Clinical Medicine 2022 Vol 22, No 3: 278–9

IMAGES OF THE MONTH

Images of the month 1: Ischaemic stroke due to pulmonary
arteriovenous fistula

ABSTRACT

Authors: Shunpeng Xu, A Mingfan HongB and Zhihua ZhouC

A 38-year-old man was admitted to the hospital due to a ‘suddenly developed right hemiplegia, unconsciousness and gaze
to the right’. Pulmonary arteriovenous fistulas (PAVFs) are rare
but an important cause of stroke in young people, which is
easy to be clinically neglected. Therefore, for young patients
with pulmonary diseases and cerebral infarction, the possibility of PAVF should be considered.
KEYWORDS: ischaemic stroke, pulmonary arteriovenous fistula,
right-to-left shunt
DOI: 10.7861/clinmed.2022-0092

Case presentation
A 38-year-old man was admitted to the hospital due to a
‘suddenly developed right hemiplegia, unconsciousness and
gaze to the right’. The patient had a 19-year history of recurrent
pulmonary embolism. A neurological examination showed delirium
and the right limb was plegic (grade 0). No obvious abnormality
was found in the rest of the nervous system. Computed
tomography (CT) of the head showed a high density of the left
middle cerebral artery and swelling of left cerebral hemisphere
(Fig 1a). Pulmonary angiography demonstrated a pulmonary
arteriovenous fistula (PAVF) in the left bronchial artery (Fig 1b).
Digital subtraction angiography (DSA) showed occlusion of the
left internal carotid artery (Fig 1c). Laboratory examinations
revealed abnormal coagulation, such as D-dimer of 20 μg/mL,
activated partial thrombin time of 34.0 seconds and prothrombin
time of 14.7 seconds. He was not tested for the thrombophilia
gene. During the period of hospitalisation, the patient received
comprehensive treatment, including vascular intervention therapy,
reduce cranial pressure, lowering blood lipid, nerve rehabilitation
and so on. Sadly, despite treatments, the patient died as a result of
cerebral herniation.

Authors: Aresident in internal medicine, The First Affiliated Hospital
of Guangdong Pharmaceutical University, Guangdong, China;
B
professor of neurology, The First Affiliated Hospital of Guangdong
Pharmaceutical University, Guangdong, China; Cassociate
professor of neurology, The First Affiliated Hospital of Guangdong
Pharmaceutical University, Guangdong, China

278

Fig 1. a) Computed tomography of the head showing high density of
left middle cerebral artery and swelling of left cerebral hemisphere. b)
Pulmonary angiography demonstrating a pulmonary arteriovenous
fistula in the left bronchial artery. c) Digital subtraction angiography
revealing occlusion of the left internal carotid artery.

© Royal College of Physicians 2022. All rights reserved.

Ischaemic stroke and pulmonary arteriovenous fistula

Discussion
Right-to-left shunt (RLS) is considered to be the main cause of death
in young and middle-aged patients with ischaemic stroke. RLS can be
divided into intracardiac and extracardiac types. The former includes
patent foramen ovale, atrial septal defect and ventricular septal defect,
the latter includes PAVF, patent ductus arteriosus and so on. Among
them, ischaemic stroke due to PAVF is rare, so there is a lack of clinical
awareness and vigilance.1 PAVF, a vessel alformation connecting the
pulmonary circulation to the systemic circulation while bypassing the
pulmonary capillaries, can cause paradoxical cerebral infarction.2
Pulmonary artery digital angiography is the gold standard for
diagnosing PAVF, which can provide information such as the size
and number of lesion sites. Multi-detector row CT enhancement
can not only reveal the lesion itself and corresponding blood
vessels but also detect smaller lesions, and can be used to interpret
peripheral and complex PAVF more accurately.4 In this case, the
patient had abnormal coagulation and pulmonary angiography
showed PAVF in the left bronchial artery. Therefore, the patient
had cerebral infarction due to an RLS formed by PAVF.
A study has shown that patients with ischaemic stroke due to PAVF
are 15 years younger than patients with routine stroke. Patients who
died were 13 years younger than those who died after routin stroke,
overall losing 9 extra healthy life-years per patient.3
PAVFs are rare but an important cause of stroke in young
people, which is easy to be clinical neglected. Therefore, for young

© Royal College of Physicians 2022. All rights reserved.

patients with pulmonary diseases and cerebral infarction, the
possibility of PAVF should be consid. ■

References
1 Belopasova AV, Dobrynina LA, Kalashnikova LA et al. [Pulmonary
arteriovenous shunt - a rare cause of recurrent stroke due to
paradoxical embolism]. Zh Nevrol Psikhiatr Im S S Korsakova
2020;120:107–13.
2 Hasegawa I, Abe T, Mino T et al. Paradoxical Brain Embolism
Caused by Isolated Pulmonary Arteriovenous Fistula Successfully
Treated with Recombinant Tissue Plasminogen Activator. J Stroke
Cerebrovasc Dis 2019;28:e100–1.
3 Topiwala KK, Patel SD, Pervez M, Shovlin CL, Alberts MJ. Ischemic
stroke in patients with pulmonary arteriovenous fistulas. Stroke
2021;52:e311–5.
4 Suga K, Iwanaga H, Tokuda O et al. Steal phenomenon-induced
lung perfusion defects in pulmonary arteriovenous fistulas: assessment with automated perfusion SPECT-CT fusion images. Nucl
Med Commun 2010;31:821–9.

Address for correspondence: Dr Mingfan Hong, Department
of Neurology, The First Affiliated Hospital, School of
Clinical Medicine of Guangdong Pharmaceutical University,
Guangzhou, Guangdong 510080, China.
Email: hmf9007@163.com

279