Economy class syndrome complicated by stroke: a rare condition due to paradoxical embolism--a case report and review of the literature

Risk management of free radicals involved in air travel syndromes by antioxidants

Frequent air travelers and airplane pilots may develop various types of illnesses. The environmental risk factors associated with air travel syndromes (ATS) or air travel-related adverse health outcomes raised concerns and need to be assessed in the context of risk management and public health. Accordingly, the aim of the present review was to determine ATS, risk factors, and mechanisms underlying ATS using scientific data and information obtained from Medline, Toxline, and regulatory agencies. Additional information was also extracted from websites of organizations, such as the International Air Transport Association (IATA), International Association for Medical Assistance to Travelers (IAMAT), and International Civil Aviation Organization (ICAO). Air travelers are known to be exposed to environmental risk factors, including circadian rhythm disruption, poor cabin air quality, mental stress, high altitude conditions, hormonal dysregulation, physical inactivity, fatigue, biological infections, and alcoholic beverage consumption. Consequences of ATS attributed to air travel include sleep disturbances (e.g., insomnia), mental/physical stress, gastrointestinal disorders, respiratory diseases, circulatory-related dysfunction, such as cardiac arrest and thrombosis and, at worst, mechanical and terrorism-related airplane crashes. Thus safety measures in the cabin before or after takeoff are undertaken to prevent illnesses or accidents related to flight. In addition, airport quarantine systems are strongly recommended to prepare for any ultimate adverse circumstances. Routine monitoring of environmental risk factors also needs to be considered. Frequently, the mechanisms underlying these adverse manifestations involve free radical generation. Therefore, antioxidant supplementation may help to reduce or prevent adverse outcomes by mitigating health risk factors associated with free radical generation.

Airplane stroke syndrome

Only 37 cases of stroke during or soon after long-haul flights have been published to our knowledge. In this retrospective observational study, we searched the Royal Melbourne Hospital prospective stroke database and all discharge summaries from 1 September 2003 to 30 September 2014 for flight-related strokes, defined as patients presenting with stroke within 14days of air travel. We hypothesised that a patent foramen ovale (PFO) is an important, but not the only mechanism, of flight-related stroke. We describe the patient, stroke, and flight characteristics. Over the study period, 131 million passengers arrived at Melbourne airport. Our centre admitted 5727 stroke patients, of whom 42 (0.73%) had flight-related strokes. Flight-related stroke patients were younger (median age 65 versus 73, p<0.001), had similar stroke severity, and received intravenous thrombolysis more often than non-flight-related stroke patients. Seven patients had flight-related intracerebral haemorrhage. The aetiology of the ischaemic strokes was cardioembolic in 14/35 (40%), including seven patients with confirmed PFO, one with atrial septal defect, four with atrial fibrillation, one with endocarditis, and one with aortic arch atheroma. Paradoxical embolism was confirmed in six patients. Stroke related to air travel is a rare occurrence, less than one in a million. Although 20% of patients had a PFO, distribution of stroke aetiologies was diverse and was not limited to PFO and paradoxical embolism.

Stroke in Commercial Flights

BACKGROUND AND PURPOSE

Stroke on board aircraft has been reported in retrospective case series, mainly focusing on economy class stroke syndrome. Data on the actual incidence, pathogenesis, and prognosis of stroke in commercial flights are lacking.

METHODS

A prospective registry was designed to include all consecutive patients referred from an international airport (40 million passengers a year) to our hospital with a diagnosis of ischemic stroke or transient ischemic attack and onset of symptoms during a flight or immediately after landing.

RESULTS

Forty-four patients (32 ischemic strokes and 12 transient ischemic attacks) were included over a 76-month period (January 2008 to April 2014). The estimated incidence of stroke was 1 stroke in 35 000 flights. Pathogeneses of stroke or transient ischemic attack were atherothrombotic in 16 (36%), economy class stroke syndrome in 8 (18%), cardioembolic in 7 (16%), arterial dissection in 4 (9%), lacunar stroke in 4 (9%), and undetermined in 5 (12%) patients. Carotid stenosis >70% was found in 12 (27%) of the patients. Overall prognosis was good, and thrombolysis was applied in 44% of the cases. The most common reason for not treating patients who had experienced stroke onset midflight was the delay in reaching the hospital. Only 1 patient with symptom onset during the flight prompted a flight diversion.

CONCLUSIONS

We found a low incidence of stroke in the setting of air travel. Economy class stroke syndrome and arterial dissection were well represented in our sample. However, the main pathogenesis was atherothrombosis with a high proportion of patients with high carotid stenosis.