Section 15
Cerebrovascular diseases (including stroke)


  • Patients who have experienced either a single or recurrent transient ischemic attack or are experiencing residual symptoms from a probable stroke should not drive a motor vehicle until a medical assessment has been completed.
  • Reporting of patients who have had a stroke and may be unsafe to drive is mandatory for physicians in some but not all regional or provincial jurisdictions. Physicians should check their local reporting requirements.

15.1 Overview

Cerebrovascular disease can cause physical, visuospatial, neuropsychological, or cognitive symptoms that can lead to unsafe driving. Driving is significantly associated with community reintegration at 1 year following stroke (Finestone et al., 2010). Various lesion locations may be associated with greater or lesser risks of driving impairment after stroke (Rapoport et al., 2019). A detailed history and a thorough physical examination, documenting hemiparesis, motor or sensory losses, ataxia, and visual field deficits, as well as cognitive or communication (e.g., dementia/aphasia) issues, are required.

In-office tools for cognitive testing (e.g., clock-drawing test, Montreal Cognitive Assessment [MoCA;], Trail Making Test parts A and B) can also help in defining the patient’s disability state.

Finally, where resources are available, a comprehensive driving evaluation, sanctioned by a motor vehicle licensing authority, may be required to determine fitness to drive.

15.2 Cerebrovascular disease

15.2.1 Transient ischemic attack

The abrupt onset of a partial loss of neurologic function during a transient ischemic attack (TIA), even if the loss of function persists for less than 24 hours and clears without residual signs, should not be ignored in anyone who drives a motor vehicle, as it raises the possibility of a later stroke. After a TIA, patients’ risk of a stroke within the first 2 days is 2.0% to 4.1% (Giles et al., 2007) and at 90 days is 10.5% (Johnston et al., 2000). Patients who have experienced either a single or recurrent TIA or are experiencing residual symptoms from a probable stroke should not be allowed to drive any type of motor vehicle until a medical assessment and appropriate investigations are completed. They may resume driving if the neurologic assessment discloses no residual loss of functional ability and any underlying cause has been addressed with appropriate treatment.

15.2.2 Stroke

Patients who have had a stroke should not drive for at least 1 month. During this time, assessment by their regular physician is required. Such patients may resume driving if the following conditions are met:

• The physician notes no clinically significant motor, sensory, coordination, cognitive, perceptual, visual, or neuropsychological deficits during the general and neurologic examinations.

• Any underlying cause has been addressed with appropriate treatment.

• A seizure has not occurred in the interim.

Any available information from the patient’s treating nurse, occupational therapist, psychologist, physiotherapist, speech pathologist, or social worker should be reviewed to assist with the determination of deficits that may not be visible or detected during an office visit.

The physician should take particular care to note any changes in personality, alertness, insight (executive functions), and decision-making ability, however subtle and inconsistent, in patients who have had a stroke; these types of changes could significantly affect driving ability. Reports from reliable family members may help the physician in discerning whether the patient’s judgment and awareness are altered in day-to-day activities.

Patients with a right-brain stroke are usually verbally intact but very much impaired with regard to their insight, judgment, and perceptual skills. Such patients may pass a standard on-road test, because such testing does not challenge their deficits. Patients with a left-brain stroke frequently present with some degree of aphasia. Although aphasia is not an absolute contraindication to safe driving, it requires the physician’s attention and further evaluation.

Where there is a residual loss of motor power, sensation, or other physical, perceptual, neuropsychological, or cognitive deficit, a driving evaluation at a designated driver assessment centre (Appendix B) may be required. The driver assessment centre can make recommendations for driving equipment or vehicle modification strategies, such as use of a steering wheel “spinner knob” or left-foot accelerator. Training in the safe use of the equipment should be provided.

Patients with a visual field deficit from a stroke must undergo a visual field study by an optometrist or ophthalmologist. Patients with major changes to their visual field should be counselled not to drive. The reporting requirements to the licensing agency vary according to the jurisdiction, although a patient’s refusal to follow advice not to drive should be reported in all Canadian jurisdictions.

Patients who have had a stroke and subsequently resume driving should remain under regular medical supervision, as the episode may be the forerunner of a gradual decline in their thinking processes (e.g., multi-infarct dementia or vascular cognitive impairment due to microvascular disease). In some provinces, licence restrictions, such as denial of expressway or high-speed driving privileges or limitation of driving to areas familiar to the driver, are available at the discretion of the licensing authorities. The aim of this restricted licensing is to bring the level of driving difficulty into alignment with driving ability; however, evidence to support this intervention remains limited.

15.2.3 Cerebral aneurysm

Symptomatic cerebral aneurysms (characterized by headaches, dilatation of the pupils, seizures, and pain behind the eyes) that have not been surgically repaired are an absolute contraindication to driving any class of motor vehicle. Following successful treatment, the patient may drive a non-commercial vehicle after a symptom-free period of 3 months and will be eligible to drive commercial vehicles after being symptom-free for 6 months. However, this guideline is empirically based, and each patient should be considered on an individual basis. Any significant residual physical, psychological, or cognitive symptoms should be fully evaluated. Patients with significant residual impairments that may affect driving need to be cautioned not to drive, and the condition should be reported to the licensing authority, if appropriate. Recommendations for patients with cerebral aneurysm are summarized in Table 11.

TABLE 11: Recommendations for patients with symptomatic cerebral aneurysm
Patient conditionNon-commercial drivingCommercial driving
Untreated cerebral aneurysmDisqualifiedDisqualified
After surgical treatmentSymptom-free for 3 months*Symptom-free for 6 months*
*With the caveat that each case must be considered on an individual basis.

15.3 Counselling

Support and counselling should be offered to patients who are unsafe to drive or who resist giving up driving or being tested. Patients may find it difficult to deal with the loss of their perceived independence. In addition, obtaining alternative transportation may be challenging and time-consuming.

The physician should point out to patients that they may place themselves and others at risk of injury by driving and that driving is a privilege, not a right. Referral to social services will help patients to identify and apply for community resources, such as assisted transportation. Stroke survivors with physical disabilities may require medical justification to obtain such services. The physician should expect requests for documentation when patients apply for such assistance or when they fill out a disabled parking pass application to allow them to park in more convenient designated areas.

For additional detail, see Section 4, Driving cessation.

15.4 Summary

Driving after stroke is possible, but patients must recognize that it is a privilege, not a right. Evaluation of the patient must take into account any residual physical, visuospatial, neuropsychological, or cognitive impairment that might affect safe driving. This is not an easy task, and the doctor–patient relationship can be affected as a result.

In general, if there is uncertainty about the patient’s ability to drive after a history, physical examination, and possibly in-office testing have been carried out, a formal driving evaluation, sanctioned by a motor vehicle licensing authority and including an on-road assessment, should be performed.


Finestone HM, Guo M, O’Hara P, Greene-Finestone L, Marshall SC, Hunt L, et al. Driving and reintegration into the community in patients after stroke. PM R. 2010;2(6):497-503.

Giles MF, Rothwell PM. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2007;6(12):1063-72. 

Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000;284(22):2901-6.

Rapoport MJ, Plonka SC, Finestone H, Bayley M, Chee JN, Vrkljan B, et al. A systematic review of the risk of motor vehicle collision after stroke or transient ischemic attack. Top Stroke Rehabil. 2019;26(3):226-35.

Other resources

Anderson SW, Aksan N, Dawson JD, Uc EY, Johnson AM, Rizzo M. Neuropsychological assessment of driving safety risk in older adults with and without neurologic disease. J Clin Exp Neuropsychol. 2012;34(9):895-905.

Devos H, Akinwuntan AE, Nieuwboer A, Ringoot I, Van Berghen K, Tant M, et al. Effect of simulator training on fitness-to-drive after stroke: a 5-year follow-up of a randomized controlled trial. Neurorehabil Neural Repair. 2010;24(9):843-50.

George S, Crotty M, Gelinas I, Devos H. Rehabilitation for improving automobile driving after stroke. Cochrane Database Syst Rev. 2014;2014(2):CD008357.

Hird MA, Vetivelu A, Saposnik G, Schweizer TA. Cognitive, on-road, and simulator-based driving assessment after stroke. J Stroke Cerebrovasc Dis. 2014;23(10):2654-70.

Motta K, Lee H, Falkmer T. Post-stroke driving: examining the effect of executive dysfunction. J Safety Res. 2014;49:33-8.

Pearce AM, Smead JM, Cameron ID. Retrospective cohort study of accident outcomes for individuals who have successfully undergone driver assessment following stroke. Aust Occup Ther J. 2012;59(1):56-62.

Staples JA, Erdelyi S, Merchant K, et al. Syncope and the risk of subsequent motor vehicle crash: a population-based retrospective cohort study. JAMA Intern Med. 2022;182(9):934-42.

Staples JA, Erdelyi S, Merchant K, et al. Syncope and subsequent traffic crash: a responsibility analysis. PLoS One. 2023;18(1):e0279710.