Neurological disorders: assessing fitness to drive

Question

Accepted Answer

✘- Must not drive

! - May continue to drive subject to medical advice and/or notifying DVLA

✓- May continue to drive and need not notify DVLA

Serious neurological disorders

Changes to Annex III to the EC Directive 2006/126/EC require that driving licences may not be issued to, or renewed for, applicants or drivers who have a serious neurological disorder unless there is medical support from their doctors.

A serious neurological disorder is considered as:

any condition of the central or peripheral nervous system presently with, or at risk of progression to a condition with, functional (sensory (including special senses), motor and/or cognitive) effects likely to impact on safe driving

Further information relating to specific functional criteria is provided on:

specific neurological conditions in this chapter (Neurology)
cognitive and related conditions
visual conditions and disorders
excessive sleepiness

When considering licensing for these customers, the functional status and risk of progression will be considered. A short term medical review licence is generally issued when there is a risk of progression.

Epilepsy and seizures

Appendix B sets out the relevant regulations.

The following definitions apply:

epilepsy encompasses all seizure types, including major, minor and auras
if within a 24-hour period more than one epileptic event occurs, these are treated as a single event for the purpose of applying the epilepsy and seizure regulations
from a licensing perspective, epilepsy means 2 or more unprovoked seizures over a period which exceeds 24 hours and less than five years apart
epilepsy is prescribed in legislation as a relevant disability where there have been 2 or more epileptic seizures during the previous 5 year period
isolated seizure means one or more unprovoked seizures within a 24 hour period, or one or more unprovoked seizures within a 24 hour period where that period of seizure has occurred more than 5 years after the last unprovoked seizure

The following features, in both Group 1 car and motorcycle and Group 2 bus and lorry drivers, are considered to indicate a good prognosis for a person under care for a first unprovoked or isolated epileptic seizure:

no relevant structural abnormalities on brain imaging
no definite epileptiform activity on EEG
support of a neurologist
annual risk of seizure considered to be 2% or lower for bus and lorry drivers

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Epilepsy or multiple unprovoked seizures	✘- Must not drive and must notify DVLA. Driving must cease for 12 months from the date of the most recent seizure, unless the seizure meets legal criteria to be considered as a permitted seizure (see Appendix B).	✘- Must not drive and must notify DVLA. The person with epilepsy must remain seizure-free for 10 years (without epilepsy medication) before licensing may be considered.
First unprovoked epileptic seizure/isolated seizure	✘- Must not drive and must notify DVLA. Driving must cease for 6 months from the date of the seizure, or for 12 months if there is an underlying causative factor that may increase risk.	✘- Must not drive and must notify DVLA. Driving must cease for 5 years from the date of the seizure. If, after 5 years, a neurologist has made a recent assessment and clinical factors or investigation results (for example, EEG or brain scan) indicate no annual risk greater than 2% of a further seizure, the licence may then be restored. Such licensing also requires that there has been no need for epilepsy medication throughout the 5 years up to the date of the licence being restored.
Withdrawal of epilepsy medication	! - See the special considerations below, and Appendix B gives full guidance on withdrawing epilepsy medication.	! - See the special considerations below, and Appendix B gives full guidance on withdrawing epilepsy medication.
Provoked seizures	✘ - Must not drive and must notify DVLA. In most cases driving must cease for 6 months after the provoked seizure. See the special considerations in Appendix B and Provoked seizures.	✘ - Must not drive and must notify DVLA. Driving must cease for up to 5 years after the provoked seizure. See the special considerations in Appendix B and Provoked seizures.
Dissociative seizures	✘- Must not drive and must notify DVLA. Licensing may be considered when the driver or applicant has been event free for 3 months. If episodes have occurred or are considered likely to occur whilst driving, a specialist’s review would also be required prior to licensing.	✘- Must not drive and must notify DVLA. Licensing may be considered once episodes have been satisfactorily controlled for 3 months and there are no relevant mental health issues. If high risk features, a specialist’s review would be required prior to relicensing.

Special considerations

Here are the special considerations.

Group 1 car and motorcycle

The following special considerations apply to drivers of cars and motorcycles:

The person with epilepsy may qualify for a driving licence if they have been free from any seizure for 1 year. This needs to include being free of minor seizures, including those that do not involve a loss of consciousness, and epilepsy signs such as limb jerking, auras and absences.
The person who has had a seizure while asleep must stop driving for 1 year from the date of the seizure unless point 3 or 5 apply.
Relicensing may be granted if the person, over the course of at least 1 year from the date of the sleep seizure, establishes a history or pattern of seizures occurring only ever while asleep.
Relicensing may be granted if the person, over the course of at least 1 year from the date of the first seizure, establishes a history or pattern of seizures which affect neither consciousness nor cause any functional impairment. The person must never have experienced any other type of unprovoked seizure.
Regardless of preceding seizure history, if a person establishes a pattern of asleep seizures only (all seizures had onset during sleep), starting at least 3 years prior to licence application and there have been no other unprovoked seizures during those 3 years, a licence may be issued.

Overriding all of the above considerations is that the licence holder or applicant with epilepsy must not be regarded as a likely source of danger to the public while driving and that they are compliant with their treatment and follow up.

If the licensed driver has any epileptic seizure, they must stop driving immediately unless DVLA has established that considerations 3, 4 or 5 can be met, and they must notify DVLA.

If a licence is issued under considerations 3, 4 or 5 and the driver has a different type of seizure, they lose the concession, must stop driving, and must notify DVLA.

Isolated seizures

An isolated seizure is an unprovoked seizure experienced by a person who has not had any other unprovoked seizures during the preceding 5 years. A person who has an isolated seizure will qualify for a driving licence if they are free from any further seizure for 6 months, unless there are clinical factors or results of investigations suggesting an underlying causative factor that may increase the risk of a further seizure, in which case 12 months is required before relicensing.

Withdrawal of epilepsy medication (also see Appendix B)

Individuals should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose.

For a driver with epilepsy, if a seizure occurs within 6 months of, and because of a documented physician-advised substitution, reduction or withdrawal of anti-epilepsy medication, the regulations allow relicensing prior to the usual 12 month post-seizure period. Earlier relicensing may be considered if previously effective medication has been reinstated for at least 6 months and the driver has remained seizure free for at least 6 months.

Group 2 bus and lorry

Drivers of buses and lorries must satisfy all of the following conditions under the regulations. They must:

hold a full ordinary driving licence
have been free of epileptic seizures for the last 10 years
not have taken any medication to treat epilepsy during these 10 years (there are thus no special considerations for withdrawal)
have no continuing increased risk of epileptic seizures
not be a source of danger whilst driving

Isolated seizure

Drivers of buses and lorries must satisfy all the following conditions in relation to an isolated seizure. They must:

hold a full ordinary driving licence
have been free of epileptic attacks for the last 5 years
not have taken any medication to treat epilepsy or a seizure during these 5 years
have undergone a recent assessment by a neurologist
have no continuing increased risk of seizures

Transient loss of consciousness (‘blackouts’) – or lost/altered awareness

Transient loss of consciousness (TLoC) or ‘blackout’ is very common – it affects up to half the population in the UK at some point in their lives. An estimated 3% of A&E presentations and 1% of hospital admissions are due to TLoC.

Road traffic collisions resulting from blackouts are two or three times more common than those resulting from seizures.

Recurrent TLoC (more than one isolated event), not including syncope, is uncommon – but always requires detailed medical assessment.

There are several causes of transient loss of consciousness:

Syncope
Seizure/epilepsy - see epilepsy
Hypoglycaemia - see diabetes
Drug/alcohol
Sleep disorders - see excessive sleepiness
Undetermined - see syncope
Medication - see medications

In relation to TLoC, 3 features are of note to medical practitioners:

provocation
posture
prodrome

In relation to road safety, however, the 2 most important features are:

prodrome – are there warning symptoms sufficient in both nature and duration?
posture – do the episodes of TLoC occur while sitting?

A prodrome must allow time for a driver to find a safe place to stop before losing consciousness. A prodrome is reliable if the signs are clear, consistent across all events and provide sufficient duration to find a safe stop, or unreliable if these are absent.

Licence holders or applicants should be informed that they must notify DVLA when TLoC occurs while sitting.

For syncope occurring while standing or sitting, the following factors indicate high risk:

abnormal ECG
clinical evidence of structural heart disease

Further investigations such as 48-hour ambulatory ECG, echocardiography and exercise testing may be indicated after specialist opinion has been sought.

Transient loss of consciousness – solitary episode

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Typical vasovagal syncope
While standing	✓- May drive and need not notify DVLA.	✘- Must not drive and must notify DVLA.
While sitting	! - May drive and need not notify DVLA if there is an avoidable trigger which will not occur whilst driving. Otherwise, must not drive until annual risk of recurrence is assessed as below 20%.	✘- Must not drive for 3 months and must notify DVLA. Will require investigation for identifiable and/or treatable cause.
Syncope with avoidable trigger or otherwise reversible cause (see cough syncope)
While standing	✓- May drive and need not notify DVLA.	✘- Must not drive and must notify DVLA.
While sitting	✘- Must not drive for 4 weeks. Driving may resume after 4 weeks only if the cause has been identified and treated. Must notify DVLA if the cause has not been identified and treated.	✘- Must not drive for 3 months. Driving may resume after 3 months only if the cause has been identified and treated. Must notify DVLA if the cause has not been identified and treated.
Unexplained syncope, including syncope without reliable prodrome
This diagnosis may apply only after appropriate neurological and/or cardiological opinion and investigations have detected no abnormality.
While standing or sitting	✘- Must not drive and must notify DVLA. If no cause has been identified, the licence will be refused or revoked for 6 months.	✘- Must not drive and must notify DVLA. If no cause has been identified, the licence will be refused or revoked for 12 months.
Cardiovascular, excluding typical syncope
While standing or sitting	✘- Must not drive and must notify DVLA. Driving may be allowed to resume after 4 weeks if the cause has been identified and treated. If no cause has been identified, the licence will be refused or revoked for 6 months.	✘- Must not drive and must notify DVLA. Driving may be allowed to resume after 3 months if the cause has been identified and treated. If no cause has been identified, the licence will be refused or revoked for 12 months.
Blackout with seizure markers
This category is for those where on the balance of probability there is clinical suspicion of a seizure but no definite evidence. Individuals will require assessment by an appropriate specialist and investigation, for example EEG and brain scan, where indicated. The following factors indicate a likely seizure: ■ loss of consciousness for more than 5 minutes ■ amnesia longer than 5 minutes ■ injury ■ tongue biting ■ incontinence ■ post ictal confusion ■ headache post attack
While standing or sitting	✘ - Must stop driving and notify DVLA. 6 months off driving from the date of the episode. If there are factors that may lead to an increased risk of recurrence, 1 year off driving would be required.	✘ - Must stop driving and notify DVLA. 5 years off driving from the date of the episode.

Transient loss of consciousness – recurring episodes

Recurrent episodes of TLoC are less common than isolated episodes but the relevance to increased risk in driving cannot be overemphasised.

Recurrent TLoC is most commonly due to recurrent syncope, occurring in around 20% to 30% of patients. Recurrence of syncope is usually within 3 years of the first episode, and in over 80% of these cases there has been at least one additional episode within 2 years of the first episode.

In relation to road safety however, the 2 most important features of temporary loss of consciousness are:

prodrome – are there warning signs sufficient in both nature and duration?
posture – do the episodes of TLoC occur while sitting?

A prodrome must allow time for a driver to find a safe place to stop before losing consciousness. A prodrome is reliable if the signs are clear, consistent across all events and provide sufficient duration to find a safe stop, or unreliable if these are absent.

Recurrent pre-syncopal events should be treated (from a licensing point of view) in the same way as recurrent syncope and should therefore be categorised according to the standards for recurrent syncope.

Licence holders or applicants should be informed that they must notify DVLA when transient loss of consciousness occurs while sitting.

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Recurrent typical vasovagal syncope with identifiable consistent prodrome
While standing	✓- May drive and need not notify DVLA.	✘- Must not drive and must notify DVLA.
While sitting	! - May drive and need not notify DVLA if there is an avoidable trigger which will not occur whilst driving. Otherwise, must not drive until annual risk of recurrence is assessed as below 20%.	✘- Must not drive and must notify DVLA. Must not drive until annual risk of recurrence is assessed as below 2%. Will require investigation for identifiable and/or treatable cause.
Recurrent syncope with avoidable trigger or otherwise reversible cause (see cough syncope)
While standing	✓- May drive and need not notify DVLA.	✘- Must not drive and must notify DVLA.
While sitting	✘- Must not drive for 4 weeks. Driving may resume after 4 weeks only if the cause has been identified and treated. Must notify DVLA if the cause has not been identified and treated.	✘- Must not drive for 3 months. Driving may resume after 3 months only if the cause has been identified and treated. Must notify DVLA if the cause has not been identified and treated.

For syncope occurring while standing or sitting, the following factors indicate high risk:

abnormal ECG
clinical evidence of structural heart disease

Further investigations such as 48-hour ambulatory ECG, echocardiography and exercise testing may be indicated after specialist opinion has been sought.

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Recurrent unexplained syncope, including syncope without reliable prodrome
This diagnosis may apply only after appropriate neurological and/or cardiological opinion and investigations have detected no abnormality.
While standing or sitting	✘- Must not drive and must notify DVLA. If no cause has been identified, the licence will be refused or revoked for 12 months.	✘- Must not drive and must notify DVLA. If no cause has been identified, the licence will be refused or revoked for 10 years.
Recurrent cardiovascular but excluding typical vasovagal syncope
While standing or sitting	✘- Must not drive and must notify DVLA. Driving may resume after 4 weeks only if the cause has been identified and treated. If no cause has been identified, the licence will be refused or revoked for 12 months.	✘- Must not drive and must notify DVLA. Driving may resume after 3 months only if the cause has been identified and treated. If no cause has been identified, the licence will be refused or revoked for 2 years.
Recurrent blackout with seizure markers
This category is for those where on the balance of probability there is clinical suspicion of a seizure but no definite evidence. Individuals will require assessment by an appropriate specialist and investigation, for example EEG and brain scan, where indicated.
While standing or sitting	✘- Must stop driving and notify DVLA. Depending on previous medical history, the standards for isolated seizure or epilepsy will apply.	✘- Must stop driving and notify DVLA. Depending on previous medical history, the standards for isolated seizure or epilepsy will apply.

Cough syncope

Having experienced an episode or episodes of cough syncope, a person has identified themselves as being in a higher risk group that is predisposed to cough syncope. Therefore, even if the cough syncope episode occurred during a short-lived period of increased cough (such as an episode of acute respiratory infection), this would not alter the fact that the person is then at a higher risk of experiencing an episode of cough syncope whenever they cough, regardless of the cause.

Treatment, management or resolution of the condition which caused the cough does not reduce the risk of syncope with further episodes of cough.

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive and must notify DVLA. Must not drive for 6 months following a single episode and for 12 months following multiple episodes over 5 years. If more than one episode of cough syncope occurs within a 24 hour period, this will be counted as a single event. However, if the episodes of cough syncope are more than 24 hours apart, these are considered as multiple episodes.	✘- Must not drive and must notify DVLA. Must not drive for 12 months following a single episode and 5 years following multiple episodes over 5 years. If more than one episode of cough syncope occurs within a 24 hour period, this will be counted as a single event. However, if the episodes of cough syncope are more than 24 hours apart, these are considered as multiple episodes.

Primary/central hypersomnias – including narcolepsy type 1 (narcolepsy with cataplexy) and type 2

For other causes of excessive sleepiness, see Chapter 8 (miscellaneous conditions).

Group 1
Car and motorcycle

Group 2
Bus and lorry

✘- Must not drive and must notify DVLA.

A licence may be issued only when there has been satisfactory symptom control for at least 3 months.

Should an assessment of symptom control be required, including those instances when an applicant or licence holder is not receiving treatment, relicensing may be considered after satisfactory objective assessment of maintained wakefulness, such as an on-road driving assessment*.

Should treatment be discontinued (e.g. when pregnant or when planning pregnancy), driving should cease until a minimum period of one month’s stability of satisfactory symptom control has been attained.

✘- Must not drive and must notify DVLA.

A licence may be issued only when there has been satisfactory symptom control for at least 3 months.

The following requirements must all be met:

■ under the clinical care of an appropriate specialist and receiving at least annual specialist review
■ a concomitant diagnosis of obstructive sleep apnoea syndrome (OSAS) has either been specifically excluded or, if the condition is present, the medical standards for OSAS are met
■ an on-road driving assessment* has confirmed satisfactory control of symptoms

Should treatment be discontinued (e.g. when pregnant or when planning pregnancy), driving should cease until specialist opinion confirms stability of condition and low risk.

*The on-road assessment should require a minimum period of 90 minutes driving in an appropriate vehicle.

Chronic neurological disorders – including multiple sclerosis and motor neurone disease

Any chronic neurological disorder that may affect vehicle control because of impaired coordination and muscle strength.

For information on in-car driving assessments for those with a disability, see Appendix G.

Group 1 Car and motorcycle	Group 2 Bus and lorry
! - Must notify DVLA. May continue to drive as long as safe vehicle control is maintained at all times. A licence valid for 1, 2, 3 or 5 years may be issued provided medical enquiries by DVLA confirm that driving performance is not impaired. The licence may specify a restriction to cars with certain controls.	! - Must notify DVLA. May continue to drive as long as safe vehicle control is maintained at all times. A licence will be refused or revoked if the individual's condition is progressive or disabling. If driving is not impaired and the underlying condition is stable, licensing will be considered on an individual basis subject to satisfactory medical reports and annual review.

Parkinson’s disease

Group 1
Car and motorcycle

Group 2
Bus and lorry

! - Must notify DVLA.

May drive as long as safe vehicle control is maintained at all times.

If the individual's condition is disabling and/or there is clinically significant variability in motor function, the licence will be refused or revoked.

If driving is not impaired, licensing will be considered subject to satisfactory medical reports.

A licence may be issued subject to regular review.

! - Must notify DVLA.

May drive as long as safe vehicle control is maintained at all times.

If the individual's condition is disabling and/or there is clinically significant variability in motor function, the licence will be refused or revoked.

If driving is not impaired, licensing will be considered subject to satisfactory medical reports and assessment.

A licence may be issued subject to annual review.

Dizziness – liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness

Sudden is defined as ‘without sufficient warning to allow safe evasive action when driving’ and disabling is defined as ‘unable to continue safely with the activity being performed’.

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive on presentation and must notify DVLA. When satisfactory control of symptoms has been achieved, relicensing may be considered for restoration of the ’til 70 licence.	✘- Must not drive on presentation and must notify DVLA. If there are sudden and disabling symptoms, the licence will be refused or revoked. If an underlying diagnosis is likely to cause recurrence, the patient must be asymptomatic and completely controlled for 1 year from an episode before reapplying for their licence.

Stroke, transient ischaemic attack (TIA) and cerebral venous thrombosis – including amaurosis fugax and retinal artery occlusion

For Group 2 bus and lorry drivers, the guidance is the same whether concerning stroke, or single or multiple transient ischaemic attack (TIA).

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Stroke and cerebral venous thrombosis	✘- Must not drive but may not need to notify DVLA. Driving may resume after 1 month if there has been satisfactory clinical recovery. DVLA does not need to be notified unless there is residual neurological deficit 1 month after the episode and, in particular: ■ visual field defects ■ cognitive defects ■ impaired limb function Minor limb weakness alone after a stroke will not require notification to DVLA unless restriction to certain types of vehicle or adapted controls may be needed. With adaptations, severe physical impairment may not be an obstacle to driving. Seizures occurring at the time of a stroke or TIA, or in the ensuing first week, may be treated as provoked for licensing purposes, provided there is no previous history of unprovoked seizure or cerebral pathology. Such provoked seizures will usually necessitate driving cessation. See Appendix B.	✘- Must not drive and must notify DVLA. A licence will be refused or revoked for 1 year following a stroke or TIA. Relicensing after 1 year may be considered if: ■ there is no debarring residual impairment likely to affect safe driving and ■ there are no other significant risk factors. Licensing may be subject to a satisfactory medical report, including results of exercise ECG testing. Following an isolated stroke or TIA, if there is imaging evidence of less than 50% carotid artery stenosis and there is no previous history of cardiovascular disease, a licence may be issued without the need for functional cardiac assessment. Patients with recurrent TIAs or strokes will be required to undergo functional cardiac testing. If the condition is cerebral venous thrombosis, a licence may be issued without the need for functional cardiac assessment.
Transient ischaemic attack	✘- Must not drive for 1 month but need not notify DVLA. Where more than one TIA is experienced, 1 month off driving is required following each episode of TIA.

Cerebral amyloid angiopathy (CAA)-related transient focal neurological episodes (TFNE) are usually recurrent, stereotyped attacks of unilateral spreading symptoms including paraesthesia, numbness, or weakness (alone or in combination), lasting less than 10 minutes. In most cases, TFNE are associated with either convexity sub-arachnoid haemorrhage (cSAH), cortical superficial siderosis (the chronic form of cSAH), or both.

CAA related TFNE

Group 1 Car and motorcycle	Group 2 Bus and lorry
X - Must not drive and must notify DVLA. Driving must cease for 6 months from the most recent CAA-related TFNE.	! - Must notify DVLA. Driving must cease for 5 years from the most recent CAA-related TFNE.

See also the section on non-aneurysmal subararchnoid haemorrhage (including perimesencephalic).

Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS)

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive but need not notify DVLA. Driving may resume following clinical recovery. If associated with stroke (cerebral infarct or haemorrhage), the stroke standards will apply. If associated with seizure(s), the provoked seizure guidance will apply (see Appendix B).	✘- Must not drive and must notify DVLA. Driving may resume following clinical recovery. If associated with stroke (cerebral infarct or haemorrhage), the stroke standards will apply (see Appendix B).

Visual inattention

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive and must notify DVLA. Clinically apparent visual inattention is debarring for licensing.	✘- Must not drive and must notify DVLA. Clinically apparent visual inattention is debarring for licensing.

Carotid artery stenosis

Group 1 Car and motorcycle	Group 2 Bus and lorry
✓- May drive and need not notify DVLA.	! - Should not drive unless, in the view of an appropriate healthcare professional, it is safe to do so. Must notify DVLA. If the level of stenosis is over 50%, the requirements for exercise or other functional test must be met – see Appendix C.

Acute encephalitic illness and meningitis - including limbic encephalitis associated with seizures

Group 1
Car and motorcycle

Group 2
Bus and lorry

✘- Must not drive and may need to notify DVLA.

If there are no seizures, driving may resume after complete clinical recovery and DVLA need not be notified unless there is residual disability.

If associated with seizure(s) DVLA must be notified and driving must cease.

a. If seizures occur during an acute febrile illness, providing there is no previous history of unprovoked seizure or pre-existing cerebral pathology, a licence will be revoked or refused for 6 months.

b. If seizures occur during or after convalescence, or if there is a previous history of unprovoked seizure or pre-existing cerebral pathology, a licence will be refused or revoked for 12 months - see (Appendix B).

✘- Must not drive and may need to notify DVLA.

a. If there are no seizures, may resume driving after complete clinical recovery and need not notify DVLA unless there is residual disability.

b. If seizures occur, DVLA must be notified and will refuse or revoke a licence until the regulations are met - see (Appendix B).

Transient global amnesia

Group 1 Car and motorcycle	Group 2 Bus and lorry
! - May drive provided epilepsy, any sequelae from head injury and other causes of altered awareness have been excluded. DVLA does not need to be notified and a ’til 70 licence may be retained.	! - Driving is not barred by a single confirmed episode, and the licence may be retained. Driving should stop if 2 or more episodes occur, and DVLA must be notified. Specialist assessment will be required to exclude all other causes of altered awareness.

Arachnoid cysts

Management	Group 1	Group 2
Observation without any symptoms likely to affect driving	Supratentorial ✓- May drive and need not notify DVLA. Infratentorial ✓- May drive and need not notify DVLA.	Supratentorial ✓- May drive and need not notify DVLA. Infratentorial ✓- May drive and need not notify DVLA.
Treatment – burr hole/craniotomy	Supratentorial ✘- Must not drive for 6 months and must notify DVLA. Infratentorial ✓- May drive and need not notify DVLA.	Supratentorial ✘- Must not drive and must notify DVLA. Relicensing may be considered after 1 year following treatment, provided there is no debarring residual impairment likely to affect safe driving. Infratentorial ! - Must notify DVLA and may drive on recovery from surgery.

Colloid cysts

Management	Group 1	Group 2
Observation and without any symptoms likely to affect driving	✓- May drive and need not notify DVLA.	! - Must notify DVLA. May be able to drive provided there are no symptoms or impairment that affects driving. If prophylactic medication for seizures is prescribed, cases will be individually assessed. Ongoing licensing will be subject to review.
Treatment	Neuroendoscopy ✘- Must not drive for 6 months and must notify DVLA. Craniotomy ✘- Must not drive for 6 months and must notify DVLA.	Neuroendoscopy ✘- Must not drive and must notify DVLA. Relicensing may be considered after 1 year following treatment, provided there is no debarring residual impairment likely to affect safe driving. Craniotomy ✘- Must not drive and must notify DVLA. Relicensing may be considered after two years following treatment. Individual consideration will be given as to whether driving may be allowed to resume after this time depending on surgical approach and recovery with no debarring residual impairment likely to affect safe driving.

Pituitary tumour

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Treated by craniotomy	✘- Must not drive and must notify DVLA. Driving may resume after 6 months provided there is no visual field defect. If there is visual field loss, see visual disorders.	✘- Must not drive and must notify DVLA. Driving will remain prohibited for 2 years.
No need for treatment, or treated by transsphenoidal surgery or therapy such as drugs or radiotherapy	✘- Must not drive but need not notify DVLA. Driving may resume on recovery provided there is no debarring visual field defect.	✘- Must not drive but need not notify DVLA. Driving may resume on recovery provided there is no debarring visual field defect.

Brain tumours

The standards will apply to first occurrence, recurrence and progression.

Section 1 classifies the different tumour types into 4 groups:

very low risk primary brain tumours
low risk primary brain tumours
high risk primary brain tumours
metastatic cerebral disease, primary and secondary lymphoma, and non-Central Nervous System (CNS) tumours invading intracranially and breaching the dura

The risk refers to seizure risk and/or risk of recurrence and also the risk of deterioration.

Section 2 then provides the medical standards of fitness to drive for Group 1 licensing (cars and motorcycles) and Group 2 licensing (lorries and buses) for each of these 4 groups.

The standards for acoustic neuroma/schwannoma, pituitary tumours and arachnoid and colloid cysts are detailed elsewhere.

In individuals where there are mixed grades of tumours and/or two types of therapy, the higher standard (longer time off driving) will apply.

When a tumour or its treatment is being monitored with imaging, this should usually demonstrate an absence of progression or deterioration.

Pineal tumours have been categorised as infratentorial in the classification table. DVLA acknowledges these tumours are not anatomically considered to be infratentorial. It was concluded this classification best reflected the risk of seizures and potential effect on driving of this tumour type.

If the tumour has been associated with seizures, please refer to the seizure guidelines within Assessing Fitness to Drive: A guide for medical professionals, which will apply in addition to the standards listed in this document. A brain tumour is generally considered to be an underlying risk factor that increases risk of further seizures, and a longer time off driving will be applied. Licensing is dependent on there being no residual impairment likely to affect safe driving, for example, debarring hemianopia or cognitive impairment.

Section 1 – Classification of tumour

Classification	Brain tumours
Very low risk (0-6 months off driving for Group 1)	Supratentorial ■ WHO Grade 1 meningioma, without seizures or any persisting neurological impairment that would affect driving. ■ Asymptomatic, diagnosed or suspected low-grade tumours identified on imaging which are being monitored only and not treated or biopsied. Infratentorial ■ Meningiomas (WHO Grade 1 and 2) ■ WHO Grade 1 glioma ■ WHO Grade 1 glioneuronal tumour ■ WHO Grade 1 haemangioblastoma ■ Subependymoma ■ Ependymomas ■ IDH mutant WHO Grade 2 and 3 Gliomas ■ Pineocytoma ■ Germinoma, pineal parenchymal tumours of indeterminate differentiation and papillary tumours of the pineal region ■ Asymptomatic, diagnosed or suspected low-grade tumours identified on imaging which are being monitored only and not treated or biopsied
Low risk (1 year off driving for Group 1)	Supratentorial ■ WHO Grade 1 meningioma associated with seizure ■ WHO Grade 2 meningioma ■ WHO Grade 1 Glioma or glioneuronal tumour ■ IDH mutant WHO Grade 2 and Grade 3 glioma (astrocytoma and oligodendroglioma) except IDH mutant astrocytoma with the CDKN2A/B homozygous deletion ■ Ependymoma except RELA fusion positive ependymomas (please see high risk) Infratentorial ■ PNET ■ Medulloblastoma ■ Pineoblastoma
High risk (2 years off driving for Group 1)	Supratentorial ■ IDH wild type WHO Grade 2 and 3 astrocytoma ■ IDH mutant Grade 4 astrocytoma ■ IDH mutant Grade 2 or 3 astrocytoma with the CDKN2A/B homozygous deletion ■ Glioblastoma/Gliosarcoma ■ Diffuse Midline Glioma ■ PNET ■ WHO Grade 3 or malignant (anaplastic) meningioma ■ RELA fusion positive ependymoma Infratentorial ■ WHO Grade 4 astrocytoma ■ IDH wild type WHO Grade 2 and 3 astrocytoma ■ Diffuse Midline Glioma ■ WHO Grade 3 or malignant (anaplastic) meningioma
Brain Metastases Primary and Secondary CNS lymphoma Non-CNS tumours invading intracranially and breaching the dura	Standards apply to first occurrence and any cerebral recurrence but not to recurrence elsewhere in the body.

Section 2 – Medical standards of fitness to drive

Very low risk brain tumours

Management	Group 1 licensing	Group 2 licensing
Observation	✓- May drive and need not notify DVLA.	✘- Must not drive and must notify DVLA. Driving must stop for at least 12 months. A return to driving can be considered after 2 scans performed 12 months apart confirm stability of the lesion.
Biopsy only	Supratentorial ✘- Must not drive and must notify DVLA. Driving must stop until at least 6 months after the biopsy. Infratentorial ! - Must notify DVLA and may drive on recovery. If a supratentorial approach is used, then driving must stop until at least 6 months after the biopsy.	Supratentorial ✘- Must not drive and must notify DVLA. Driving must stop until 2 scans 12 months apart confirm stability of the lesion AND driving cannot resume until at least 6 months after the biopsy. Infratentorial ✘- Must not drive and must notify DVLA. A return to driving can be considered after 2 scans performed 12 months apart confirm stability of the lesion and there is full recovery from the biopsy. If a supratentorial approach is used, driving cannot resume until at least 6 months after the biopsy.
Surgical management (neuroendoscopy)	Supratentorial ✘- Must not drive and must notify DVLA. Driving must stop until at least 6 months after the neuroendoscopic treatment. Infratentorial ! - Must notify DVLA and may drive on recovery from the neuroendoscopic treatment. However, if a supratentorial approach is used, then driving must stop until at least 6 months after the neuroendoscopic treatment.	Supratentorial ✘- Must not drive and must notify DVLA. Driving must stop until at least 3 years after the neuroendoscopic treatment. Provided there is evidence of stability on imaging a return to driving can be considered after 3 years. Infratentorial ! - Must notify DVLA and may drive on recovery from the neuroendoscopic treatment. However, if a supratentorial approach is used, then driving must stop until at least 1 year after neuroendoscopic treatment.
Surgical management (craniotomy)	Supratentorial ✘- Must not drive and must notify DVLA. Driving must stop until at least 6 months after surgery. Infratentorial ! - Must notify DVLA and may drive on recovery from surgery. However, if a supratentorial approach is used, driving must stop until at least 6 months after surgery.	Supratentorial ✘- Must not drive and must notify DVLA. Driving must stop until at least 3 years after surgery. Provided there is evidence of stability on imaging a return to driving can be considered after 3 years. Infratentorial ! - Must notify DVLA and may drive on recovery from surgery. However, if a supratentorial approach is used, driving must stop until at least 1 year after surgery.
Radiotherapy (this includes stereotactic radiosurgery)	✘- Must notify DVLA and may drive on full recovery from treatment.	Supratentorial ✘- Must not drive and must notify DVLA. Driving must stop until at least 3 years after completion of radiotherapy. Provided there is evidence of stability on imaging a return to driving can be considered after 3 years. Infratentorial ! - Must notify DVLA and may drive on full recovery from treatment.
Chemotherapy	! - Must notify DVLA and may drive on full recovery from treatment.	Supratentorial ✘- Must not drive and must notify DVLA. Driving must stop until at least 3 years after starting chemotherapy treatment. Provided there is evidence of stability on imaging a return to driving can be considered after 3 years. Infratentorial ! - Must notify DVLA and may drive on full recovery from treatment.

Low risk brain tumours

Management	Group 1 licensing	Group 2 licensing
Observation	! - Must notify DVLA and may drive, provided there are no seizures and no impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. Driving must stop for at least 1 year. A return to driving can be considered after 2 scans performed 12 months apart confirm stability of the lesion.
Biopsy only	✘- Must not drive and must notify DVLA. Driving must stop until at least 6 months after the biopsy.	✘- Must not drive and must notify DVLA. In cases of meningioma driving must stop until at least 3 years after the biopsy. In cases of glioma driving must stop until at least 5 years after the biopsy. Provided there is evidence of stability on imaging a return to driving can be considered after this time.
Surgical management (neuroendoscopy)	✘- Must not drive and must notify DVLA. Driving must stop until at least 6 months after neuroendoscopic treatment.	✘- Must not drive and must notify DVLA. In cases of meningioma driving must stop until at least 3 years after neuroendoscopic treatment. In cases of glioma driving must stop until at least 5 years after neuroendoscopic treatment. Provided there is evidence of stability on imaging a return to driving can be considered after this time.
Surgical management (craniotomy)	✘- Must not drive and must notify DVLA. Driving must stop until at least 1 year after surgery.	✘- Must not drive and must notify DVLA. In cases of meningioma driving must stop until at least 3 years after surgery. In cases of glioma driving must stop until at least 5 years after surgery. Provided there is evidence of stability on imaging a return to driving can be considered after this time.
Radiotherapy	✘- Must not drive and must notify DVLA. Driving must stop until at least 1 year after completion of radiotherapy.	✘- Must not drive and must notify DVLA. In cases of meningioma driving must stop until at least 3 years after the completion of radiotherapy. In cases of glioma driving must stop until at least 5 years after the completion of radiotherapy. Provided there is evidence of stability on imaging a return to driving can be considered after this time.
Chemotherapy	✘- Must not drive and must notify DVLA. If chemotherapy is the only primary treatment driving must stop for at least 1 year after starting the chemotherapy treatment. If chemotherapy is used in addition to surgery and/or targeted radiotherapy treatment driving must stop for at least 1 year from the completion of the surgical and/or radiotherapy treatment. If there is evidence, on imaging, of stability or improvement a return to driving can then be considered after 1 year.	✘- Must not drive and must notify DVLA. In cases of meningioma driving must stop until at least 3 years after starting the chemotherapy treatment. In cases of glioma driving must stop until at least 5 years after starting chemotherapy treatment. Provided there is evidence of stability on imaging a return to driving can be considered.
Recurrence or progression identified on imaging alone	! - Must notify DVLA. May be able to drive where there is imaging evidence of tumour recurrence or progression, if: ■ the seizure standards are met ■ there is no clinical disease progression ■ no further primary treatment (except for chemotherapy) was required for the recurrence If these criteria cannot be met, driving must stop for at least 1 year following further primary treatment for recurrence/progression. Following a seizure the seizure regulations would have to be satisfied.	✘- Must not drive and must notify DVLA. In cases of meningioma driving must stop until at least 3 years after treatment. In cases of glioma driving must stop until at least 5 years after treatment. Provided there is evidence of stability on imaging a return to driving can be considered after this time.

High risk brain tumours

Management	Group 1 licensing	Group 2 licensing
Observation	✘- Must not drive and must notify DVLA. If a high-risk tumour is not treated a licence application will not be considered.	✘- Must not drive and must notify DVLA. If a high-risk tumour is not treated a licence application will not be considered.
Biopsy only	✘- Must not drive and must notify DVLA. If a high-risk tumour is not treated a licence application will not be considered.	✘- Must not drive and must notify DVLA. If a high-risk tumour is not treated a licence application will not be considered.
Surgical management with craniotomy	✘- Must not drive and must notify DVLA. Driving must stop until at least 2 years after surgery.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked permanently.
Radiotherapy	✘- Must not drive and must notify DVLA. Driving must stop until at least 2 years after completion of radiotherapy.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked permanently.
Chemotherapy	✘- Must not drive and must notify DVLA. If chemotherapy is the only primary treatment driving must stop for at least 2 years after starting the chemotherapy treatment. If chemotherapy is used in addition to surgery and/or radiotherapy treatment driving must stop for at least 2 years from the completion of the surgical and/or radiotherapy treatment. Relicensing after the 2 years will also require evidence of stability or improvement, on imaging.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked permanently.

Metastatic brain disease, CNS Lymphoma and non-CNS tumours invading intracranially and breaching the dura – these standards apply to any cerebral recurrences as well as first occurrence

Management	Group 1 licensing	Group 2 licensing
Observation (incidental – only those identified on interval scanning without symptoms)	! - May drive and must notify DVLA.	✘- Must not drive and must notify DVLA. Driving must stop for at least 1 year. A return to driving can be considered after 2 scans performed 12 months apart confirm stability of the lesion. Licence will be issued on annual review
Observation (symptomatic)	✘- Must not drive and must notify DVLA. If a symptomatic metastatic lesion is not treated a licence application will not be considered.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked permanently.
Biopsy only	✘- Must not drive and must notify DVLA. If a symptomatic metastatic lesion is not treated a licence application will not be considered. If there are no symptoms and the lesion(s) was identified on interval scanning then driving must stop for 6 months after the biopsy. If after 6 months there is evidence on imaging of stability, with no progression, and the person remains asymptomatic, a return to driving can then be considered.	✘- Must not drive and must notify DVLA. Driving must stop for 1 year after identification of the tumour and 6 months after a biopsy for incidental lesions identified on interval scanning. A return to driving may be considered after 2 scans performed 12 months apart confirm stability of the lesion. The licence will be refused or revoked permanently if symptomatic.
Surgical management (neuroendoscopy)	✘- Must not drive and must notify DVLA. Driving must stop until at least 1 year after neuroendoscopic treatment.	✘- Must not drive and must notify DVLA. Driving must stop until at least 5 years after neuroendoscopic or surgical treatment. Provided there is evidence of stability on imaging a return to driving can be considered after 5 years.
Surgical management (craniotomy)	✘- Must not drive and must notify DVLA. Driving must stop until at least 1 year after surgery.	✘- Must not drive and must notify DVLA. Driving must stop until at least 5 years after neuroendoscopic or surgical treatment. Provided there is evidence of stability on imaging a return to driving can be considered after 5 years.
Radiotherapy (targeted)	✘- Must not drive and must notify DVLA. Driving must stop until at least 1 year after completion of targeted radiotherapy.	✘- Must not drive and must notify DVLA. Driving must stop until at least 5 years after the completion of targeted radiotherapy. Provided there is evidence of stability on imaging a return to driving can be considered after 5 years.
Radiotherapy (whole brain)	✘- Must not drive and must notify DVLA. Driving must stop until at least 2 years after completion of the whole brain radiotherapy.	✘- Must not drive and must notify DVLA. Driving must stop until at least 5 years after the completion of targeted radiotherapy. Provided there is evidence of stability on imaging a return to driving can be considered after 5 years. Driving must stop until at least 5 years after treatment with whole brain radiotherapy. Each case will then be considered individually.
Chemotherapy	✘- Must not drive and must notify DVLA. If chemotherapy is the only primary treatment driving must stop for at least 1 year after starting the chemotherapy treatment. If chemotherapy is used in addition to surgery and/or radiotherapy treatment driving must stop for at least 1 year from the completion of the surgical and/or radiotherapy treatment. Providing there is evidence, on imaging, of stability or improvement a return to driving can be considered after 1 year.	✘- Must not drive and must notify DVLA. Driving must stop until at least 5 years after starting chemotherapy treatment. Provided there is evidence of stability on imaging a return to driving can be considered after 5 years.
Molecular targeted therapy/immunotherapy	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Driving must stop until at least 1 year after the completion of the primary surgery or targeted radiotherapy (or 1 year after starting immunotherapy or molecular targeted therapy if no other primary treatment for the intracranial disease has been given). Provided there is clinical and imaging evidence of disease stability or improvement, with no deterioration intracranially, a return to driving can then be considered.	✘- Must not drive and must notify DVLA. Driving must stop until at least 5 years after the completion of the primary surgery or targeted radiotherapy (or 5 years after starting the molecular targeted therapy or immunotherapy if no other primary treatment for the intracranial disease has been given). Provided there is clinical and imaging evidence of disease stability or improvement, with no deterioration intracranially, a return to driving can then be considered after 5 years. If these criteria cannot be met the Group 2 licence will be permanently revoked.

Acoustic neuroma/schwannoma

Group 1 Car and motorcycle	Group 2 Bus and lorry
! - May drive and need not notify DVLA unless there is sudden and disabling giddiness.	! - May drive and need not notify DVLA unless there is sudden and disabling giddiness and/or the condition is bilateral.

Brain biopsy

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive and must notify DVLA. Relicensing may be considered after 6 months if the biopsy shows insignificant (from a licensing perspective) histology and if there is no debarring residual impairment likely to affect safe driving. If a tumour is diagnosed on biopsy please refer to the relevant tumour standard.	✘- Must not drive and must notify DVLA. Relicensing may be considered after a minimum of 6 months depending on individual assessment of the underlying condition and if the biopsy shows insignificant (from a licensing perspective) histology. If a tumour is diagnosed on biopsy please refer to the relevant tumour standard.

Traumatic brain injury

Group 1
Car and motorcycle

Group 2
Bus and lorry

✘- Must not drive but may need to notify DVLA.

Relicensing may be considered usually after 6 to 12 months dependent on features such as seizures, post-traumatic amnesia (more than 24 hours), dural tear, haematoma and/or contusions seen on CT imaging.

There will need to have been satisfactory clinical recovery and in particular no visual field defects or cognitive impairment likely to affect safe driving.

Driving can resume on recovery and DVLA need not be notified if all of the following can be satisfied:

■ there is full clinical recovery
■ there are no seizures (other than an immediate seizure at the moment of impact)
■ there is no post traumatic amnesia lasting more than 24 hours
■ there is no intracranial haematoma and/or contusions seen on CT imaging (a small traumatic subarachnoid haemorrhage in isolation would be acceptable)

✘- Must not drive and must notify DVLA.

The licence will be refused or revoked.

Drivers may be relicensed after the annual risk of seizure has fallen to 2% or below and provided no debarring residual impairment is likely to affect safe driving.

The Advisory Panel has suggested that by five years, and sometimes after 2 or 3 years following a head injury, when there has been a full recovery with no residual functional deficit likely to affect safe driving, licensing can usually be permitted for Group 2.

Relicensing can be reconsidered after 3 months if all of the following can be satisfied:

■ there is full clinical recovery
■ there are no seizures (other than an immediate seizure at the moment of impact)
■ there is no post traumatic amnesia lasting more than 24 hours
■ there is no intracranial haematoma and/or contusions seen on CT imaging

If there has been a small subarachnoid haemorrhage but the bullet points above can otherwise be satisfied, and there is documented evidence of a full clinical recovery, driving may resume after 6 months.

Subdural haematoma

With any procedure, if another one is also undertaken (for example a ventriculoperitoneal shunt, and a craniotomy for a haematoma), the standards for that procedure also apply, and may take precedence.

Isolated subdural haematoma without traumatic brain injury

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Treated surgically or non-surgically	✘- Must not drive and must notify DVLA. Resume driving on recovery.	✘- Must not drive and must notify DVLA. At least 6 months off driving and will require an individual assessment.
Chronic subdural haematoma or acute-on-chronic subdural haematoma
Treated with or without surgery	✘- Must not drive and must notify DVLA. Resume driving on recovery.	✘- Must not drive and must notify DVLA. 6 months to 1 year off driving, depending on features (seizure risk must be less than 2%). 6 months is required if all of the following apply: ■ the condition is uncomplicated ■ there is only 1 drainage procedure ■ there is no recurrence ■ there are no multiple membranes seen in the haematoma All other cases require 1 year.
Traumatic subdural haematoma
	✘- Must not drive and must notify DVLA. At least 6 months off driving.	✘- Must not drive and must notify DVLA. Please see standards above for traumatic brain injury. Refusal or revocation: May be able to return to driving when risk of seizure has fallen to no greater than 2% per annum.

Subarachnoid haemorrhage

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Non-aneurysmal subarachnoid haemorrhage (including perimesencephalic) This includes subarachnoid haemorrhage where no intracranial aneurysm has been detected after investigation, including perimesencephalic subarachnoid haemorrhage as well as subarachnoid haemorrhage assoicated with reversible cerebral vasoconstriction syndrome (RCVS).
	✘- Must not drive and must notify DVLA. Driving may resume on clinical confirmation of recovery and, if no other cause has been identified, documented cerebrovascular (intracranial arterial) imaging that has excluded an aneurysm.	✘- Must not drive and must notify DVLA. Relicensing may be considered after 6 months provided comprehensive cerebrovascular (intercranial arterial) imaging has excluded an aneurysm, if no other cause has been identified, and no debarring residual impairment is likely to affect safe driving.
With intracranial aneurysm
Intervention not currently needed	✘ - Must not drive and must notify DVLA. Relicensing may be considered after 6 months if there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked permanently.
With intracranial aneurysm – non-middle cerebral artery
Treated by craniotomy	✘- Must not drive but need not notify DVLA. Driving may resume following clinical recovery.	✘- Must not drive and must notify DVLA. Relicensing may be considered after 1 year if the patient scored below 2 on the Modified Rankin Scale (MRS) at 2 months. If the MRS score is 2 or higher at 2 months, relicensing will not be considered until after 2 years. There must be no debarring residual impairment likely to affect driving.
Treated endovascularly	✘- Must not drive but need not notify DVLA. Driving may resume following clinical recovery.	✘- Must not drive and must notify DVLA. Relicensing may be considered after 6 months if the patient scored below 2 on the Modified Rankin Scale (MRS) at 2 months. If the MRS score is 2 or higher at 2 months, relicensing will not be considered until after 2 years. There must be no debarring residual impairment likely to affect driving.
With intracranial aneurysm – middle cerebral artery
Treated by craniotomy	✘- Must not drive but need not notify DVLA. Driving may resume following clinical recovery.	✘- Must not drive and must notify DVLA. Relicensing may be considered after 2 years if the patient scored below 2 on the Modified Rankin Scale (MRS) at 2 months. If the MRS score is 2 or higher at 2 months, the licence will be refused or revoked. Relicensing will not be considered until after at least 2 years and a specialist assessment. Annual seizure risk should be no greater than 2%. There must be no residual impairment likely to affect driving.
Treated endovascularly	✘- Must not drive but need not notify DVLA. Driving may resume following clinical recovery.	✘- Must not drive and must notify DVLA. Relicensing may be considered after 2 years if the patient scored below 2 on the Modified Rankin Scale (MRS) at 2 months. If the MRS score is 2 or higher at 2 months, the licence will be refused or revoked. Relicensing will not be considered until after at least 2 years and a specialist assessment. Annual seizure risk should be no greater than 2%. There must be no residual impairment likely to affect driving.

Intracranial aneurysm – truly incidental finding without haemorrhage

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Treatment not currently needed	✓- Providing there is no other relevant condition, driving may continue and DVLA need not be notified.	✘- Must not drive and must notify DVLA. Relicensing may be considered if: ■ an aneurysm in the anterior circulation (excluding cavernous carotid) is less than 13 millimetres in diameter ■ an aneurysm in the posterior circulation is less than 7 millimetres in diameter.
Treated by craniotomy	✘- Must not drive but need not notify DVLA. Driving may resume following clinical recovery.	✘- Must not drive and must notify DVLA. Relicensing may be considered after 1 year.
Treated endovascularly	✘- Must not drive but need not notify DVLA. Driving may resume following clinical recovery.	✘- Must not drive but need not notify DVLA. Driving may resume following clinical recovery provided there are no complications from the procedure.

Arteriovenous malformation (AVM)

With any of the procedures, if another is also undertaken (for example, a ventriculoperitoneal shunt or a craniotomy for a haematoma) the standards for that procedure also apply and may take precedence.

Supratentorial

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Intracerebral haemorrhage due to supratentorial AVM
Treatment not currently needed	✘- Must not drive but need not notify DVLA. Driving may resume after 1 month provided there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked permanently.
Treated by craniotomy	✘- Must not drive and must notify DVLA. Relicensing may be considered after 6 months if there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Relicensing may be considered after 10 years free of seizure since the last definitive treatment and the lesion was completely removed or ablated. There must be no debarring residual impairment likely to affect safe driving.
Treated by embolisation	✘- Must not drive but need not notify DVLA. Driving may resume after 1 month provided there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Relicensing may be considered after 10 years free of seizure since the last definitive treatment and the lesion was completely removed or ablated. There must be no debarring residual impairment likely to affect safe driving.
Treated by stereotactic radiotherapy	✘- Must not drive but need not notify DVLA. Driving may resume after 1 month provided there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Relicensing may be considered after 5 years free from seizure since the last definitive treatment and if the lesion was completely removed or ablated. There must be no debarring residual impairment likely to affect safe driving.
Incidental finding of supratentorial AVM (with no history of intracranial bleed)
Treatment not currently needed	✓- May drive and need not notify DVLA.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked permanently.
Treated by surgery or other mode	✘- Must not drive and must notify DVLA. As for intracerebral haemorrhage due to supratentorial AVM.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. As for intracerebral haemorrhage due to supratentorial AVM.

Infratentorial AVM

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Intracranial haemorrhage due to infratentorial AVM
No treatment	! - May drive and need not notify DVLA. Driving may resume after 1 month provided there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked permanently.
Treated by craniotomy	! - May drive and need not notify DVLA. Driving may resume after 1 month provided there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Relicensing may be considered without the need for review on confirmation of complete obliteration provided there is no debarring residual impairment likely to affect safe driving.
Treated by embolisation or stereotactic radiotherapy	! - May drive and need not notify DVLA. Driving may resume after 1 month provided there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Relicensing may be considered without the need for review on confirmation of complete obliteration provided there is no debarring residual impairment likely to affect safe driving.
Incidental finding of infratentorial AVM
No treatment	✓- May drive and need not notify DVLA.	✘- Must not drive and must notify DVLA. Relicensing may be considered on an individual assessment.
Treated by surgery or other mode	! - May drive and need not notify DVLA. There must be no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Relicensing may be considered without the need for review on confirmation of complete obliteration provided there is no debarring residual impairment likely to affect safe driving.

Dural arteriovenous fistula

Not associated with haemorrhage or neurological deficit.

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Antegrade flow into draining sinus / no cortical venous drainage or reflux	✓- may drive and need not notify DVLA.	✘- Must not drive and must notify DVLA. Relicensing may be considered on an individual assessment.

Not associated with haemorrhage or neurological deficit.

	Group 1 Car and motorcycle	Group 2 Bus and lorry
All other drainage patterns	✘- Must not drive and must notify DVLA. Relicensing may be considered on an individual assessment.	✘- Must not drive and must notify DVLA. Relicensing may be considered on an individual assessment.

Associated with haemorrhage or neurological deficit.

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive and must notify DVLA. Relicensing may be considered on an individual assessment.	✘- Must not drive and must notify DVLA. Relicensing may be considered on an individual assessment.

Cavernous malformation

Cavernomas are also known as cavernous malformations, cavernous angiomas, or cavernous haemangiomas. They are all surrounded by haemosiderin on brain MRI, but this does not necessarily imply that they have ‘bled’ in the past. The risk of events that might affect driving differs according to cavernoma location (brainstem vs. other locations) and symptoms attributable to the cavernoma (stroke vs. epileptic seizure vs. no symptoms).

A person’s age, the number of cavernomas, and the size of the cavernoma do not seem to affect these risks. With multiple cavernomas, licensing restrictions differ according to cavernoma location, symptoms, or treatment. The most restrictive guidance will apply.

Supratentorial cavernoma

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Incidental finding, no surgical treatment	✓- May drive and need not notify DVLA.	✓- May drive and need not notify DVLA.
With seizure, no surgical treatment	✘- Must not drive and must notify DVLA. The seizure rules (see Appendix B) apply if there is a history of seizure.	✘- Must not drive and must notify DVLA. The seizure rules (see Appendix B) apply if there is a history of seizure.
With haemorrhage and/or focal neurological deficit, no surgical treatment	! - May drive but must notify DVLA. Driving will depend on the following: ■ there must be no debarring residual impairment likely to affect safe driving. The seizure rules (see Appendix B) apply, and the patient must not drive and must notify DVLA if there is a history of seizure.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked permanently.
Treated by craniotomy	✘- Must not drive and must notify DVLA. Driving may resume after 6 months if there is no debarring residual impairment likely to affect safe driving. The seizure rules (see Appendix B) apply if there is a history of seizure.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Relicensing may be considered 10 years after surgical obliteration of the lesion. The seizure rules (see Appendix B) apply.
Treated by radiosurgery, after haemorrhage and/or focal neurological deficit	! - May drive but must notify DVLA. Driving will depend on the following: ■ there must be no debarring residual impairment likely to affect safe driving. The seizure rules (see Appendix B) apply, and the patient must not drive and must notify DVLA if there is a history of seizure.	✘ - Must not drive and must notify DVLA. The licence will be refused or revoked permanently.

Infratentorial cavernoma

	Group 1 Car and motorcycle	Group 2 Bus and lorry
Incidental finding	✓- May drive and need not notify DVLA.	✓- May drive and need not notify DVLA.
With haemorrhage and/or focal neurological deficit, no surgical treatment	! - May drive but must notify DVLA. Driving will depend on the following: ■ there must be no debarring residual impairment likely to affect safe driving. The seizure rules (see Appendix B) apply, and the patient must not drive and must notify DVLA if there is a history of seizure.	✘ - Must not drive and must notify DVLA. The licence will be refused or revoked permanently. The seizure rules (see Appendix B) apply, and the patient must not drive and must notify DVLA if there is a history of seizure.
Surgical treatment by craniotomy	! - May drive but must notify DVLA. Driving will depend on the following: ■ there must be no debarring residual impairment likely to affect safe driving. The seizure rules (see Appendix B) apply, and the patient must not drive and must notify DVLA if there is a history of seizure.	! - May drive but must notify DVLA. There must be no debarring residual impairment likely to affect safe driving. The seizure rules (see Appendix B) apply, and the patient must not drive and must notify DVLA if there is a history of seizure.
Treated by radiosurgery (after haemorrhage and/or focal neurological deficit)	! - May drive but must notify DVLA. Driving will depend on the following: ■ there must be no debarring residual impairment likely to affect safe driving. The seizure rules (see Appendix B) apply, and the patient must not drive and must notify DVLA if there is a history of seizure.	✘ - Must not drive and must notify DVLA. The licence will be refused or revoked permanently.

Intracerebral abscess/subdural empyema

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive but need not notify DVLA. Driving may resume after 1 year.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked. Given that there is a very high prospective risk of seizure, it will be 10 years before relicensing may be considered and there must have been no seizures and no treatment for seizures in that time.

Cranioplasty

Group 1
Car and motorcycle

Group 2
Bus and lorry

! - May drive but must notify DVLA.

Driving may resume on recovery.

The underlying conditions that made the surgical treatment necessary should be considered and the appropriate medical standard applied.

Individual consideration will be needed in cases where subsequent revision surgery is required or the procedure is complicated by post-operative intracranial infection.

✘- Must not drive and must notify DVLA.

Driving may resume 6 months following the surgical procedure.

The underlying conditions that made the surgical treatment necessary should be considered and the appropriate medical standard applied.

Individual consideration will be needed in cases where subsequent revision surgery is required or the procedure is complicated by post-operative intracranial infection.

Chiari malformation

No treatment required

Group 1 Car and motorcycle	Group 2 Bus and lorry
✓ - May drive and need not notify DVLA.	✓ - May drive and need not notify DVLA.

Surgical treatment/foramen magnum decompression

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘ - Must not drive but need not notify DVLA. Driving may resume following clinical confirmation that there are no residual impairments likely to affect safe driving.	✘ - Must not drive but need not notify DVLA. Driving may resume following clinical confirmation that there are no residual impairments likely to affect safe driving.

Hydrocephalus

Group 1 Car and motorcycle	Group 2 Bus and lorry
✓- May drive and need not notify DVLA. Driving may continue for as long as the hydrocephalus remains asymptomatic.	✘- Must not drive and must notify DVLA. Driving will be allowed to continue if the hydrocephalus is asymptomatic and there are no associated neurological problems.

Intraventricular shunt or extraventricular drain – insertion or revision of upper end of shunt or drain

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive and must notify DVLA. May be relicensed after 6 months if there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. May be relicensed/licensed after a minimum of 6 months depending on individual assessment of the underlying condition.

Neuroendoscopic procedures – for example, third ventriculostomy

Group 1 Car and motorcycle	Group 2 Bus and lorry
✘- Must not drive and must notify DVLA. May be relicensed/licensed after 6 months if there is no debarring residual impairment likely to affect safe driving and no other disqualifying condition.	✘- Must not drive and must notify DVLA. May be relicensed/licensed after a minimum of 6 months depending on individual assessment of the underlying condition.

Intracranial pressure monitoring device – inserted by burr hole surgery

Group 1 Car and motorcycle	Group 2 Bus and lorry
! - May drive but need not notify DVLA. The prospective risk from the underlying condition must be considered.	✘- Must not drive and must notify DVLA. The prospective risk from the underlying condition must be considered.

Implanted electrodes

Group 1 Car and motorcycle	Group 2 Bus and lorry
Deep brain stimulation for movement disorder or pain
! - Must not drive until clinical confirmation of recovery. May drive if: ■ there are no complications from surgery ■ the patient is seizure-free ■ there is no debarring residual impairment likely to affect safe driving. Need not notify DVLA.	✘- Must not drive and must notify DVLA. Fitness to drive may be assessed for relicensing if: ■ there are no complications from surgery ■ the patient is seizure-free with an underlying condition that is non-progressive ■ there is no debarring residual impairment likely to affect safe driving.
Implanted motor cortex stimulator for pain relief
✘- Must not drive and must notify DVLA. May be relicensed/licensed after 6 months if the aetiology of the pain is non-cerebral – trigeminal neuralgia, for example. If the aetiology is cerebral – stroke, for example – may be relicensed/licensed after 12 months provided there is no debarring residual impairment likely to affect safe driving.	✘- Must not drive and must notify DVLA. The licence will be refused or revoked.

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Neurological disorders: assessing fitness to drive

Serious neurological disorders

Epilepsy and seizures

Special considerations

Group 1 car and motorcycle

Isolated seizures

Withdrawal of epilepsy medication (also see Appendix B)

Group 2 bus and lorry

Isolated seizure

Transient loss of consciousness (‘blackouts’) – or lost/altered awareness

Transient loss of consciousness – solitary episode

Transient loss of consciousness – recurring episodes

Cough syncope

Primary/central hypersomnias – including narcolepsy type 1 (narcolepsy with cataplexy) and type 2

Chronic neurological disorders – including multiple sclerosis and motor neurone disease

Parkinson’s disease

Dizziness – liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness

Stroke, transient ischaemic attack (TIA) and cerebral venous thrombosis – including amaurosis fugax and retinal artery occlusion

Cerebral amyloid angiopathy-related transient focal neurologic episodes (previously termed “amyloid spells”)

Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS)

Visual inattention

Carotid artery stenosis

Acute encephalitic illness and meningitis - including limbic encephalitis associated with seizures

Transient global amnesia

Arachnoid cysts

Colloid cysts

Pituitary tumour

Brain tumours

Section 1 – Classification of tumour

Section 2 – Medical standards of fitness to drive

Very low risk brain tumours

Low risk brain tumours

High risk brain tumours

Metastatic brain disease, CNS Lymphoma and non-CNS tumours invading intracranially and breaching the dura – these standards apply to any cerebral recurrences as well as first occurrence

Acoustic neuroma/schwannoma

Brain biopsy

Traumatic brain injury

Subdural haematoma

Isolated subdural haematoma without traumatic brain injury

Subarachnoid haemorrhage

Intracranial aneurysm – truly incidental finding without haemorrhage

Arteriovenous malformation (AVM)

Supratentorial

Infratentorial AVM

Dural arteriovenous fistula

Cavernous malformation

Supratentorial cavernoma

Infratentorial cavernoma

Intracerebral abscess/subdural empyema

Cranioplasty

Chiari malformation

No treatment required

Surgical treatment/foramen magnum decompression

Hydrocephalus

Intraventricular shunt or extraventricular drain – insertion or revision of upper end of shunt or drain

Neuroendoscopic procedures – for example, third ventriculostomy

Intracranial pressure monitoring device – inserted by burr hole surgery

Implanted electrodes

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