Recurrent strokes in the setting of anomalous left coronary artery from the pulmonary artery

A young woman presented with a syncopal episode. As part of the work-up for her presentation, an MRI of the brain was performed which showed a small acute stroke. She subsequently had a further embolic-appearing stroke 9 months later. The initial investigations for the work-up of her strokes did not reveal any major abnormalities, including an unremarkable ECG and transthoracic echocardiogram (TTE). A transoesophageal echocardiogram (TOE) showed aneurysmal apical and mid-anteroseptal akinesis with mildly reduced left ventricular ejection fraction. Anomalous left coronary artery from the pulmonary artery (ALCAPA) was confirmed on coronary angiogram. Although ALCAPA presenting in adulthood is rare, our case highlights the value of TOE over TTE in the work-up of cryptogenic strokes, particularly in young patients with embolic strokes of undetermined source.