A case of surgical resection of a pulmonary arteriovenous fistula with a cryptogenic stroke

Abstract

The first choice of treatment for pulmonary arteriovenous fistula (PAVF) is coil embolization, which requires continuation of antithrombotic drugs for a certain period. In this article, we present a probable case of hereditary hemorrhagic telangiectasia (HHT) associated with a cryptogenic stroke, which was treated surgically with PAVF allowing discontinuation of antithrombotic drugs. A 76-year-old woman was brought to the emergency room with right hemiplegia from waking up. Diffusion-weighted magnetic resonance imaging revealed acute infarction on the left side of the pons and the left cerebellum, and magnetic resonance angiography showed occlusion of the left posterior cerebral artery. Contrast-enhanced computed tomography revealed PAVF in the left upper lobe of the lung, but sonography revealed no deep venous thrombus. However, there were no other possible embolic sources, and we diagnosed the patient with cryptogenic stroke due to PAVF. She had a history of recurrent nosebleeds before the onset of stroke, which worsened after administration of antithrombotic agents. The PAVF was removed via thoracoscopic partial left pneumonectomy. After surgery, antithrombotic drugs were discontinued, but the patient did not experience any recurrence of ischemic stroke. HHT is complicated by easy bleeding, and prevention of recurrent cerebral infarction by antithrombotic drugs is risky. In this case, antithrombotic drugs could be discontinued through surgical eradication of PAVF.