Stroke after prolonged air travel associated with a pulmonary arteriovenous malformation

Abstract: Several reports describe a potential association between prolonged flights and stroke. However, causes of travel-related stroke due to paradoxal embolism other than patent foramen ovale have not been previously reported. We here describe the case of a 44-year-old woman who presented with an acute anterior circulation stroke after a transoceanic flight. The patient received intravenous thrombolytic therapy, with complete recanalization of the anterior and middle cerebral arteries. Contrast transthoracic echocardiography was suggestive of an extracardiac right-to-left shunt. Both cardiothoracic CT and MR angiography revealed a single pulmonary arteriovenous malformation (PAVM) in the lower lobe of the right lung. No cardiac abnormalities were identified. Careful examination of the patient revealed telangiectatic skin lesions, and recurrent epistaxis was reported to occur in first-grade relatives. Genetic testing for hereditary haemorrhagic telangiectasia revealed no mutations in the endoglin and activin receptor-like kinase 1 genes. Intravascular embolization of the PAVM was performed and effective occlusion was later confirmed. To our knowledge, this is the first reported case of travel-related stroke associated with a PAVM. These should be considered in patients with stroke after prolonged flights, particularly when right-to-left shunt is detected and patent foramen ovale is ruled out. [Copyright &y& Elsevier]