Acute ischemic stroke in anterior choroidal artery territory Angel Ois a, ⁎, Elisa Cuadrado-Godia a , Alberto Solano b , Xavier Perich-Alsina b , Jaume Roquer a a Neurology Department, Hospital del Mar, Universitat de Barcelona, IMIM-Hospital del Mar, Barcelona, Spain b Radiology Department, Hospital Del Mar, Universitat de Barcelona, IMIM-Hospital del Mar, Barcelona, Spain abstract article info Article history: Received 12 October 2008 Received in revised form 19 January 2009 Accepted 2 February 2009 Available online 25 March 2009 Keywords: Cardiovascular diseases Stroke Anterior choroidal artery Outcome Objective: The aim of the study was to describe a series of patients with acute ischemic infarct in the anterior choroidal artery (AChA) territory. Moreover, we analyzed the prevalence of these strokes and compared them with hemispheric and deep infarcts. Finally, we hypothesized that the size of the infarct could be related to aetiology and prognosis. Methods: We studied a prospective series of 1350 patients with acute ischemic stroke. We analyzed the following factors: age, gender, diabetes mellitus, hypertension, hyperlipidaemia, current smoking, ischemic heart disease, previous stroke, peripheral arterial disease, prior antithrombotic treatment, major cardioembolic source, severe arterial stenosis, initial severity, progression, mortality, disability, and recurrence rate at three months. AChA strokes were classified as small (b 20 mm) or large (≥ 20 mm), as measured by diffusion-weighted MRI, and compared by size in the analysis. Results: 112 patients (8.3%) had an ischemic lesion restricted to the AChA territory (large: 42 patients, small: 70 patients). Patients with AChA infarcts were younger, more likely to be diabetic, and predominantly male. We found significant differences in the rate of major embolic sources, recurrence, progression and prognosis. Large AChA strokes were associated with embolic pathologies and had worse prognosis than small AChA strokes. Interpretation: Infarcts in the AChA territory have different aetiological mechanisms and outcome than other territories. Large AChA infarcts have a higher association with an embolic source and worse prognosis than small lesions. © 2009 Elsevier B.V. All rights reserved. 1. Introduction In 1925, Foix [1] described the Anterior choroidal artery (AChA) syndrome, which includes, in its complete form, the triad of hemiparesis, hemianaesthesia, and hemianopia. The AChA is a small artery that commonly originates in the posterior wall of the internal carotid, 2 to 5 mm distal to the posterior communicant artery (PCoA) and 2 to 5 mm proximal to the intracranial carotid bifurcation in 96–99.5% of cases [2]. The AChA territory shows large variations amongst individuals. The most reported supply areas include: the posterior limb of the internal capsule, optical tract, lateral geniculate body, medial temporal lobe, and medial part of the pallidum [3–12]. Other territories, such as the lateral thalamic border and the medial part of the lentiform nucleus, are still subject to debate, although the most controversial territory is the posterior paraventricular territory [5,13–15]. Despite its small size (0.5–2.0 mm), the AChA has perforating branches (between 2 and 9 AChA perforators with a diameter that varies from 90 to 600 μM) that have been identified in microdissection studies [16]. The origin and incidence of AChA infarcts is controversial [17–35]. It has been postulated that AChA infarcts are due to Small Vessel Disease (SVD) [17–19], although other studies related AChA infarcts to Large Vessel Disease (LVD) [20–22], cardioembolic, or other determined or undetermined causes [15,23–25]. Moreover, there are few studies of prognosis in AChA infarcts and most of them are case studies [18]. The main objective of our study was to study the vascular risk factors, aetiology and clinical evolution in patients with AChA infarct and compare them with unselected patients with ischemic lesion at other deep or cortical sites. Additionally, we evaluated whether the ischemic lesion size, dichotomized at 20 mm in patients with AChA infarct, allowed us to establish potential causes of stroke or provided prognostic data. 2. Patients and methods From January 2003 to January 2007, 1669 consecutive patients with a diagnosis of acute ischemic stroke were prospectively evaluated at Hospital del Mar during the first 24 h after symptoms onset. We excluded 231 patients who presented transient ischemic stroke without radiological ischemic lesion and 88 patients without definitive localization of the ischemic lesion or lost during follow-up. The study included 1350 patients. Journal of the Neurological Sciences 281 (2009) 80–84 ⁎ Corresponding author. Servei de Neurologia, Passeig Maritim 25-29, CP 08003, Barcelona, Spain. Tel.: +34 932483234; fax: +34 932483615. E-mail address: 94931@imas.imim.es (A. Ois). 0022-510X/$ – see front matter © 2009 Elsevier B.V. All rights reserved. doi:10.1016/j.jns.2009.02.323 Contents lists available at ScienceDirect Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns