Stroke and pulmonary thromboembolism after a long flight

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.