Chronic migraine and transient ischemic attack due to isolated pulmonary arteriovenous malformation successfully treated with transcatheter embolization

A 37-year-old woman, nonsmoker, with a history of chronic migraines with aura, was referred to our emergency room due to dysarthria and left faciobrachial paresis. Her family history was unremarkable. Physical examination was normal except for a mild oxygen desaturation (88% on room air). Electrocardiogram, echocardiography, peripheral venous and arterial Doppler ultrasound, and brain magnetic resonance imaging were normal. However, transcranial Doppler analysis showed a significant (shower pattern) right-to-left shunt late after isotonic saline. This pattern was present at rest and did not significantly change after Valsalva maneuver. At chest radiograph, a lobular smoothmargined opacity in the right lower lobe made us suspect the diagnosis of pulmonary arteriovenous malformation (PAVM). Chest computed tomography (CT) showed a large complex PAVM fed by two large and tortuous descending pulmonary arteries and draining through a straight vessel directed posterosuperiorly to the right lower pulmonary vein (Fig. 1). Thus, cardiac catheterization was planned to occlude the vascular malformation. The patient’s informed consent to the procedure and agreement with the thoracic surgeons were obtained. The procedure was performed with local anesthesia through the femoral vein entry. Pulmonary angiography confirmed the presence of multiple large PAVMs into the right lower lobe fed by a single 1.1-cm-large vessel originating from the right inferior pulmonary artery (Fig. 2a). Transcatheter embolization of the feeding vessel was achieved with a 14-mm-large Amplatzer Vascular Plug type II (AGA Medical, Golden Valley, Minnesota, USA) device (Fig. 2b) and resulted in a sudden increase in the oxygen saturation, from 88 to 96% on room air. Clinical status and