Stroke and pulmonary thromboembolism after a long flight

Abstract

In the economy class syndrome (ECS) the patient presents a deep venous thrombosis (DVT) with or without pulmonary thromboembolism (PTE) during or after a long trip as a result of prolonged immobilization. Economy class stroke syndrome is an infrequent ECS variant in which ischemic stroke is associated with a patent foramen ovale (PFO). Few cases have been published in the literature to date. We present a patient who suffered a PTE and an ischemic stroke immediately after a transoceanic flight. A 36-year-old woman with no significant medical or familial history flew economy class from Lima, Peru, to Madrid, Spain. On disembarkation she presented sudden dyspnea and a depressed level of consciousness, global aphasia, and right hemiparesis. A pulmonary scintigraphy showed a PTE and a cranial MRI revealed an ischemic infarct in the left middle cerebral artery territory. We simultaneously performed a transesophageal echocardiography and a transcranial Doppler and observed a massive right-to-left shunt through a PFO. The patient was a heterozygous carrier of the C46T mutation of coagulation factor XII. The appearance of a stroke following a long trip is suggestive of paradoxical embolism through a PFO, mainly if it is associated with a DVT and/or a PTE. The cause of the initial event, the DVT, could be a prothrombotic state.

Watershed Infarct due to Massive Pulmonary Embolism: A Rare Diagnosis at the Emergency Department

“…The first case is of a young woman with no significant medical history who suffered pulmonary embolism and stroke after a long flight from Peru to Spain. This long travel was considered as a risk factor for deep venous thrombosis and emboli (7). The second case is of a young woman who had been diagnosed with PE and stroke because of PFO after undergoing varicose vein stripping of the leg, which is a risk factor for thromboembolism (8).…”

“…There are three reported cases of patients with coexisting pulmonary embolism and stroke, where the common mechanism of coexisting stroke is the migration of emboli from a patent foramen ovale (PFO) (7,8,9). The first case is of a young woman with no significant medical history who suffered pulmonary embolism and stroke after a long flight from Peru to Spain.…”

Maximal Potential Patent Foramen Diameter Does Not Correlate with the Type or Frequency of the Neurologic Event prior to Closure

“…However, data are insufficient to draw definite conclusions, because either PFO alone, or combined with atrial septal aneurysm, was not associated with an increased risk for stroke [15] or recurrent stroke [12] in other studies. Factors such as age [16], deep venous thrombosis [16, 17], coagulation abnormalities such as prothrombin gene and factor V Leiden mutations [18, 19], prolonged immobilization [20], lower limb surgery [21],or chronic indwelling venous catheters, which increase the likelihood of transient venous thrombi, may also be important in the genesis of cryptogenic stroke. All of these factors have been implicated, but not thoroughly, and systematically evaluated.…”

Stroke after prolonged air travel associated with a pulmonary arteriovenous malformation

“…In contrast, arterial thromboembolism and ischemic stroke are extremely rare in this context. Several reports describe a potential association between prolonged flights and stroke due to paradoxal embolism through patent foramen ovale (PFO) or due to cervicocephalic arterial dissection [3,4]. However, causes of paradoxal embolism other than PFO have not been previously described.…”