Diagnosis and treatment of pulmonary arteriovenous malformation with cryptogenic stroke caused by paradoxical embolism as the first manifestation / 中华神经科杂志

ABSTRACT

Objective To investigate the clinical and radiological features of the patients with cryptogenic stroke as the first manifestation of pulmonary arteriovenous malformation (PAVM),and to explore the mechanism and summarize the diagnostic strategy.Methods Transcmnial Doppler (TCD) bubble tests,non-contrast or contrast-enhanced transthoracic and transesophageal echocardiography,contrast-enhanced thoracic CT and pulmonary angiography were performed in 2 patients with cryptogenic stroke for the detection of right to left shunt (RLS) and the diagnosis of PAVM.Then interventional catheter embolization of PAVM and postoperative follow-up were arranged.Results TCD bubble tests in these 2 patients showed the following characteristics indicating RLS:spontaneous continuous shunt at rest,earlystage shunt appeared rapidly after injection,considerable large amount of shunt volume as a shower of microbubble,the extent of shunt volume not attenuated by Valsalva Maneuver (VM).One patient was diagnosed as PAVM,the other was PAVM plus patent foramen ovale (PFO).Both patients of PAVM were successfully treated with interventional catheter embolizations.Then TCD bubble test was repeated and showed significantly decreased amount of RLS.They remained asymptomatic during the 3-year and 1-year follow-up.Conclusions In patients with cryptogenic stroke due to suspected paradoxical embolism,TCD bubble test should be performed for screening RLS.Besides PFO,a traditional access to intracardiac shunt,PAVM should be considered as a new access to extracardiac shunt in paradoxical embolism.