Massive Resting Shunt on c-TCD: A Clue to Pulmonary Arteriovenous Malformation in a Young Stroke Patient

A 17-year-old female teen presented with migraine with visual aura.Brain magnetic resonance imaging demonstrated a hyperintense area on diffusion-weighted imaging with corresponding hypointensity on the ADC adjacent to the right cerebral aqueduct [also hyperintense on fluid-attenuated inversion recovery, indicating an acute ischemic infarction (Figures 1a-c)].No traditional cerebrovascular risk factors were identified.A right-to-left shunt was considered owing to the combination of early-onset cryptogenic stroke, migraine with aura, and a family history of persistent epistaxis affecting her mother, grandfather, and all four maternal aunts. 1,