A 60-year-old woman presented to our medical center for evaluation of acute onset headache and confusion. Her past medical history was remarkable for alcoholic cirrhosis and hepatitis C. Physical examination revealed the presence of mild ascites and hypoxemia (91%) on room air with no response to supplemental oxygen. Noncontract head CT was without focal abnormality, but cerebrospinal spinal fluid analysis showed xanthrochromia suggestive of subarachnoid hemorrhage. Catheter angiography of the cerebral vessels confirmed the presence of a right middle cerebral artery (MCA) aneurysm, and the patient underwent endovascular coiling without complication. Postprocedure day number two, the patient decompensated and developed respiratory and congestive heart failure. A right internal jugular catheter was placed for venous access and hemodynamic monitoring. Daily surveillance transcranial Doppler (TCD) and noncontrast head CT showed no abnormality until postprocedure day number four when embolic signatures were detected in the basilar and bilateral MCAs. Given the multiple vascular territories involved in the ultrasound findings, a search for the source of emboli was initiated. The patient was unable to undergo transesophageal echocardiogram due to the presence of varices, but transthoracic echocardiogram with agitated saline contrast was performed while mechanically ventilated and repeated once she was extubated. No patent foramen ovale was identified, but a large amount of echogenic contrast was detected in the left atrium after 3-4 heartbeats. The delayed appearance of saline contrast in the left atrium and its origination from the right pulmonary vein were anatomically consistent with shunting through the pulmonary circuit, and similarly confirmed by TCD. The patient was started on daily antiplatelet therapy with 325 mg aspirin and the embolic signatures on TCD ceased within three days. She soon recovered from the events surrounding her hospitalization, however suffered a fatal intracranial hemorrhage five months later.