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BRIEF COMMUNICATIONS: Y. Isayev, R. K.T. Chan, and P. M. Pullicino "Economy Class" stroke syndrome? Neurology 2002; 58: 960-961 [Abstract] [Full text] [PDF]

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"Economy Class" stroke syndrome?

Shuichi Suzuki, Andre Fredieu and Jeffrey L. Saver   (28 May 2003)

Reply to Letter to the Editor

Patrick Pullicino, Richard K. Chan   (10 June 2002)

"Economy Class" stroke syndrome?

Christian Foerch, Kirn R Kessler, Helmuth Steinmetz, and Matthias Sitzer   (10 June 2002)

"Economy Class" stroke syndrome? 28 May 2003
Shuichi Suzuki UCLA School of Medicine Los Angeles CA, Andre Fredieu and Jeffrey L. Saver Send Correspondence to journal: Re: "Economy Class" stroke syndrome? jsaver{at}ucla.edu Shuichi Suzuki, et al.	We read with interest the article by Isayev et al. and letter by Foerch et al., collectively describing six cases of the "Economy Class" stroke syndrome, all attributed to paradoxical embolism through a patent foramen ovale.[1,2] We recently encountered a case that demonstrates the "economy class stroke syndrome" may arise from vascular mechanisms other than paradoxical embolism. A 35-year-old radiology technologist with a history of migraine headaches presented with vertigo and double vision 10 days after completing a protracted plane flight from New York to Los Angeles with one layover. During the flight, her aisle seat did not recline. She was unable to move for approximately 10 hours and dozed in unusual head positions, often with her head rotated right. After the flight she noted right neck pain different from her usual migraine headache. Ten days after the flight she suddenly developed vertigo, double vision, ataxia, and severe worsening of right neck pain. A radiologist co-worker noted that she had nystagmus. All symptoms and signs resolved within a few hours. MRI, including diffusion imaging, showed no brain parenchymal abnormality. CT angiogram showed segmental dissection of a nondominant right cervical vertebral artery, with the circumferential subintimal intramural hematoma spanning a 3 cm segment extending from C2-3 to C4-5, with 40% luminal stenosis. A transesophageal echocardiogram demonstrated no intracardiac shunt. Anticardiolipin antibody testing was notable for strongly elevated IgG antibody titer, with mildly positive IGM and moderately positive Dilute Russell Viper Venom Time. She was treated with enoxaparin and warfarin. Follow-up CTA 3 months later showed resolution of vertebral artery dissection. This patient experienced a vertebral artery dissection for which the immediate precipitant was mechanical injury related to prolonged maintenance of a rotated head posture in flight. Likely underlying contributing risk factors were migraine and antiphospholipid antibody syndrome, conditions associated with cervicocephalic dissections in case control studies. This case suggests there is an etiologic differential diagnosis to the "Economy Class" stroke syndrome that includes dissection related to head positioning, in addition to paradoxical embolization. "Stretch your legs but not your neck" is likely sound advice for travelers on long airflights. References 1. Isayev Y, Chan RKT, Pullicino PM. "Economy Class" stroke syndrome. Neurology 2002;58:960-961. 2. Foerch C, Kessler KR, Steinmetz H, Sitzer M. Economy class stroke syndrome. Neurology 2002;59:962-963.
Reply to Letter to the Editor 10 June 2002
Patrick Pullicino UMDNJ Newark NJ, Richard K. Chan Send Correspondence to journal: Re: Reply to Letter to the Editor Jjspmp{at}aol.com Patrick Pullicino, et al.	We thank Foerch et al for their comment and for bringing our attention to the article by Masson et al. [1] Similar to the three cases we reported, the strokes reported by Foerch et al appear to be related to prolonged air travel. Their cases were related to flights of duration of about 10 hours or more. Although longer duration flights have a higher risk of pulmonary embolism and probably also of stroke, our cases suggest that stroke can be related to shorter duration flights as well. An important similarity to our experience is that the three cases reported by Foerch were collected from a single center within a very short period of time. This suggests that the "economy class" stroke syndrome is probably not rare, particularly with current high volumes of intercontinental flights. Reference: 1) Masson C, Perrotte P, Mariescu A. Cerebral ischemic complication after transatlantic flight. Press Med 1997; 26: 269-270.
"Economy Class" stroke syndrome? 10 June 2002
Christian Foerch J W Goethe-University Frankfurt Germany, Kirn R Kessler, Helmuth Steinmetz, and Matthias Sitzer Send Correspondence to journal: Re: "Economy Class" stroke syndrome? Foerch{at}em.uni-frankfurt.de Christian Foerch, et al.	We have read with interest the recent paper by Isayev et al. [1] They describe three cases of ischemic stroke in young adults that occurred during or after air travel. All patients were diagnosed to have a persistent foramen ovale (PFO) and no other plausible cause of stroke could be found suggesting the existence of an "economy class stroke syndrome". To underscore the importance of their report, we would like to add three very similar patients (aged 21, 63, and 64 years) with otherwise unexplained ischemic strokes which occurred during long-distance air travel (> 9000 km in each case) who were admitted to our department within the last year. All patients developed their symptoms towards the end of their flights, one patient immediately following a prolonged defecation with repeated Valsalva maneuvers. All infarcts appeared embolic upon brain imaging. They were located in the right middle cerebral artery territory in one patient and in the posterior thalamus with transient "top of the basilar" syndrome in another. The third patient had multiple embolic cerebral infarctions accompanied by fulminant pulmonary embolism. The latter patient carried a homozygote prothrombin gene G20210a mutation and subsequently died due to cerebral herniation. The other two patients recovered with no or minimal residual deficits. All patients had a PFO as demonstrated by transesophageal echocardiography, one patient had an additional intraseptal aneurysm. Similar to the patients reported by Isayev et al. lower limb venous Doppler performed within 1-3 days after the events was negative in all three cases, as were their extracranial and intracranial Doppler/duplex examinations, ECG-Holter recordings, and all other coagulation studies (antithrombin, Factor V Leiden mutation, anticardiolipin antibodies, lupus anticoagulant, proteins C and S). Although two of our patients were already in there sixties, none of them showed evidence of atherosclerosis or other cardiovascular risk factors. Of course, due to the worldwide increase of air travel activities more people will suffer a stroke in flight by mere chance. Nevertheless, we also assume that embolic strokes during or due to long-distance air travel have been underreported in the literature, but one more patient was reported a few years ago in a French journal.2 Until more systematic investigations become available ischemic stroke should be included in the list of potential complications of long-distance air travel, especially in the presence of PFO. References: 1. Isayev Y, Chan RKT, Pullicino PM. "Economy Class" stroke syndrome. Neurology 2002; 58: 960-961. 2. Masson C, Perrotte P, Mariescu A. Cerebral ischemic complication after transatlantic flight. Press Med 1997; 26: 269-270.