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@article{Topiwala:2021:10.1212/WNL.0000000000013169,
author = {Topiwala, KK and Patel, SD and Saver, JL and Streib, CD and Shovlin, CL},
doi = {10.1212/WNL.0000000000013169},
journal = {Neurology},
pages = {1--1},
title = {Ischemic stroke and pulmonary arteriovenous malformations: a review.},
url = {http://dx.doi.org/10.1212/WNL.0000000000013169},
volume = {98},
year = {2021}
}

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TY  - JOUR
AB  - The potential of covert pulmonary arteriovenous malformations (PAVMs) to cause early onset, preventable ischemic strokes is not well known to neurologists. This is evident by their lack of mention in serial American Heart Association/ American Stroke Association (AHA/ASA) Guidelines, and the single case-report biased literature of recent years. To inform, we performed PubMed and Cochrane database searches for major studies on ischemic stroke and PAVMs published from January 1, 1974 through April 3, 2021. This identified twenty-four major observational studies, three societal guidelines, one nationwide analysis, three systematic reviews, twenty-one other review/opinion articles, and eighteen recent (2017-2021) case-reports/series that were synthesized. Key points are that patients with PAVMs suffer ischemic stroke a decade earlier than routine stroke, losing nine extra healthy-life-years per patient in the recent US nationwide analysis (2005-2014). Large-scale thoracic CT screens of the general population in Japan estimate PAVM prevalence to be 38/100,000 (95% confidence interval 18-76), with ischemic stroke rates exceeding 10% across PAVM series dating back to the 1950s, with most PAVMs remaining undiagnosed until the time of clinical stroke. Notably, the rate of PAVM diagnoses doubled in US ischemic stroke hospitalizations between 2005-2014. The burden of silent cerebral infarction approximates to twice that of clinical stroke. Over 80% patients have underlying hereditary hemorrhagic telangiectasia (HHT). The predominant stroke mechanism is paradoxical embolization of platelet-rich emboli, with iron-deficiency emerging as a modifiable risk-factor. PAVM related ischemic strokes may be cortical or subcortical, but very rarely cause proximal large vessel occlusions. Single antiplatelet therapy maybe effective for secondary stroke prophylaxis, with dual antiplatelet or anticoagulation therapy requiring nuanced risk-benefit analysis given their risk of aggravating iron
AU  - Topiwala,KK
AU  - Patel,SD
AU  - Saver,JL
AU  - Streib,CD
AU  - Shovlin,CL
DO  - 10.1212/WNL.0000000000013169
EP  - 1
PY  - 2021///
SN  - 0028-3878
SP  - 1
TI  - Ischemic stroke and pulmonary arteriovenous malformations: a review.
T2  - Neurology
UR  - http://dx.doi.org/10.1212/WNL.0000000000013169
UR  - https://www.ncbi.nlm.nih.gov/pubmed/34880092
UR  - https://n.neurology.org/content/early/2021/12/07/WNL.0000000000013169
UR  - http://hdl.handle.net/10044/1/93462
VL  - 98
ER  -

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Claire L. Shovlin PhD FRCP

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