Paradoxical Embolic Stroke via Pulmonary Arteriovenous Malformation Complicated by Bubble-Study-Induced Non-ST-Segment Elevation Myocardial Infarction

Pulmonary arteriovenous malformations (PAVMs) are uncommon vascular anomalies that predispose patients to paradoxical embolic phenomena, including stroke. Contrast echocardiography is a key diagnostic tool, but complications are rarely reported. We describe a 44-year-old woman with no significant past medical history who presented with acute ischemic stroke involving the right superior parietal lobe. Initial workup with echocardiography and bubble study demonstrated right-to-left shunting, considered to be of intracardiac origin, typically a patent foramen ovale. However, this was complicated by acute chest pain and troponin elevation consistent with non-ST-segment elevation myocardial infarction (NSTEMI). Coronary angiography revealed angiographically normal coronary arteries. Chest CT subsequently identified a large PAVM, and the patient underwent successful transcatheter occlusion and coil embolization. This case highlights the importance of considering PAVMs in cryptogenic stroke evaluation and underscores the potential for contrast echocardiography to rarely provoke coronary ischemia, even in the absence of obstructive coronary artery disease.