Brain (1986), 109, 1071-1085 INFARCTION IN THE TERRITORY OF THE ANTERIOR CHOROIDAL ARTERY A CLINICAL AND COMPUTERIZED TOMOGRAPHIC STUDY OF 16 CASES by J. P. D E C R O I X , 1 PH. G R A V E L E A U , 2 M. MASSON 1 and J. CAMBIER 1 SUMMARY Sixteen cases of the anterior choroidal artery syndrome are reported. In its completed form, this rare syndrome combines the triad of hemiplegia, hemianaesthesia, and homonymous hemianopia. CT examination confirms the diagnosis by revealing an area of reduced density situated in the posterior limb of the internal capsule, sparing the thalamus medially and encroaching upon the tip of the globus pallidus laterally, and corresponding to the distribution of the anterior choroidal artery. Incomplete forms of the syndrome are more frequent. Left-sided spatial neglect may accompany right-sided lesions, as may slight disorders of speech in left-sided lesions. Clinical-anatomical correlations are discussed. INTRODUCTION The syndrome of the anterior choroidal artery was described in 1925 by Foix et al., although 2 cases had been reported by Kolisko in 1891. Subsequent cases, with anatomical confirmation, were published by Poppi (1928), Ley (1932), Abbie (1933), and Buge et al. (1979), making a total of 7 cases. In its complete form, the syndrome comprises hemiplegia, hemianaesthesia, and homonymous hemianopia contralateral to the lesion. The absence of a cognitive deficit classically permits the differential diagnosis from cortical and subcortical lesions. In 1983 and 1984 we reported 5 cases and described the clinical, neuropsychological and computerized tomographic (CT) signs (Masson et al., 1983; Viader et al., 1984). There have been subsequent descriptions by Ward et al. (1984) and Derouesne et al. (1985). The present study of 11 new cases makes it possible to distinguish the principal signs and their variations related to infarction in the territory of the anterior choroidal artery. Correspondence to: Dr J. P. Decroix, Clinique Neurologique, Hopital Beaujon, 100 Bd du General Leclerc, 92110Clichy, France. © Oxford University Press 1986 Downloaded from http://brain.oxfordjournals.org/ by guest on November 13, 2015 (From the 1Clinique Neurologique, Hopital Beaujon, Clichy, and 2the Service de Neurologic, Hopital Foch, Suresnes, France) 5. P. DECROIX AND OTHERS 1072 CASE REPORTS The clinical observations are summarized in Table 1 and the CT scans infig.4. Cases 1,2,4, 6 and 15 have already been published (Cambier et al., 1983; Masson et al., 1983; Viader et al., 1984). Case 1 (N 2260 D) A right-handed man, aged 62 years, was admitted to hospital on September 13, 1981, with a left hemiplegia of sudden onset. He had previously had untreated arterial hypertension and diabetes. Examination on admission revealed a massive left hemiplegia, anaesthesia for all sensory modalities down the left half of the body, and a left homonymous hemianopia. TABLE 1. CLINICAL SYMPTOMS Side of lesion R R L R Hemiplegia Severe Severe Moderate Severe Sensory deficit Severe Severe Moderate Severe 5 6 M/7I F/68 R L Brachiofacial Moderate Moderate Moderate Visual extinction 0 0 7 8 M/45 F/67 L L Moderate Moderate Moderate Moderate 0 0 9 10 11 12 13 14 15 16 F/83 F/60 F/75 M/46 M/72 F/42 M/84 F/71 L R R L Moderate Severe Brachiofacial Severe 0 0 Severe Moderate Moderate 0 0 0 Severe Severe Moderate Moderate 0 0 0 0 0 0 0 0 ase L L L L . Homonymous hemianopia + + + Language deficit 0 0 0 0 Neglect syndrome Severe Severe 0 Moderate 0 0 0 'Thalamic' aphasia Dysarthria 'Thalamic' aphasia Dysarthria Dysarthria 0 Dysarthria 0 0 Dysarthria Dysarthria 0 0 0 0 0 0 0 0 0 0 Neuropsychological examination was undertaken between the second and ninth days after the stroke. Orientation in time and space was satisfactory, but he showed severe visual neglect to the left; the head and eyes were permanently turned to theright.He could look to the left on command, turning first his head and then his eyes. When asked to cross out marks, only those on the extreme right-hand edge of the page were deleted. When asked to describe a picture, only the right-hand quarter was identified. The placing of principal towns on an outline map of France was correctly performed, despite some imprecision; this test did not reveal left visual neglect, as there was no displacement of town sites to the right. Voluntary drawing (circle, square, cube, bicycle,flower)was defective and imprecise; the pictures were nevertheless complete except for the flower, which lacked petals on the left. When copying a picture, the drawing was identical, but neglect of the left part was more evident. There was a partial agnosia for pictures which seemed to depend on the left visual neglect: out of 21 pictures, 11 were correctly identified immediately, 5 after one or more mistakes, and 5 were not identified or wrongly identified. In Poppelreuter's test, performance was better when the picture was presented in its normal form than when enlarged; in the latter case the left part was then ignored. There was no agnosia for objects or colours, and no prosopagnosia. Language was normal. Reading of letters gaveriseto a constant error, as W was identified as N. Syllables were correctly identified if they comprised only two letters, although the first was sometimes neglected. From 3 letters upwards, paralexia was frequent owing to neglect of one or more letters at the beginning of the syllable. Reading of words was correct Downloaded from http://brain.oxfordjournals.org/ by guest on November 13, 2015 1 2 3 4 Sex/Age (yrs) M/62 M/53 F/64 F/68 l ANTERIOR CHOROIDAL ARTERY INFARCTION 1073 with the exception of rare but significant mistakes: mappemonde was read monde and esquimau as mau. In general, mistakes were more frequent when the right-hand part of the word, in isolation from the left, was meaningful: plateau was read as eau and cartable as table. When reading a text, the left-hand part was neglected and there were mistakes in changing line; the result was incoherent. Dichotic listeningrevealeda total extinction on the left. There was motor impersistence, but no anosognosia. CT scan without contrast (17/9/81) showed an area of reduced density in the posterior limb of the right internal capsule. ECG revealed left ventricular hypertrophy. The neurological signs and symptoms remained virtually unchanged. At discharge after one month the hemiplegia was as severe as on admission, hypoaesthesia for all modalities persisted down the left half of the body, and the hemianopia was unchanged, but the neglect syndrome had improved. FIG. 1. Case 2. Spontaneous drawings. Downloaded from http://brain.oxfordjournals.org/ by guest on November 13, 2015 Case 2 (N 2191 D) A right-handed man, aged 53 years, was admitted to hospital following a left hemiplegia of sudden onset on August 7, 1981. He had had a primary tuberculous infection at the age of 20. Examination on admission showed a severe left hemiplegia, anaesthesia for all sensory modalities down the left half of the body, and a left homonymous hemianopia. Blood pressure was normal. Neuropsychological examination was carried out between the days 26 and 28 after the stroke. Orientation in space and time was satisfactory. There was severe visual neglect on the left. The head and eyes were spontaneously turned to the right, but the patient could look to the left on command, 1074 J. P. DECROIX AND OTHERS turning first his head and then his eyes. When asked to cross out marks on paper, only those on the extreme right of the page were deleted. When asked to describe complex images, only therightfifthof the picture was identified. Placement of towns on an outline map of France was correct, as were freehand drawings of a cube, aflowerand a bicycle (fig. 1). However, when copying the same pictures from a model, the left-hand part was completely neglected (fig. 2). Copying Rey's figure produced disorganization of the left part of thefigure.There was partial agnosia for image recognition, with 10 mistakes in 32 pictures. In Poppelreuter's test, performance was better when the design was presented in its normal form than when enlarged, when the left part was neglected. There was no agnosia for objects, colours or prosopagnosia. Speech was normal. When writing spontaneously or from dictation, the patient did not use the left-hand side of the paper. When copying from a text, only the right-hand part of the sentences were copied. There were reading deficits, such that Y was identified as I; all other letters were correctly identified. Reading of syllables revealed neglect of the left-hand part, particularly if the syllable comprised more than three letters: oul was read as ul, drain as ain, splan as plan and stronc as tronc. Reading of logatomes revealed the same deficit. Mistakes appeared in the reading of words, particularly when theright-handpart, isolated from the left, retained a meaning (chevrefeuille was read asfeuille). When reading a text, the left-hand part was completely ignored. The patient was aware of the resulting incoherence but was unable to correct it. There was motor impersistence: the patient was unable to keep his eyes closed on command, and every verbal communication automatically produced opening of the eyes, despite repeated requests to close them. Immediately after admission, there was anosognosia. Cervical Doppler, ECG, Holter and echocardiogram were normal. CT scan without contrast (21/8/81) showed an area of diminished density in the posterior limb of the right internal capsule (fig. 3), which was unchanged by injection of contrast. Right carotid angiography did not reveal atheroma in the cervical or cranial vessels and the right anterior choroidal artery was visible and apparently normal. The neurological deficits did not change. A month later, the patient suffered an infarct in the territory of the left middle cerebral artery, suggesting a diagnosis of multiple emboli of cardiac origin, despite the negative cardiac findings. Downloaded from http://brain.oxfordjournals.org/ by guest on November 13, 2015 FIG. 2. Case 2. Copied drawings. ANTERIOR CHOROIDAL ARTERY INFARCTION 1075 Case 3 (N 5713 D) A woman, aged 64 years, was admitted on February 14, 1983, with a right hemiplegia. There was no significant previous history. The right hemiplegia had developed suddenly on the previous day. Examination on admission showed an incomplete right hemiplegia, anaesthesia for pin prick over the whole right half of the body, a defect of deep sensation on the right and a right homonymous hemianopia. There was no speech deficit. Blood pressure was normal. ECG and Doppler examination of the cervical vessels were normal. Fasting blood sugar was slightly elevated at 8.7 mmol/1. CT scan (15/2/1983) showed diminished density in the posterior limb of the left internal capsule, unchanged by injection of contrast. On discharge a month later the patient was able to walk without help, the motor deficit was not severe, the hemianopia had disappeared but the sensory deficit persisted. Case 4 (N 2889 D) A woman, aged 68 years, was admitted on December 25, 1981. Her past history included calcified aortic narrowing. A left hemiplegia of sudden onset had developed on December 22, 1981. On admission, examination revealed a total left hemiplegia, anaesthesia of all sensory modalities down the left half of the body, and left visual extinction. Blood pressure was normal. Neuropsychological examination was performed between days 11 and 16 after the stroke. Orientation in time and space was normal. At the beginning of her stay in hospital, the patient manifested left visual neglect, with the head and eyes most frequently turned to the right. When asked to enumerate the people in the room, she 'forgot' those on her left. There was left visual extinction, but this feature was notably improved by the time of neuropsychological examination. Crossing out marks across a page was normal. However, when asked to bisect a horizontal line, there was a distinct shift to the right. When asked to describe pictures, details on the extreme left were omitted. Placing of the principal towns on an outline map of France was correctly carried out. Spontaneous drawing (circle, square, bicycle, house, flower) was defective and imprecise, but slightly better when copying. Copying of Rey's figure was disorganized, with omission of detail on the extreme left. There was no agnosia for pictures, objects, or colours and no prosopagnosia. Speech was normal. Spontaneous and dictated writing revealed a failure to use the left side of the paper. Reading of letters, syllables and words was normal. Reading a text revealed difficulties in returning to the line. Mental arithmetic was unaffected. In arithmetical calculations, the operational sign placed at the left was sometimes neglected. There was an anosognosia when she was first in hospital. She suffered from motor impersistence. Blood pressure was normal. ECG showed arrhythmia due to atrial fibrillation, but she returned to Downloaded from http://brain.oxfordjournals.org/ by guest on November 13, 2015 FIG. 3. Case 2. CT scan, showing area of reduced density in posterior limb of right internal capsule. 1076 J. P. DECROIX A N D OTHERS Case 2 (14 days) Case 3 (2 days) Case 4 (6 days) Case 5 (6 days) Case 6 (42 days) Case 7 (7 days) Case 8 (39 days) Case 9 (4 days) Case 10 (2 days) Case 11 (11 days) Case 12 (3 days) Case 13 (6 days) Case 14 (1 day) Case 15 (19 days) Case 16 (66 days) Fio. 4. Diagrams illustrating CT appearances in all 16 patients: time between onset of symptoms and CT scan is indicated in brackets. sinus rhythm the following day. No biochemical abnormalities were detected. Doppler examination showed moderate stenosis at the origin of the right internal carotid artery, without reversal of flow in the ophthalmic artery. CT scan (28/12/82) showed diminished density in the posterior limb of the right internal capsule unchanged by injection of contrast. On discharge one month later, there was no alteration in symptoms. Case 5 (N 1073 E) A man, aged 71 years, was admitted on March 12, 1980, with a left hemiplegja. There was a history of hypertension and of a rapidly regressing left hemiplegia in 1975. On the evening of March 11,1980, he Downloaded from http://brain.oxfordjournals.org/ by guest on November 13, 2015 Case 1 (4 days) ANTERIOR CHOROIDAL ARTERY INFARCTION 1077 experienced paraesthesiae in the left leg, and on waking the next morning was hcmiplegic. Examination on admission showed a left hemiplegia with brachiofacial predominance, diminished pin prick sensation over the whole left half of the body, but no deficit of position sense. There were no visual field disturbances and higher cerebral function was unaffected. ECG was normal. Doppler examination showed stenosis of the left internal carotid artery. Blood sugar was raised to 7.92 mmol/1. CT scan (17/3/1980) showed reduced density in the posterior limb of the right internal capsule. The symptoms were unchanged on discharge fifteen days later. Case