Abstract Details

Title Pulmonary Arteriovenous Malformation (PAVM): An Uncommon Cause of Cryptogenic and Embolic Stroke of Undetermined Source (ESUS).

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P3 - Poster Session 3 (5:30 PM-6:30 PM)

Poster/Presentation
Number 13-009

Background Pulmonary arteriovenous malformations (PAVM) are an uncommon etiology of ischemic strokes by mechanism of right-to-left circulatory shunting and should be considered in patients with embolic stroke of undetermined source (ESUS).

Objective NA

Design/Methods A 46 year-old female with a history of hypertension, hyperlipidemia, and polysubstance abuse presented with acute onset dysarthria and left hemiparesis. Additional findings included right gaze preference, left homonymous hemianopia, and left inattention. NIHSS was 12. Noncontrast head CT demonstrated a right middle cerebral artery hyperdense vessel sign and ASPECTS score was 10. The patient received intravenous tenecteplase (0.25 mg/kg) and underwent successful mechanical thrombectomy. MRI brain demonstrated patchy right temporoparietal lobe acute ischemic stroke. Ejection fraction was 55-60% on transthoracic echocardiogram (TTE). Telemetry and EKG revealed no arrhythmia. Transcranial doppler with agitated saline identified Spencer grade 3 spontaneous right-to-left shunting without valsalva. Transesophageal echocardiogram revealed right-to-left shunt with agitated saline injection from a possible patent foramen ovale. Repeat TTE performed with agitated saline injection, revealed the delayed appearance of agitated saline in the left atrium entering from the pulmonary vein. The patient underwent a contrast chest CT angiogram, which reported a less-than 2cm PAVM in the peripheral aspect of the left lung lingula lobe with a single arterial feeder draining into the left lower pulmonary vein. She underwent successful percutaneous coil embolization on the PAVM, thus preventing further right-to-left shunting and propensity for embolic events.

Results NA

Conclusions This case demonstrates a rare possible stroke etiology in ESUS. In our patient, intracardiac shunt was initially proposed as the mechanism of stroke, however, further diagnostic testing confirmed extra-cardiac, intrapulmonary shunt from PAVM as primary mechanism. In the ESUS population without traditional neurovascular risk factors, a comprehensive workup that includes exclusion of less common pathology (i.e. extracardiac shunting) may be critical to mitigate morbidity and assure appropriate interventions for secondary stroke prevention.

Authors/Disclosures
Farah Y. Fourcand, MD (Cleveland Clinic Indian River) PRESENTER	Dr. Fourcand has nothing to disclose.
Teye A. Umanah, MD (St Thomas Elgin General Hospital)	Dr. Umanah has nothing to disclose.
Siddhart K. Mehta, MD	Dr. Mehta has nothing to disclose.
	No disclosure on file
Jawad F. Kirmani, MD (RWJBarnabas Medical)	Dr. Kirmani has nothing to disclose.
Sara Strauss, DO (JFK Medical Center Neuroscience Department)	Dr. Strauss has nothing to disclose.