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Case 34

Pulmonary AVM with paradoxical embolus

A young lady with a stroke following insertion of a central line

This young lady presented to the Emergency Department with severe abdominal pain. She was dehydrated and hypotensive. She was thought to have small bowel obstruction due to adhesions. As part of her management a central venous catheter was inserted via the jugular vein. During this procedure she became acutely aphasic and developed a hemiplegia. This recovered over the next few days. Meanwhile her abdominal symptoms resolved, without a definite diagnosis ever being made.

The clinicians were at a loss to explain the cerebrovascular episode, but an explanation was offered by the radiologists on review of her films. The chest X-ray shown was unchanged in appearance on several occasions.

The chest film demonstrates (albeit faintly) a small nodule in the left upper lobe. There is also a further such opacity adjacent to the right heart border.

A CT was performed, which confirmed the diagnosis suspected on the plain film. Three non contiguous but illustrative images are presented.

Findings

The chest film shows two nodules, one in the left upper zone, and the other adjacent to the right heart border. In addition there are abnormally large feeding and draining vessels associated with them, more obvious on the right.

These CT images demonstrate three of the four AVMs that were seen. Note the well defined serpiginous lesions with associated vessels. The left upper lobe lesion and part of the right middle lobe lesion are shown. A third lesion is visible adjacent to the left heart border, and a fourth was present in the right upper lobe (not shown); neither were visible on the plain film.

Diagnosis

Multiple pulmonary arteriovenous malformations, with paradoxical embolus.

Discussion

The cerebrovascular event was thought to be due to paradoxical embolisation of air or thrombus introduced during the venous cannulation. The AVMs are sufficiently large that particles that would normally be trapped in the pulmonary capillary bed can pass direct to the systemic circulation.

Other complications include brain abcess, haemoptysis, haemothorax, cyanosis and polycythaemia. Multiple pulmonary AVMs are closely associated with Hereditary Haemorrhagic Telangiectasia (Osler-Weber-Rendu syndrome).

The episode of abdominal pain was never fully explained.

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