Left MCA Stroke With Hemianopia and Neglect: Return-to-Driving Decision

Not ready for independent driving. The combination of right homonymous hemianopia and left visual neglect is a high-risk pattern: the hemianopia causes missed right-side hazards, while neglect causes failure to scan and integrate the left side. The garage scrapes are real-world evidence of a scanning or lateralization problem, not just a parking error. MoCA 24/30 with visuospatial/executive losses also raises concern about divided attention and judgment. I would not authorize practice with his wife or solo driving. I would schedule a comprehensive driver rehabilitation evaluation in a dual-brake vehicle only after a pre-drive clinical screen, including confrontation and field testing, neglect testing, and a road-sign or scanning task. The on-road assessment should be framed as diagnostic, not a licensure test, and terminated if he shows unsafe left or right scanning. Prerequisites are stable medical status (already met), no sedating medications, AFO clearance, and family agreement not to supervise driving. If neglect persists on repeat testing, I would recommend driving retirement and alternative transportation, because scanning training for dense neglect has limited transfer to real traffic.

Equipment should follow observed performance, not the stroke label. A left-foot accelerator is a reasonable trial because right foot drop and paresis may slow brake response, but only if he has adequate left foot sensation, control, and reaction time; otherwise hand controls should be trialed. Because his right grip is 3/5, a spinner knob mounted for left-hand steering may reduce demands, but he must be able to maintain control with the left hand while operating secondary controls. Wide-angle or cross-view mirrors can help with hemianopia, but they do not replace scanning and may distort distance. An automatic transmission and power steering are already helpful; no reduced-effort system is needed unless he fails a force test. I would trial each item on a closed course and then in low-traffic on-road conditions, documenting before-and-after performance. The justification for each adaptation is a measured reduction in errors or workload, not convenience. If he cannot scan both sides reliably, no equipment combination makes him safe.

Recommendation: not cleared for driving at this time. If a later on-road evaluation is passed, I would recommend a restricted license: daylight only, no freeway or high-traffic routes initially, maximum 25-mile radius for work, modified vehicle with the specific equipment listed, and no driving when fatigued. Review at 3 months with repeat on-road and visual-perceptual testing, then at 6 months if stable. For the employer, state that he is medically stable but currently meets no driving standard; do not require him to drive until the rehabilitation team clears him, and consider a temporary accommodation or ride share. For the licensing authority, provide objective findings rather than diagnosis alone: hemianopia, neglect, MoCA, on-road errors, and the recommendation. Include that he lacks insight into the garage scrapes, which is itself a safety concern. Document that he was counseled about risk and alternative transport. Avoid promising that he will eventually drive; the review is conditional.