Case StudiesIschemic Stroke Secondary to Paradoxical Embolism Through a Pulmonary Arteriovenous Malformation: Case Report and Review of the Literature
Section snippets
Case Report
A 32-year-old right-handed man was admitted after experiencing sudden onset right facial weakness and language disturbance. He described a 15-minute episode of blurred vision, right-sided facial weakness, slurred speech, and inability to read with intact comprehension of the number system. Past medical history included hypertension, hyperlipidemia, tobacco use, and epilepsy on phenytoin. He was hospitalized 2.5 months prior for perimyocarditis with hypokinesis of the apex noted on cardiac
Discussion
Paradoxical embolization is a recognized cause of ischemic stroke that occurs when thrombotic or bacterial emboli of venous origin occlude arteries of various organs, including the brain, after bypassing the filtering system of the pulmonary capillaries and traveling to the arterial circulation via an abnormal channel.1 While most paradoxical emboli are likely attributed to patent foramen ovales, PAVMs are another less common source of right-to-left shunting contributing to risk of stroke in
Conclusion
This case highlights the need to consider PAVM in the differential diagnosis for cryptogenic stroke, particularly in young persons with evidence of right to left shunting on cardiac imaging. Embolization is the definitive treatment for clinically significant PAVMs or those with high risk shunting physiology. Current guidelines suggest that patients with treated PAVMs receive follow-up imaging at 3-year intervals.
References (14)
- et al.
Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: an overview
Diagn Interv Imaging
(2013) - et al.
Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications: a striking association
Chest
(2013) - et al.
Pulmonary arteriovenous malformations
Chest
(2013) - et al.
Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997
Mayo Clin Proc
(1999) - et al.
Patent foramen ovale as a risk factor for cryptogenic stroke
Ann Intern Med
(1992) - et al.
Pulmonary arteriovenous malformations. A state of the art review
Am J Respir Crit Care Med
(1998) - et al.
Prevalence of pulmonary arteriovenous malformations as estimated by low-dose thoracic CT screening
Intern Med
(2012)
Cited by (13)
Noncontrast time-resolved pulmonary magnetic resonance angiography with consecutive beam saturation pulse and variable flip angles using three-dimensional fast spin echo: A preliminary study
2022, Magnetic Resonance ImagingCitation Excerpt :Pulmonary arteriovenous malformations (PAVMs) are pulmonary vascular abnormalities that create shunts between the pulmonary arteries and veins [1]. Although most patients with PAVMs are asymptomatic, the direct connection between their vessels can cause various symptoms, such as exertional dyspnea, hypoxemia, ischemic stroke [2], and brain abscesses [3]. Transcatheter embolization of the feeding artery is the primary treatment of choice [4].
Neurologic Complications in Hereditary Hemorrhagic Telangiectasia with Pulmonary Arteriovenous Malformations: A Systematic Review
2023, Canadian Journal of Neurological SciencesNeurologic Complications in HHT with Pulmonary Arteriovenous Malformations: Systematic Review
2022, Acta Microbiologica BulgaricaRenal Embolism Associated with Foramen Ovale Coexisting Acute Pulmonary Embolism
2023, Case Reports in PulmonologyRight-to-Left Shunts Occur during Cardiopulmonary Resuscitation: Echocardiographic Observations
2022, Critical Care Medicine