CASE STUDY
Latent Epilepsy in Pilots: Two Case Reports
Ali M. Refai, MD
Abstract
Although epilepsy is rare in aviation personnel, 2 long-term
duty pilots were discovered to have latent epilepsy. The first
case presented is that of a 36-year-old male pilot, with 16
years flight time, and the second case describes a 30-year-old
male Black Hawk pilot with 11 years duty time. Both report-
edly experienced a sudden onset of tonic and clonic convul-
sions after they had been exposed to stressful conditions.
Both of their clinical presentations were consistent with grand
mal epilepsy, and their electroencephalogram (EEG) findings
were consistent with epilepsy. Both were subsequently sus-
pended from flying duties. An EEG has since been added as
part of the pilot selection medical examination in the Royal
Jordanian Air Force Medical Services.
Introduction
Epilepsy is a neurologic disorder characterized by recurrent
and brief disturbances in normal electrical function of the
brain that result in seizure. Although it is a common disorder
in the population worldwide,1 it is rare in aviation personnel,
especially among those under consideration as potential class
1a fighter pilots in the Royal Jordanian Air Force. This is, in
part, due to the meticulous and sensitive selection process, as
well as the induction medical examination conducted for
pilot selection.
Two such pilots were discovered to have latent epilepsy, after
diagnosis at King Hussein Medical City. While there, they had
been admitted to the neurology department, where I followed
up as their flight surgeon. The 2 patients described appear to be
actual epileptic patients; neither case could have been detected
by prior medical procedures in place, because at that time, no
screening electroencephalogram (EEG) was required as part of
the air medical examination for pilot selection.
Family and aviation medicine, Royal Jordanian Medical Services, King
Hussein Medical City, Amman, Jordan
Address for correspondence:
Ali M. Refai, MD, Family and aviation medicine, Royal Jordanian Medical
Services, King Hussein Medical City, Amman, Jordan,
refalius2002@yahoo.com
1067-991X/$36.00
Copyright 2012 by Air Medical Journal Associates
http://dx.doi.org/10.1016/j.amj.2011.12.002
November-December 2012
Case Reports
The first case involves a 36-year-old male C-130 pilot,
with 16 years of flying duty time who had 2 attacks of loss
of consciousness, witnessed by his wife, after tonic and
clonic convulsions. These were reportedly associated with
rolling eyeballs, loss of urine control, and diaphoresis after
return from a long, nonstop trip. The patient woke up 2
hours later that same day, with stiffness of his left lower
limb followed by general weakness. Two days preceding this
event, he flew for 27 continuous hours with exhaustion,
fatigue, and, subsequently, jet lag. In his past medical his-
tory, similar attacks took place in 1998 that the patient had
not declared; notably, they had reportedly occurred after
stress. He had also experienced febrile convulsions during
his childhood that he did not admit at the time of his pilot
induction medical examination. He did not have any known
family history of convulsions, nor a history of psychotropic
medication use. There was a history of sinusitis. The patient
was referred to the neurology department of King Hussein
Medical City, where he was admitted for further evaluation,
diagnosis, and management.
The second case describes a 30-year-old male Black Hawk
pilot with 11 years of flight time who was brought by a col-
league to the emergency room of the Royal Jordanian Air
Force medical facility, in a confused neurologic state. His col-
league reported that the patient had tonic and clonic move-
ments of his hands with frothy discharge from his mouth, and
the patient then lost consciousness. The patient was then
referred to the emergency room of King Hussein Medical City
as a case of postictal state following his first epileptic episode.
He was subsequently admitted to the neurology department,
where he exhibited a similar episode of previously reported
movements and another loss of consciousness. The patient
said that he had no history of similar attacks in the past.
There appeared to be no family history of convulsions. He
had no history of febrile convulsions or use of psychotropic
medications.
In both cases, there was no history of taking any medica-
tions before the event and no alcohol abuse, chronic med-
ical illness, or trauma. An internist, otolaryngology
specialist, neurosurgeon, and cardiologist were consulted,
with nothing abnormal detected in either patient. Complete
blood count and liver and kidney function electrolytes,
lipid profile, and thyroid function test results were all
found to be within normal limits.
305
 Brain computed tomography (CT) scan, magnetic reso-
nance imaging (MRI), and magnetic resonance angiography
(MRA) were performed and also found to be normal for both
pilots. An EEG showed occasional, generalized,2 sharpened
slow transient waves, which is consistent with grand mal
epilepsy. Serum prolactin levels were elevated to 4 times the
normal value after the epileptic episode and returned to nor-
mal after a few days for both pilots. Because of their newly
diagnosed medical condition, however, they were both subse-
quently suspended from flying duties.
Two months later, they were again seen by the neurologist,
and EEGs were performed for reconfirmation; results were
consistent with epilepsy. Ultimately, medical records and
events for both pilots were reviewed by the Royal Jordanian
Aeromedical Board, who subsequently grounded them.
Discussion
The basic event common to all seizures is a paroxysmal dis-
charge of cerebral neurons. However, not all paroxysmal dis-
charge results in overt events. For example, between seizures,
the EEG of a person with epilepsy may show spikes over 1
temporal lobe, which represents the paroxysmal discharge of
neurons. Such events, unaccompanied by any clinical phe-
nomenon, are not generally considered to be seizures. For the
definition of a seizure, it is necessary to add that the paroxys-
mal discharge of cerebral neurons must be apparent to either
an external observer, as in the case with a grand mal seizure,
or as an abnormal perceptual experience suffered by the sub-
ject. When a patient has a single seizure, it does not automati-
cally generate a diagnosis of epilepsy.3
In this case study, both patients presented clinically with
tonic-clonic seizures (grand mal), with EEG records consis-
tent with epilepsy. In the case of the C-130 pilot, he appar-
ently had experienced seizures many years previously, but
had not declared so in his medical history. By the time they
recurred and became more frequent, he could not hide them.
In the second case, the pilot presented with a sudden onset of
seizures, which was considered secondary to jet lag and
exhaustion after returning from the United States. The parox-
ysmal discharge may be a primary or secondary generalized
discharge from a cortical focus, with the hallmark of a grand
mal seizure being disordered muscular contraction.4
Comprehensive evaluations were performed in both cases,
which included complete blood count, liver and renal func-
tion tests, brain CT scan, MRI, and MRA to determine poten-
tial secondary causes such as trauma, tumors, or infectious
diseases. However, no specific etiology could be detected.
Many factors may precipitate an epileptic episode,
including alcohol and drugs, lack of sleep, and underlying
illness. In both cases presented, it appears that lack of
sleep, drowsiness, fatigue, flicker vertigo,5 and jet lag may
have precipitated seizures the day after exposure. In fact,
drowsiness is such a potent activator of abnormal EEG dis-
charges that the subject will often be encouraged to try to
sleep during the recording.
306
Looking at a repetitive pattern of movements, staring at
an object, reading, or even watching the screen (television
epilepsy) of the simulator or in the cockpit of aircraft, as
occurs with all flights, may be presumed as a perception of
such external stimuli that result in particular patterns of
neuronal discharge.
During comprehensive evaluation, numerous conditions
were considered as part of the differential diagnosis. These
included, but were not limited to, cardiogenic syncope, hypo-
glycemia, and narcolepsy, which in and of themselves have an
impact on health and flight safety and should be disqualify-
ing, with the exception of vasovagal syncope associated with
emotional stress6; syncope was distinguished from epilepsy in
that it does not occur in bed during sleep.
Cardiac arrhythmia was ruled out by consulting the cardi-
ologist for a comprehensive targeted evaluation, with findings
found to be normal. Migraine is another type of transient dis-
turbance of cerebral function in which positive phenomena
such as visual hallucinations may occur. However, such hallu-
cinations are virtually always ill-formed, classically scintillat-
ing scotomatas (blackouts) rather than the formed visual
hallucination that may be part of a complex partial seizure,
which did not occur in either case. If the area of cortical
ischemia is located further forward in the hemisphere, then
the associated symptomatology is similar to that of a transient
ischemic attack, with weakness, numbness, or language dis-
turbance, none of which occurred in either case.7
Conclusion
Air medical disposition should consider the prognosis of
the seizure patient and the effect of a seizure on control of an
aircraft. A portion of healthy young adults who have a single
idiopathic convulsion will have another, most often within
the first 3 years after the initial seizure. Therefore, a seizure in
an adult should lead to disqualification from flying duties.8
The air medical disposition of secondary seizures should
account for the prognosis of the underlying disease, such as
abrupt withdrawal of neurotropic drugs or alcohol, but in
principle should lead to disqualification.9 Medications for
seizure control do not predictably control the seizures, and
they have side effects that are incompatible with the effective
and reliable control of aircraft.
Epilepsy may be discovered latently after pilot selection,
even after thorough and meticulous entry medical examina-
tion. Stressful conditions such as exhaustion, fatigue, jet lag,
lack of sleep, and drowsiness may precipitate seizures the fol-
lowing day; any potential aura may be weak and prolonged.
Since 2004, to reduce hidden or latent epileptic patients, we
have recommended, initiated, and implemented inclusion of
EEGs for all cadet candidates as part of the induction medical
examination required during the pilot selection process in the
Royal Jordanian Air Force Medical Services.10,11 It is notable
that EEG is not a mandatory requirement for evaluation of
pilots in the Medical Provisions for Licensing by the
International Civil Aviation Organization, and the Federal
Air Medical Journal 31:6
Aviation Administration does not require a mandatory EEG for
any class of flight crew.12

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