends, usually within one to two
minutes. Tongue biting and incontinence commonly occur. Post-ictal confusion is characteristic, as is
amnesia for the event. Headache, nausea, vomiting, muscle soreness, and fatigue frequently follow a
seizure.
When evaluating seizures one must consider many factors, including family history, medication, alcohol,
illicit drugs, and remote neurological insult, as well as EEG and imaging findings. History is of
paramount importance in separating seizure from syncope with convulsive accompaniment.
History, neurological examination, electroencephalogram, and most often an imaging study (CT4 or MRI5
of the brain) are the components of a seizure evaluation. A drug screen may be appropriate along with
routine laboratory studies. The EEG can be normal in up to 40 per cent of individuals with seizures, and a
small number of persons have epileptiform EEGs but no seizures (respectively “fits without spikes” and
“spikes without fits”).
Seizures tend to recur, and thorough evaluation is warranted before considering medical certification.
Specific syndromes such as benign Rolandic6 epilepsy with centro-temporal spikes are characterized by
permanent remission from seizures. In others, seizures may recur after long intervals. Thorough
neurological evaluation is warranted when considering medical certification in individuals with a history
of seizures. A small number of individuals have been certified following epilepsy surgery.
Operational implications:
The existence of or history of a seizure disorder is disqualifying for all classes of medical certification.
3 Jacksonian march: the spread of abnormal electrical activity from one area of the cerebral cortex to adjacent areas.
After John Hughlings Jackson, English neurologist (1835-1911)
4 CT: computerised tomography
5 MRI: magnetic resonance imaging
6 Rolandic: named after Luigi Rolando, Italian anatomist (1773-1831)
ICAO Preliminary Unedited Version — October 2008 III-10-8
Aeromedical considerations:
It is prudent to adopt the position that seizures tend to recur, warranting permanent disqualification.
Medical certification is appropriate only in very specific circumstances in which the subject has been
fully evaluated and permanent remission has been assured. A history of febrile seizures does not portend
long term seizure potential. Specific self-limited conditions such as Benign Rolandic Epilepsy with
Centro-temporal Spikes will allow medical certification after an observation period of five years or more.
Acute symptomatic seizures (e.g. related to hyponatraemia) do not portend chronic seizure potential and
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Manual of Civil Aviation Medicine 2(27)
