This Article Full Text Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yeung, M. Articles by Shuaib, A. Search for Related Content PubMed PubMed Citation Articles by Yeung, M. Articles by Shuaib, A.

(Stroke. 1995;26:1941-1944.)
© 1995 American Heart Association, Inc.

Articles

Transcranial Doppler Ultrasonography and Transesophageal Echocardiography in the Investigation of Pulmonary Arteriovenous Malformation in a Patient With Hereditary Hemorrhagic Telangiectasia Presenting With Stroke

M. Yeung, MD; K.A. Khan, MBBCH; D.H. Antecol, MD; D.R. Walker, MD A. Shuaib, MD

From the Saskatchewan Stroke Research Centre (M.Y., K.A.K., A.S.), the Department of Medicine, Divisions of Neurology (M.Y., K.A.K., A.S.) and Cardiology (D.H.A.), and the Department of Medical Imaging (D.R.W.), Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Background Hereditary hemorrhagic telangiectasia (HHT) is associated with a high incidence of pulmonary arteriovenous malformations (PAVMs), which can be the underlying cause for cerebral ischemia or brain abscess. The diagnosis of these malformations may be difficult, as clinical or radiological findings may be absent. Transcranial Doppler ultrasound (TCD) with saline contrast and transesophageal echocardiography (TEE) with saline contrast are useful in identifying patients with right-to-left shunts and may help identify PAVMs.

Case Description A 68-year-old woman with HHT presented with two strokes over a 1-year period. After the first stroke, a transthoracic echocardiogram with saline contrast demonstrated significant right-to-left shunt that was interpreted as a patent foramen ovale. After the second stroke, a TCD contrast study confirmed this right-to-left shunt; however, a TEE contrast study discovered an extracardiac shunt. Pulmonary angiography revealed a left lower lobe PAVM and three telangiectasias involving the right lung. The PAVM was subsequently embolized. Postembolization radiographic imaging showed complete occlusion of the feeding vessel to the PAVM. However, repeated contrast TCD and TEE demonstrated persistent right-to-left shunting.

Conclusions In our patient, stroke may have resulted from peripheral venous emboli passing through the PAVM or from endogenous thromboemboli originating within the PAVM. TCD and TEE contrast studies were helpful in judging the efficacy of catheter embolization therapy of PAVM. TCD and TEE with saline contrast may be clinically useful follow-up examinations for recurrence or development of new PAVMs.

Key Words: cerebral arteriovenous malformations • echocardiography, transesophageal • telangiectasia, hereditary hemorrhagic • ultrasonics

This article has been cited by other articles:

				L. J. Frazin Patent Foramen Ovale or Pulmonary Arteriovenous Malformation: An Appeal for Diagnostic Accuracy Chest, July 1, 2007; 132(1): 5 - 6. [Full Text] [PDF]

				S. Homma and R. L. Sacco Patent Foramen Ovale and Stroke Circulation, August 16, 2005; 112(7): 1063 - 1072. [Full Text] [PDF]

				H. W. Schuchlenz, G.P. Anzola, E. Morandi, F. Casilli, and E. Onorato Contrast Ultrasound Techniques in the Detection and Quantification of Patent Foramen Ovale: Myth Versus Reality * Response: Stroke, December 1, 2004; 35(12): 2755 - 2756. [Full Text] [PDF]

				K. Daly, S. Hutchinson, C. McCollum, Y.-H. Kim, J.-S. Kim, and S.-W. Oh Etiology of Mental Status Changes in Patients After Total Hip Arthroplasty: Hypoxemia or Paradoxical Embolization of Fat or Bone Marrow? J. Bone Joint Surg. Am., May 1, 2003; 85(5): 967 - 967. [Full Text] [PDF]

				D. W. Droste, S. Lakemeier, T. Wichter, J. Stypmann, R. Dittrich, M. Ritter, M. Moeller, M. Freund, and E. B. Ringelstein Optimizing the Technique of Contrast Transcranial Doppler Ultrasound in the Detection of Right-to-Left Shunts Stroke, September 1, 2002; 33(9): 2211 - 2216. [Abstract] [Full Text] [PDF]

				K. Kimura, K. Minematsu, K. Wada, M. Yasaka, M. Tagaya, S. Kuribayashi, and T. Yamaguchi Transcranial Doppler of a Paradoxical Brain Embolism Associated with a Pulmonary Arteriovenous Fistula AJNR Am. J. Neuroradiol., November 1, 1999; 20(10): 1881 - 1884. [Abstract] [Full Text]

				A. A. Almeida, H. L. Thomson, D. J. Burstow, and R. K. W. Tam Transesophageal Echocardiography in an Operation for Pulmonary Arteriovenous Malformation Ann. Thorac. Surg., January 1, 1998; 65(1): 267 - 267. [Abstract] [Full Text] [PDF]