PMC9797860_01
Magnetic resonance (MR) axial T2-weighted-FLAIR images showing multiple focal bilateral supratentorial white matter hyperintensities (yellow arrows).
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F1
Contrast TTE/TEE using agitated saline solution showed no RLS across the interatrial septum (Figure 2, Supplementary Videos 1, 2) but conversely demonstrated bubbles arriving from left pulmonary veins to the left atrium and left ventricle via a pulmonary arteriovenous fistula (Supplementary Figure 1) in basal conditions.
2D contrast-Transthoracic Echocardiography in apical 4-chambers view in basal conditions. (A-C) Agitated saline injection (red asterisk) from the right antecubital vein showed no right-to-left shunt (RLS) across the interatrial septum (IAS; small orange arrow); (D-F) While still no bubbles were crossing the interatrial septum, a delayed (17 s) RLS coming from left pulmonary veins to LA and LV through the mitral valve is shown, confirming the diagnosis of extra-cardiac RLS. LA, left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.
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F2
Contrast TTE/TEE using agitated saline solution showed no RLS across the interatrial septum (Figure 2, Supplementary Videos 1, 2) but conversely demonstrated bubbles arriving from left pulmonary veins to the left atrium and left ventricle via a pulmonary arteriovenous fistula (Supplementary Figure 1) in basal conditions. Contrast-enhanced Transcranial Doppler (cTCD) raised the suspicion of an extracardiac RLS by showing in basal conditions high-intensity transient signals passing through the middle cerebral artery with a delayed (17 s) "shower" pattern (Figure 3, Supplementary Video 2).
Contrast Transcranial Doppler in basal conditions showing high-intensity transient signals passing through the middle cerebral artery with a delayed (17 s) "shower" pattern.
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F3
Contrast-enhanced Transcranial Doppler (cTCD) raised the suspicion of an extracardiac RLS by showing in basal conditions high-intensity transient signals passing through the middle cerebral artery with a delayed (17 s) "shower" pattern (Figure 3, Supplementary Video 2). Oddly, selective right and left pulmonary arteriograms did not show abnormalities of the pulmonary vasculature or arteriovenous shunts (Figure 4, Supplementary Video 3).
Selective right (A,B) and left (C,D) pulmonary angiograms (arterial and venous phases) didn't show abnormalities of the pulmonary vasculature or arteriovenous shunts.
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F4
Oddly, selective right and left pulmonary arteriograms did not show abnormalities of the pulmonary vasculature or arteriovenous shunts (Figure 4, Supplementary Video 3).