Concurrent Pulmonary Arteriovenous Malformation and Pulmonary Embolism Causing Stroke: a Therapeutic Dilemma

Background: As pulmonary arteriovenous malformation (PAVM) include a right-to-left shunt, it can be accompanied by fatal complications such as stroke and brain abscess due to paradoxical embolism. A concurrent PAVM and pulmonary embolism (PE) is a rare condition. Therefore, the sequence of management has not been established.

Case Presentation: A 62-year-old female patient was transferred to our hospital with a sporadic simple PAVM and concurrent bilateral PE. On chest computed tomography (CT), the acute PE was extended to the segmental pulmonary artery where the feeding artery of PAVM originated. Despite the anticoagulation, the patient complained of left sided weakness on the fifth day of admission, and magnetic resonance imaging revealed an acute infarction in the right lateral thalamus, which was thought to be caused by paradoxical embolism. This situation could lead to a dilemma between the risk of thrombus migration during PAVM embolization and another embolic event due to delayed shunt occlusion during anticoagulation. After a multidisciplinary discussion, a delayed endovascular embolization was performed for PAVM after confirming the complete resolution of PE with 4 months of anticoagulation. The cause of PE in this patient was eventually diagnosed as antiphospholipid syndrome.

Conclusion: The authors reported a rare case of concurrent PAVM and PE that led to an embolic stroke during hospitalization. This patient was managed with delayed endovascular embolization for PAVM after an anticoagulation for PE and stroke. It is thought to be valuable in deciding for a treatment plan for this rare condition.