Stroke in a patient with pulmonary arteriovenous fistula: A case report study
A 40-year-old male was presented to neurology department (Alzahra Hospital, Isfahan, Iran) with chief complaint of sudden diplopia and dysarthria accompanied by facial palsy. The symptoms had started 48 h earlier and recovered within hours after admission; however, patient's diplopia and facial paresis continued. During his childhood he was treated with Phenobarbital after he was diagnosed with seizures because of recurrent cyanotic attacks and syncope. He had a therapeutic open-thorax surgery after a PAVF was found in an exploratory angiography 13 years ago. Although, the PAVF was closed in the surgery, he has been experiencing episodes of fatigue and shortness of breath during the last 13 years. He had no history of smoking or thrombotic vascular diseases. In physical exam the patient had normal vital signs. He had left-side facial palsy and hemi paresis. He was dysarthric and complained of diplopia when looking to the right side. His electrocardiogram was normal with no arrhythmias. In chest X-ray, there were no signs of cardiomegaly, structural abnormalities, increased pulmonary vascular markings or mass-related findings. Arterial blood gas test indicated normal levels of arterial Oxygen. Both laboratory tests for hypercoagulable states and vasculitis panel were negative. In computed tomography (CT-scan) no lesions were found however, in the T2-magnetic resonance imaging (MRI) images, a hyper-signal lesion in the right thalamic region of his brain was seen []. Based on the history, we tested the patient for vascular anomalies. A trans-cranial Doppler [] with positive bubble test discovered an open arteriovenous shunt, which was confirmed with a trans-esophageal echocardiogram. The patient had an open PAVF. We put the patient on proper anti-coagulants to prevent further damages. Angiographic images were used to determine the site of fistula. The fistula was closed through surgery and further examinations showed proper blood circulation in higher areas of his lungs, which previously had been bypassed by the AVF. He was put on anticoagulant for 6 months. In 1-month follow-up, he had no complaints of fatigue or shortness of breath, and neurological symptoms were minimized.