The prevalence of LVNC in patients undergoing echocardiography is rare. In our patient, LVNC was overlooked on the initial transthoracic echocardiographic study but was better distinguished on the transesophageal echocardiogram. Cardiac MRI can also be of diagnostic value when adequate echocardiographic images cannot be obtained and in cases when LVNC is highly suspicious but not confirmed. Cardiac MRI has a higher sensitivity, especially in detecting trabeculation and recesses at the apex and lateral wall. The use of anticoagulation for stroke prevention in patients with LVNC appears to be controversial. Some authors recommend using chronic anti-coagulation for all patients with LVNC as a primary prevention of stroke. In a retrospective study by Stöllberger et al, a high CHA2DS2-VASc score was associated with increased incidence of cardio embolism, an observation that may help in guiding patient management and stroke prevention. Typically, anticoagulation is indicated if LVNC coexists with atrial fibrillation, prior stroke, severe systolic dysfunction, or the presence of an intracardiac thrombus.

Our case report demonstrates the potential of under-diagnosis of LVNC in patients with cryptogenic stroke. It also emphasizes the importance of utilization of echocardiographic studies and the need for increased awareness, particularly in patients with recurrent cryptogenic stroke.