Economy class syndrome was first reported in 1988 and refers to an association between air travel and venous thromboembolism.¹ Recently, three cases of stroke in young adults without risk factors other than a patent foramen ovale have been reported, presumably the result of paradoxical embolism.² We now present an unusual case of medial medullary infarction caused by vertebral artery dissection associated with abnormal neck posture during a long haul flight—another health related reason to travel first class.

A 56 year old right handed insurance broker on a 7K hour economy class long haul flight returning to the United Kingdom fell asleep with his head uncomfortably twisted to the right. On waking he noticed pain in the left side of his neck and paraesthesia in the right arm. The episode resolved after 15 minutes, but recurred with a right hemiparesis affecting the arm and leg. He smoked 40 cigarettes a day and drank 24 units of alcohol a week. There was no significant past medical history and no family history of vascular disease.

On examination, conscious level, cognition, speech, and the cranial nerves were entirely normal, there was no facial weakness, and the tongue was normal. There was pyramidal weakness MRC grade 3 affecting the right arm and leg with right sided hyperreflexia and a right extensor plantar response. Joint position, vibration, and light touch sensations were normal, but pain and temperature sensation were diminished down the right side. Blood pressure was 150/90 and cardiorespiratory examination was otherwise normal. Fasting cholesterol was 5.5 mmol/l, but other routine blood tests …