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.