title: Stroke in Commercial Flights.
abstract: OBJECTIVE
  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.
authors.affiliation: From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.). r.alvarez.velasco@gmail.com.
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Álvarez-Velasco
authors.affiliation: From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.).
authors.forename: Jaime
authors.initials: J
authors.lastname: Masjuan
authors.affiliation: From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.).
authors.forename: Alicia
authors.initials: A
authors.lastname: DeFelipe
authors.affiliation: From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.).
authors.forename: Iñigo
authors.initials: I
authors.lastname: Corral
authors.affiliation: From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.).
authors.forename: Carlos
authors.initials: C
authors.lastname: Estévez-Fraga
authors.affiliation: From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.).
authors.forename: Leticia
authors.initials: L
authors.lastname: Crespo
authors.affiliation: From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.).
authors.forename: Araceli
authors.initials: A
authors.lastname: Alonso-Cánovas
mesh_terms: D000337:Aerospace Medicine; D000368:Aged; D000401:Aircraft; D002545:Brain Ischemia / Q000453:epidemiology*; D005260:Female; D006801:Humans; D015994:Incidence; D002546:Ischemic Attack, Transient / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology*
keywords: air travel; dissection; embolism, paradoxical; foramen ovale, patent; ischemic attack, transient; stroke