Anterior choroidal artery syndromes

The typical symptom triad is:

• Contralateral hemiplegia
• Contralateral hemianesthesia
• Contralateral homonymous hemianopia

Of the three symptoms, hemiplegia is the most consistent. Hemianesthesia is often incomplete and may rarely be the only symptom. Hemianopia is the most variable symptom and may take the form of quadrantanopia, be transient or absent. Its absence does not preclude AChA territory infarct.

Features that help distinguish AChA territory infarction from MCA territory infarction:

• Absence of aphasia
• Absence of altered consciousness state
• Absence of head deviation

Less recognized symptoms include:

• Visual neglect (more frequent in nondominant hemisphere lesions)
• Constructional apraxia
• Anosognosia
• Motor impersistence
• Speech disturbances including decreased fluency, semantic paraphasias and speech perseverations

Most of these “cortical” symptoms are related to thalamic involvement.

Rare presentations include:

• Eye movement impairment including paralysis of upward gaze and contralateral ptosis
• Horner’s syndrome
• Transient hemiballism

These presentations may be related to paramedian upper midbrain involvement.

Lacunar syndromes

• Lacunar infarcts of the AChA territory most often present as sensorimotor syndrome. They may present as pure motor or pure sensory syndromes, however, both are uncommon.
• Ataxic hemiparesis is another possible presentation.