SESSION TITLE: Miscellaneous Cases
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Wednesday, October 28, 2015 at 11:00 AM - 12:15 PM
INTRODUCTION: Paraxdoxical embolism is a cause of cryptogenic stroke often secondary to a patent foramen ovale (PFO); however, a forgotten source of paradoxical embolism is a pulmonary arteriovenous malformation (PAVM). We present a patient newly diagnosed with hereditary hemorrhagic telangiectasia (HHT) who suffered a cryptogenic stroke in the setting of both a PAVM and PFO.
CASE PRESENTATION: A 41 year-old woman with childhood epistaxis and deep vein thrombosis presented to an outside hospital with acute painless left eye blindness. Initial work-up was negative for primary retinal dysfunction. A brain MRI showed an ischemic lesion in the corona radiata. A non-contrast chest CT was performed showing multiple PAVMs, one measuring approximately ten millimeters (Figure 1). History revealed an insidious worsening of breathlessness with exertion. Physical exam was normal with the exception of a resting oxygen saturation of 89%. Pulmonary function tests showed an isolated decrease in diffusion capacity to 58%. A echocardiogram bubble study was suggestive of both intra and extra cardiac shunt. Pulmonary angiogram with embolization using both amplatzer plugs and coils was performed resulting in rapid resolution of hypoxemia (Figure 2). Magnetic resonance angiogram of the brain did not reveal other AVMs. Aspirin was started and surgical repair of the PFO is being considered. No further embolic events have occurred.
DISCUSSION: PAVM with a feeding artery greater than three millimeters or any size with symptomatic sequelae such as hypoxemia, paradoxical embolism, or brain abscess should be treated with catheter directed embolization. The procedure is both safe and effective with success rates approaching 98% and reducing morbidity to 2%1. Multiple PAVMs warrant continued CT follow-up.
CONCLUSIONS: Our case of PAVM presenting as a paraxodical embolism is an uncommon presentation of a rare disease. It highlights the need for evaluation for both PAVM and PFO in a patient with suspected or definite HHT due to a 80-90% incidence of PAVMs in these patients2.
Reference #1: Pollak JS, Saluja S, Thabet A, Henderson KJ, Denbow N, White RI Jr. Clinical and anatomic outcomes after embolotherapy of pulmonary arteriovenous malformations. J Vasc Interv Radiol. 2006;17(1):35.
Reference #2: Wong HH, Chan RP, Klatt R, Faughnan ME. Idiopathic pulmonary arteriovenous malformations: clinical and imaging characteristics. Eur Respir J. 2011 Aug;38(2):368-75. Epub 2010 Dec 22.
DISCLOSURE: The following authors have nothing to disclose: Jason Filopei, Navitha Ramesh, Michael Bergman, Sarun Thomas, Albert Miller
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