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A 57-year-old woman with cardiovascular risk factors had recurrent strokes of undetermined origin and presented with acute right-sided weakness, dysarthria, and facial droop. CT confirmed left frontal and temporal infarcts. Transcranial Doppler with bubble contrast showed RLS, transesophageal echocardiography excluded intracardiac defects, and pulmonary CT angiography identified a right lower lobe PAVM treated by embolization with an Amplatzer Vascular Plug. The report highlights comprehensive RLS evaluation when standard stroke workup is unrevealing.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/recurrent-stroke-due-to-pulmonary-arteriovenous-malformation-diagnostic-challenges-and-management/419279/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/recurrent-stroke-due-to-pulmonary-arteriovenous-malformation-diagnostic-challenges-and-management/419279.png","ImageObject",300,407,{"name":92,"@type":93},"Cipher","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-02","2026-09-28",true,{"@type":102,"interactionType":103,"userInteractionCount":44},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What clinical problem is described in the case?","Question",{"text":112,"@type":113},"The case describes recurrent stroke in a 57-year-old woman with an undetermined origin, who presented with acute right-sided weakness, dysarthria, and facial droop.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How was the right-to-left shunt (RLS) diagnosed?",{"text":117,"@type":113},"Transcranial Doppler with bubble contrast revealed significant right-to-left shunting, and transesophageal echocardiography excluded an intracardiac defect while suggesting an intrapulmonary source.",{"name":119,"@type":110,"acceptedAnswer":120},"How was the pulmonary arteriovenous malformation managed?",{"text":121,"@type":113},"Pulmonary CT angiography identified a right lower lobe PAVM, which was embolized using an Amplatzer Vascular Plug 4, after further investigations excluded other etiologies.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},419279,1790694060,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":44,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":29,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":144,"preview_page_count":4},687208528416,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Review began 11/13/2025  \nReview ended 11/27/2025  \nPublished 12/03/2025  \n© Copyright 2025  \nRibeiro et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited.  \nDOI: 10.7759/cureus.98393  \nOpen Access Case Report  \nRecurrent Stroke Due to Pulmonary Arteriovenous Malformation: Diagnostic Challenges and Management  \nRui Pedro Ribeiro 1, Carolina Guimarães 1, Helena Hipólito Reis 1, Ana Aires 2, Ana Pastor 1, Luísa Fonseca 1  \n1. Department of Internal Medicine, Unidade Local de Saúde de São João, Porto, PRT 2. Department of Neurology, Unidade Local de Saúde de São João, Porto, PRT  \nCorresponding author: Rui Pedro Ribeiro, [ruipcribeiro@gmail.com](ruipcribeiro@gmail.com)  \nAbstract  \nPulmonary arteriovenous malformations (PAVMs) are rare vascular anomalies that establish a direct rightto-left shunt (RLS) . Although uncommon, they may cause paradoxical embolism leading to stroke, cryptogenic stroke, or hemorrhage. Despite their potential severity, PAVMs remain an unrecognized entity.  \nWe report a case of a 57-year-old woman with cardiovascular risk factors and a previous recurrent stroke of undetermined origin, admitted with acute right-sided weakness, dysarthria, and facial droop. Computed tomography (CT) confirmed acute infarcts in the left frontal and temporal cortices. During the diagnostic workup, transcranial Doppler with bubble contrast revealed RLS, and transesophageal echocardiography excluded an intracardiac defect. Pulmonary CT angiography identified a right lower lobe PAVM that was embolized with an Amplatzer Vascular Plug 4 (St. Paul, MN: Abbott) . Further investigations excluded other etiologies. A comprehensive investigation of RLS is crucial when no other etiology for a stroke is found. Transcranial Doppler and CT angiography are key tools for diagnosis, and embolization is an effective treatment.  \nCategories: Neurology, Radiology, Internal Medicine  \nKeywords: cryptogenic stroke, endovascular interventions, paradoxical embolism, pulmonary arteriovenous malformation, right-to-left shunt  \nIntroduction  \nPulmonary arteriovenous malformation (PAVM) is characterized by the presence of abnormal pulmonary blood vessels in which there is a direct connection between arterial and venous vessels. This bypass of the capillary bed can create a low-resistance and high-flow continuous intrapulmonary right-to-left shunts (RLS), which can lead to a broad spectrum of clinical manifestations, including life-threatening hemorrhage or complications from paradoxical embolization (e.g., ischemic stroke or brain abscess) [1,2] . In patients  \nwith no clear cardioembolic source but with evidence of an RLS, paradoxical embolism should be  \nconsidered. While a patent foramen ovale is a common cause, PAVMs remain an underrecognized entity, with retrospective studies showing an incidence of PAVMs in approximately 0.02% of patients with ischemic stroke [3] . Early diagnosis and management are essential to prevent recurrent cerebral ischemic events. This case emphasizes the relevance of investigating pulmonary sources of embolism when standard stroke  \nworkup is unrevealing.  \nCase Presentation  \nA 57-year-old right-handed woman presented to the emergency department two hours after the sudden onset of right-sided limb weakness, trouble speaking, and facial droop. She was a smoker (more than 20  \ncigarettes daily for over 40 years), and had a history of arterial hypertension, dyslipidemia, previous  \nhepatitis C virus infection, and a past of cocaine and heroin use. She had experienced several strokes in multiple territories of undetermined etiology (at that date, transthoracic echocardiogram, 24 h ambulatory electrocardiography, and transcranial Doppler ultrasound had revealed no obvious abnormality) and, since then, had been on antiplatelet t","cbCaicg1yrg2zYfv","https://ap.wps.com/l/cbCaicg1yrg2zYfv","pdf",3783315,"English","# Introduction\n# Case Presentation\n## Diagnostic Workup\n## Treatment and Outcome","[{\"question\":\"What clinical problem is described in the case?\",\"answer\":\"The case describes recurrent stroke in a 57-year-old woman with an undetermined origin, who presented with acute right-sided weakness, dysarthria, and facial droop.\"},{\"question\":\"How was the right-to-left shunt (RLS) diagnosed?\",\"answer\":\"Transcranial Doppler with bubble contrast revealed significant right-to-left shunting, and transesophageal echocardiography excluded an intracardiac defect while suggesting an intrapulmonary source.\"},{\"question\":\"How was the pulmonary arteriovenous malformation managed?\",\"answer\":\"Pulmonary CT angiography identified a right lower lobe PAVM, which was embolized using an Amplatzer Vascular Plug 4, after further investigations excluded other etiologies.\"}]","Recurrent Stroke Due to Pulmonary Arteriovenous Malformation - Diagnostic Challenges and Management | PDF",1790616421,15]