A new view of anterior choroidal artery territory infarction

Summary Infarction in the territory of the anterior choroidal artery (AchA) has been the subject of several recent reports. To the classical clinical syndrome of hemimotor, hemisensory, and visual field deficit has been added hemiataxia acute pseudobulbar mutism, pure motor and pure sensory syndromes and disorders of higher cortical function. The definition of anatomic and clinical correlates to AchA stroke is aided by CT-MRI findings and reveals an unexpected superior extension of infarct to include the periventricular caudate nucleus and inferior corona radiata. Prognosis depends upon unilaterality, bilateral strokes having often a fatal outcome. Etiology and treatment may be intimately related to hypertension.     

脉络膜前动脉区梗死的临床分析

目的探讨脉络膜前动脉区梗死的病因、临床特点。方法回顾性分析了22例CT证实的脉络膜前动脉梗死，针对病因进行CT、MRI、CTA及超声心动等检查，并对临床特点进行分析。结果22例患者中，未发现1例具有“三偏”症状，偏侧无力是最常见的症状。16例以TIA为前驱症状，尤其是上升型TIA。长期高血压、吸烟导致的小动脉病变是此类梗死的常见原因。结论脉络膜前动脉区梗死临床表现多样，典型的三偏症状少见，熟悉其临床特点，同时结合影像学检查是获得准确诊断的关键。     

Anatomic basis of transcortical motor aphasia

Analysis of language profiles and CT anatomy in transcortical motor aphasia (TCMA) suggests that the essential lesion is disruption of connections at sites between the supplementary motor area and the frontal perisylvian speech zone. If the lesion is extended, there may also be poor articulation (lesion deep to motor strip for face), impaired auditory comprehension (lesion in anterior head of caudate, anterior limb internal capsule, anterior putamen, and anterior portion of external capsule, claustrum, extreme capsule, and insula), or stuttering (lesion in pars opercularis and lower third of premotor region). This concept unifies disparate anatomic and psychophysiologic observations about three syndromes: classical TCMA, aphasia after left medial frontal infarction, and TCMA during recovery from Broca's aphasia.     

rtPA intravenous thrombolysis in anterior choroidal artery territory stroke

OBJECTIVE: To study the possible specific response to recombinant tissue plasminogen activator (rtPA) thrombolysis of anterior choroidal artery (AChA) stroke. BACKGROUND: Outcome and response after rtPA thrombolysis are possibly better in small-vessel infarcts, but a specific study of AChA stroke has not yet been performed. METHODS: The authors proposed an open trial of IV rtPA within 7 hours in patients age 20 and 81 years with all types of internal carotid artery territory stroke if the baseline Scandinavian Stroke Scale (SSS) score was less than 48. A dose of rtPA 0.8 mg/kg was infused over 90 minutes. Of 114 consecutive patients, 9 patients (7.9%) exhibited hypodensity in the AChA territory on day 1 brain CT. RESULTS: Seven of nine patients with AChA infarct had a primary early recovery within 6 hours after the initiation of rtPA infusion. In addition, recovery was complete in five patients and partial in two patients. No intracerebral hematoma was observed. Three patients had a "reinfarct syndrome" at 12, 25, and 48 hours respectively. However, in the two latter patients treated with IV heparin, the deficit disappeared again with the increase of heparin dose in one patient and disappeared spontaneously in the other patient. The overall outcome at day 90 was six total recoveries in nine patients (66%). Patients with a final good outcome had a slight "unstructured" hypodensity in the AChA territory on day 1 brain CT, whereas patients with a bad outcome had the classic "structured" hypodensity of AChA territory stroke. CONCLUSION: These data support a specific quick response of AChA territory stroke to IV rtPA thrombolysis, probably due to the small size of the artery and of the "clot." The high frequency of the reinfarct syndrome is a clinical fact that is difficult to explain. Efficient heparin treatment after 24 hours may control the reinfarct syndrome in some patients.     

A specific pattern of executive dysfunctions in transcortical motor aphasia

Background: Recent studies imply that executive functions (EF) are closely related to our ability to comprehend and produce language. A number of findings suggest that functional communication and language recovery in aphasia depend not only on intact language abilities but on EF as well. Some patients with transcortical motor aphasia (TMA) show language deficits only in tasks in which conflicting representations must be resolved by executive processes. In line with these results, others have proposed that TMA should be referred to as “dysexecutive aphasia”. EF in aphasia have mostly been studied using neuropsychological tests, therefore there is a need for systematic experimental investigations of these skills.

Aims: 1. To investigate EF in TMA, and to test whether executive dysfunctions are specific to TMA. 2. To experimentally measure different components of EF: updating working memory representations and inhibition of prepotent responses.

Methods & Procedures: Five individuals with TMA, five patients with conduction aphasia and ten healthy controls participated. We designed four nonverbal tasks: to measure updating of working memory representations, we used a visual and an auditory n-back task. To assess inhibition of prepotent responses, we designed a Stop-signal and a nonverbal Stroop task. All tasks involved within-subject baseline conditions.

Outcomes & Results: We found certain EF deficits in both groups of individuals with aphasia as compared to healthy controls. Individuals with TMA showed impaired inhibition as indexed by the Stop-signal and the nonverbal Stroop tasks, as well as a deficit of updating of working memory representations as indexed by the auditory n-back task. Participants with conduction aphasia had difficulties in only one of the tasks measuring inhibition, but no clear evidence for impairment of updating of working memory representations was found.

Conclusions: Although the results show different patterns of EF deficits in the groups with aphasia, the findings clearly demonstrate that EF deficits are not specific to participants with TMA. Based on these results, and on earlier data highlighting the role of executive processes in functional communication and language recovery, we suggest that tests of EF should be an inherent part of clinical aphasia assessment.     

An autopsy case of transcortical motor aphasia

An autopsy case of transcortical motor aphasia is presented with a pathology located anterior and superior to the pars opercularis of the left inferior frontal gyrus. Case H. Y. A 60-year-old right-handed man. On Nov. 14, 1978, the patient had surgery to remove cerebral hematoma in the left frontal lobe. In the neuropsychological examination before the operation, he had shown the clinical features of transcortical motor aphasia characterized by good comprehension of language, preserved repetition, and spontaneous speech disorder. In this stage, it was supposed that the underlying disturbance of spontaneous speech was due to the disabilities of contextual constructions of sentences rather than the lack of speech initiation. Following the operation, however, spontaneous speech disappeared completely for several days. At the same time, the patient showed problems in comprehension, reading, writing and confrontation naming as well as symptoms of disorientation, pathological inertia and 'loss of initiation' in the psychomotor domain. During the following three months, however, the patient did show slight improvement, except for contextual sentence constructions and pathological inertia when taking the complex animal drawing test. In his terminal stages, the clinical symptoms could be summarized as transcortical motor aphasia and mild frontal lobe syndrome. On March 1, 1979, the patient died of Hamman-Rich syndrome. Postmortem examination: The brain weighed 1294 gm. The external observation of the brain disclosed the linear tissue defect, about 15 mm in length and 10 mm in width, along the radial sulcus of the pars triangularis of the left inferior frontal gyrus.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pure homonymous hemianopia due to anterior choroidal artery territory infarction

The most consistently observed neurological deficits in the anterior choroidal artery (AChA) territory infarction are pure motor or sensorimotor syndromes. Visual field defects and higher cortical dysfunction are occasionally accompanied, but pure homonymous hemianopia without motor and sensory symptom has never been reported yet. We present 2 patients with pure homonymous hemianopia, whose MRI disclosed cerebral infarction in the well-known territory of the AChA. In most patients with ischemic stroke, pure homonymous hemianopia indicates infarction in the posterior circulation, particularly in the posterior cerebral artery territory. However, the present cases provide evidence that it can also be caused by infarction in the anterior circulation, i.e. the AChA.     

Inconspicuous visual field defect in anterior choroidal artery territory infarction.

We describe a patient with a right anterior choroidal artery territory infarction and an inconspicuous left visual defect. The anterior choroidal artery is a unique artery of the cerebral circulation. The occlusion of this artery can result in dysfunction of motor, sensory, and visual systems with only rare involvement of higher cortical function. Among symptoms reported, visual abnormalities are the most variable and the least common. However, the visual field abnormality may be overlooked and the incidence underestimated since some patients may not be aware of the problem until uncovered by formal visual field testing.     

Infarction in the territory of the anterior choroidal artery due to embolic occlusion of the internal carotid artery--report of two cases

A case with infarction in the territory of the anterior choroidal artery (AChA) due to embolic occlusion of the internal carotid artery (ICA) is rare. We described two cases and investigated the mechanism of the territory of the AChA. Case 1 was a 69-year-old man. Case 2 was a 71-year-old woman. The neurological examination in both cases showed left homonymous hemianopsia, left facial palsy, left hemiparesis and left hemisensory disturbance. CT scan in these cases showed infarctions of the right uncus, amygdaloid nucleus, genu and posterior limb of the internal capsule, globus pallidus, lateral geniculate body and tail of the caudate nucleus. The right common carotid angiogram showed a complete occlusion of the ICA at its cervical segment in case 1 and at its carotid siphon in case 2. In both cases, the left carotid injection visualized the right anterior cerebral artery and right middle cerebral artery via the anterior communicating artery well, but the right AChA was not visualized. In case 1, the collateral pathways from the right external carotid artery (ECA) and the right posterior communicating artery (PCoA) to the right ICA were not supplied and the precommunicating segment of the right posterior cerebral artery was hypoplastic. In case 2, the collateral pathway from the right ECA to the right ICA was not supplied.(ABSTRACT TRUNCATED AT 250 WORDS)     

Herpes zoster ophthalmicus and ipsilateral infarction in the territory of the anterior choroidal artery

We report a further case of retarded contralateral hemiplegia syndrome after herpes zoster ophthalmicus in which the motor deficit was caused by an ischemic infarction in the territory supplied by the anterior choroidal artery. We discuss the clinical and physiopathogenetic features of the case and consider the computed tomographic and neurological patterns of anterior choroidal infarction.

---

Sommario Gli autori riferiscono di una nuova osservazione della sindrome di emiplegia controlaterale ritardata complicante l'herpes zoster oftalmico, il cui deficit motorio fu causato da un'infarto ischemico nel territorio di irrorazione dell'arteria corioidea anteriore. Vengono discussi gli aspetti clinici e fisiopatogenetici del caso, e considerati quelli tomografici e neurologici degli infarti dell'arteria corioidea anteriore.

     

Treatment of verbal akinesia in a case of transcortical motor aphasia

Abstract

Patients with transcortical motor aphasia frequently demonstrate an ‘akinesia of speech’ resulting in decreased word fluency, reduced syntactic complexity, and diminished speech initiative. A treatment protocol targeting verbal generativity in terms of communicative expansion was instituted in this case study to address the patient's deficit area—deficient linguistic planning and goal setting. The patient demonstrated adequate lexical and syntactic skills and improved sentence generation performance as a result of treatment. However, treatment effects were short-lived as the patient returned to pre-treatment levels on the generalization measures three months post-discharge.     

Nonsymbolic movement training to improve sentence generation in transcortical motor aphasia: A case study

Background: Nonfluent verbal production in individuals with transcortical motor aphasia (TMA) relates primarily to impaired initiation of verbalisation. Luria (1973) proposed the notion of gestural reorganisation, limb movements used to provoke verbalisations, as a means to improve verbal initiation in aphasia. In particular, movements performed with the left hand in left space may engage right frontal mechanisms to enhance verbal initiation (Crosson, Singletary, Richards, Koehler, & Rothi, 2000). However, little evidence is available as to the effects of this type of treatment for nonfluent verbal production in TMA. Aims: We administered a treatment in which we incorporated nonsymbolic limb movements during production of sentences and evaluated the effects on verbal fluency in our participant, MP, who had TMA. Methods & Procedures: We used a single-participant experimental treatment design across behaviours. During training, MP tapped with his left hand in left space as he practised production of sentences for polysemous words (e.g., bank: money, river). In daily probes, we measured percent correct sentences generated and time to produce correct sentences for trained and untrained polysemous words, as well as number of words generated per minute in a control letter category fluency task. Outcomes & Results: Sentence-generation accuracy improved in two trained sets and one untrained set when movement was included during treatment. Little change was evident in the control letter category fluency task. Following training, MP produced increased numbers of words and well-formed utterances in connected speech samples as well. Conclusions: These findings suggest that movement training had some benefit for MP's sentence generation, perhaps due to recruitment of alternative frontal regions to enhance verbal initiation and fluency. Replication is needed with similar subjects who undergo treatment in conjunction with functional neuroimaging to evaluate this possibility.