GENERAL MANAGEMENT

Air travel considerations after a stroke

David Goldemund M.D.
Updated on 12/10/2024, published on 19/09/2024

Is it safe to travel on an airplane after a stroke?

the short answer is yes, but not immediately
AHA recommends waiting until the patient is stable and has recovered enough
- recovery times are different for everyone
- in general, at least 2 weeks after ischemic stroke are recommended
- intracerebral hemorrhage and SAH require longer delay (~ 6-8 weeks)
there is no data from RCTs to make a solid recommendation; low-quality cohort data suggest a low risk of stroke on a commercial flight (Riski, 2023)
air travel itself does not directly cause stroke, but underlying conditions like decompensated hypertension and arrhythmias may pose risks
certain elements of flying need to be considered before planning a trip:
- will the patient be able to board the plane, move around, and sit comfortably for a long flight?
- can a family member or friend accompany them on the trip?
- flying or not, stroke patients have an increased risk of recurrence in the first month of having a stroke ⇒ it would be unfortunate to suffer another stroke right during the flight
- always weigh the need to travel against potential health risks

Difficulties with traveling due to poststroke disability

Increased risk of recurrence in the subacute phase of stroke with no therapy available during the flight

Physiological challenges of air travel

hypobaric hypoxia
- commercial aircraft cabins are pressurized to the equivalent of 1828–2438 meters (6,000–8,000 feet) above sea level; they can’t maintain sea level pressure while flying at traditional commercial flight altitudes
- ambient oxygen pressure decreases, potentially lowering arterial oxygen saturation by 5–10%
- although reduced oxygen levels while flying are unlikely to pose a direct risk for the brain of stroke survivors, it can be an issue for those with comorbidities
  - those with pre-existing cardiovascular conditions may experience arrhythmias or changes in blood pressure
  - hypoxia may also exacerbate respiratory distress in patients with pulmonary disease
hemodynamic changes
- changes in cabin pressure can affect autonomic regulation, potentially leading to blood pressure fluctuations
- stroke may impair autoregulatory mechanisms, making patients more susceptible to hemodynamic instability
stress and fatigue
- physical exertion – navigating airports and handling luggage can be taxing
- emotional stress – travel-related stress and anxiety can impact cardiovascular and neurological status
risk of falls and injuries (depending on disability)
thrombosis risk
- prolonged sitting during long-distance flights (typically > 4-6 hours) increases venous stasis, increasing the risk of VTE
- post-stroke patients may have an elevated coagulation tendency, further increasing the risk of thrombosis

Assessing fitness to fly

clinical evaluation
- evaluate for residual deficits, potential seizure activity, and cognitive function
- assess for comorbid conditions such as hypertension, atrial fibrillation, or heart failure
- assess the risk of stroke recurrence (stroke mechanism, risk factor, etc.)
- determine baseline oxygen saturation and the need for supplemental oxygen
- identify risk factors for thrombosis (previous thrombosis, immobility, and thrombophilia)
check brain imaging
medical clearance
- provide a medical certificate if required by the airline
- discuss any special needs or accommodations

Ischemic stroke

TIA – > 2 days, if symptoms have resolved
minor stroke – after 7–10 days, provided the patient is neurologically stable
major stroke – delay air travel for ≥ 14 days to assess for complications such as hemorrhagic transformation

Intracerebral hemorrhage

flying can typically be considered after 6–8 weeks if the patient is clinically stable and imaging confirms no significant residual mass effect or rebleeding risk
blood pressure must be well managed, as changes in cabin pressure could increase the risk of rebleeding
patients should be neurologically stable without significant deficits that could impair safety or care during flight

Subarachnoid hemorrhage

non-aneurysmal SAH – similar to ICH, flying may be considered after 6–8 weeks if the patient is stable, neurologically intact, and has no vasospasm or hydrocephalus on follow-up imaging
aneurysmal SAH (post-coiling/clipping) – air travel is generally safe after 3 months if the aneurysm is secured, hydrocephalus has been treated (if present), and there are no signs of vasospasm or other complications

Cerebral sinus thrombosis

flying is generally contraindicated until the acute phase has resolved, usually 4–6 weeks, depending on the resolution of symptoms, radiological findings, and the stability of anticoagulation therapy
flying should be delayed until ICP normalizes to avoid exacerbation due to cabin pressure changes
imaging should confirm resolution or significant improvement of the sinus thrombosis and absence of intracranial complications
consider any other risk factors for thromboembolism or recurrence, such as thrombophilia, which may influence the timing of flying

Intracranial surgery

craniotomy – typically, flying is deferred for 6–8 weeks post-surgery to allow for stabilization of intracranial pressure and healing of surgical sites
if a patient has a ventriculoperitoneal shunt or decompressive craniectomy, further clearance from the neurosurgeon is required, as air pressure changes may affect intracranial dynamics

Flight recommendations for patients

Pre-flight recommendations

contact the airline in advance to arrange special assistance
- arrange for assistance at the airport to reduce physical strain; arrange for wheelchair assistance; request priority boarding, and ensure that your seat is comfortable and accessible
- consider telling the flight attendant that you may need assistance walking to the bathroom and might need a companion to help in the restroom
give yourself an extra hour to get through security and walk to the terminal
ensure an adequate supply of all medications for the duration of the trip; keep all essential medications in a carry-on bag, along with copies of the prescription
consider DVT prophylaxis for long-distance flights, consider graduated compression stockings and/or LMWH (especially in patients with limited leg mobility)
- stockings are unsuitable for people with peripheral artery disease
travel with a companion if possible (family member or caregiver)
- companion should know medical history, requirements, and how to respond in an emergency
ensure optimal blood pressure control, heart rate, and other risk factors before traveling
carry a letter from your healthcare provider detailing your medical condition, medications, and any special requirements
obtain travel insurance that covers medical emergencies related to the patient´s condition

In-flight recommendations

move the legs while seated and walk around the cabin whenever possible
ensure adequate hydration with water; avoid dehydrating drinks (such as alcohol or caffeine)
monitor blood pressure during long flights, if possible

Post-flight recommendations

identify medical centers at the destination in case of emergency
arrange for continuity of care if traveling for extended periods

Travel insurance

history of stroke must be declared to the travel insurance providers, as not doing so may invalidate any claims
standard travel insurance may not cover pre-existing conditions
look for policies that offer coverage for medical emergencies related to stroke

Medical certificate

some airlines require a medical certificate or a “fit-to-fly” letter for passengers with recent medical events like a stroke
this document should outline the medical condition, stability, and any special requirements during the flight
contact the airline in advance to determine their policies

What seating arrangements are best for someone recovering from a stroke?

requesting specific seating can enhance comfort and reduce strain during the flight
look for an aisle seat with extra legroom and proximity to restrooms