An 83 year-old cigarette smoker presented with left sided weakness. Examination revealed a left homonymous hemianopsia, left hemiparesis affecting face and arm greater than leg, and left hemihypesthesia with intact graphesthesia and stereognosis. MRI showed an area of restricted diffusion corresponding to an infarct in the anterior choroidal artery distribution (figure). Anterior choroidal artery infarcts are uncommon accounting for 2% of ischemic stroke1. They are distinguished by a unique clinical syndrome of hemiparesis, hemihypesthesia, and visual field deficits but without other cortical signs1. The most common etiologies include cardioembolism (54%), arterial embolus (17%), and small vessel disease (6%)2.

Figure: Diffusion weighted imaging (left) and corresponding apparent diffusion coefficient map (right) demonstrating acute infarction. The territory supplied by the anterior choroidal artery can include the posterior limb of the internal capsule, choroid plexus, initial segments of the optic radiations, and parts of amygdala, uncus, and globus pallidus.