SHM Converge Scientific Abstract ePoster Gallery-Recurrent Strokes From Hepatopulmonary Syndrome

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This case describes a 53-year-old woman with primary biliary cholangitis and decompensated cirrhosis complicated by ascites, esophageal varices, and hepatopulmonary syndrome. She also had a recent left lower-extremity DVT and multiple recurrent ischemic strokes thought to be due to paradoxical emboli. She presented with right-sided weakness and aphasia after a third stroke in one month, despite having been discharged three days earlier on enoxaparin. Within 24 hours, she suffered a fourth stroke and required ICU admission.<br /><br />Her exam showed right facial droop, severe right-sided weakness, dysarthria, and platypnea. Labs revealed chronic thrombocytopenia, and brain MRI showed multifocal left MCA infarcts. Initial CTA showed no MCA stenosis, but repeat CTA later revealed a new distal M1 occlusion. Echocardiography demonstrated right-to-left shunting without evidence of a PFO or ASD, supporting hepatopulmonary syndrome as the likely mechanism for paradoxical embolization.<br /><br />The hospital team managed her carefully with intermittent enoxaparin because of her low platelet count. Hepatopulmonary syndrome was felt to be the cause of her recurrent strokes, but she was not considered a transplant candidate at that time because of concerns about intraoperative stroke and hypotension risk, so she was transferred for a second opinion.<br /><br />Key teaching point: hepatopulmonary syndrome is a complication of cirrhosis that can produce intrapulmonary vascular dilatation and right-to-left shunting, allowing emboli to bypass the lungs and reach the brain. Platypnea is a classic and highly suggestive clinical feature. Diagnosis is best made with transthoracic echocardiography using agitated saline. Definitive treatment is liver transplantation, while oxygen and cautious anticoagulation may be used as supportive measures.

Asset Subtitle

Kerollos Kamel

Meta Tag

Author List Kerollos Kamel, Owen Clinger, Valerie Gobao

Category Clinical Vignettes

Concept Hepatopulmonary Syndrome

Concept Liver Transplantation

Concept Intrapulmonary Arteriovenous Shunt

Concept Cirrhosis

Concept Platypnea

Distinguished Non-Finalist

Presenter Organization University of Pittsburgh School of Medicine

Presenting Author Kerollos Kamel

Track Adult

Keywords

hepatopulmonary syndrome

primary biliary cholangitis

decompensated cirrhosis

paradoxical emboli

ischemic stroke

right-to-left shunt

platypnea

transthoracic echocardiography

agitated saline

liver transplantation

Hepatopulmonary Syndrome

Liver Transplantation

Intrapulmonary Arteriovenous Shunt

Cirrhosis

Platypnea