EXTRA-CARDIAC SHUNT: AN UNUSUAL CAUSE OF STROKE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Embolic phenomenon, while not contributing as much a cause atherosclerotic disease for ischemic stroke, remains an important stroke. While atrial fibrillation represents the majority of patients in this subset, there are other less conspicuous causes. Here, we present case found to be due isolated extra-cardiac shunt without patent foramen ovale. CASE PRESENTATION: A 56-year-old right-handed female with no significant past medical history presented left-sided weakness concerning acute On admission, her National Institute Health Stroke Scale (NIHSS) was 20. MRI showed occlusion right middle cerebral artery at M1 and carotid terminus. Dual anti-platelet therapy (DAPT) statin were started. Revascularization achieved thrombectomy. Deep vein thrombosis ruled out trans-thoracic echocardiogram unremarkable. Telemetry revealed persistent first-degree AV block. Suspecting cardioembolic etiology, loop recorder placed DAPT changed apixaban. Trans-esophageal valvular abnormalities or clots, but identified shunt, suspected from pulmonary arteriovenous malformation (PAVM). Despite findings, patient declined further workup hospital discharged management. DISCUSSION: PAVM, often associated Osler-Weber-Rendu (OWRD) migraines is rare stroke.[1] The absence capillary bed allows small thrombi bacteria reach systemic circulation. resulting manifestations can severe, including cerebrovascular accidents brain intra-medullary abscesses.[2] In study involving over 700 only 4 PAVM identified, suggesting very presentation.[3] our patient, however, clinical features OWRD than (1 per Curacao diagnostic criteria). Therefore, believe stroke likely secondary PAVM. Studies reported varied approaches on management opted embolization. There also recommendations anti-coagulation. Our managed anti-coagulation therapy. CONCLUSIONS: Cryptogenic strokes low-risk warrant evaluating common causes, such AVM, implications could devastating. Although treatments that lower risk recurrent strokes, little known best practice REFERENCE #1: Peery WH. Clinical Spectrum Hereditary Hemorrhagic Telangiectasi (Osler-Weber-Rendu Disease). Am J Med. 1987;82:9. #2: Kawano H, Hirano T, Ikeno K, Fuwa I, Uchino M. Brain Abscess Caused by Pulmonary Arteriovenous Fistulas Rendu-Osler-Weber Disease. Intern 2009;48(6):485-487. #3: Kimura Minematsu Nakajima Isolated fistula cryptogenic Neurol Neurosurg Psychiatry. 2004;75(2):311-313. DISCLOSURES: No relevant relationships Vernon Chan, source=Web Response Dana Daoud, Jayaram Thimmapuram,