Patients with hereditary hemorrhagic telangiectasia (HHT) are at risk of developing pulmonary arteriovenous malformations (pAVMs). Paradoxical embolism may occur through pAVMs or patent foramen ovale (PFO) and lead to cerebral infarction. We present a case of cerebral infarction with both pAVM associated with HHT and PFO. Evidence of a right-to-left shunt can suggest other treatment options for stroke prevention, and patients without evidence of conventional stroke etiologies require a thorough evaluation.