C63-46 From Cryptogenic to Correctable: Pregnancy Stroke and Treatable Pavms

Abstract Introduction Pregnancy and the early post-partum period are characterized by substantial physiological changes, including increased blood volume and cardiac output, which may unmask previously silent right-to-left shunts such as those caused by pulmonary arteriovenous malformations (PAVMs). Although PAVMs are relatively rare, they represent a clinically significant and often under-recognized cause of paradoxical embolism and hypoxemia, especially in young adults. When a stroke occurs during pregnancy or the post-partum period—particularly in the absence of an intracardiac shunt—PAVMs should be considered as a treatable etiology. Early identification and targeted intervention can reduce morbidity and improve patient outcomes. Case Description We present the case of a previously healthy 30-year-old woman who suffered an ischemic stroke during pregnancy in 2019, for which she was managed with clopidogrel. Two years following her stroke, she developed progressive breathlessness and fatigue, which significantly impaired her daily activities and quality of life. Initial computed tomography (CT) was misinterpreted as a pulmonary “mass,” but subsequent CT pulmonary angiography (CTPA) revealed multiple PAVMs as the culprit. Unfortunately, the patient was lost to follow-up and returned months later with severe dyspnea and resting hypoxemia. Repeat evaluation confirmed bilateral lower-lobe PAVMs and hepatic arteriovenous malformations. Brain imaging excluded cerebral AVMs, and comprehensive echocardiography with provocative maneuvers definitively ruled out an intracardiac shunt.Management consisted of staged, transcatheter coil embolization of the right and then left pulmonary AVMs, both of which were uncomplicated and well tolerated. Following the intervention, the patient’s oxygen saturation normalized, her breathlessness resolved, and she was able to resume caring for her child and participating fully in daily life. Multidisciplinary follow-up was established, including surveillance CTPA at 6-12 months and every 3-5 years, as well as ongoing assessment of hepatic AVMs. Discussion This case reframes “cryptogenic” pregnancy-associated stroke as preventable when intrapulmonary shunting is considered. Three key clinical messages are emphasized: (1) in young stroke patients during pregnancy/post-partum, evaluate for intrapulmonary shunt with contrast echocardiography and thin-section CT/CTPA; (2) embolize all accessible PAVMs to reverse hypoxemia and reduce embolic risk rapidly; and (3) ensure structured follow-up and multisystem screening. Raising awareness of PAVMs can close the diagnostic gap and improve outcomes for affected individuals. This abstract is funded by: Myself