Right homonymous visual field defect with language impairment is most consistent with stroke in which territory?

• A. Left PCA stroke
• B. Right MCA inferior stroke
• C. Left ACA stroke
• D. Left MCA stem stroke

Answer: (D)

When language impairment is present, the lesion is in the dominant hemisphere, usually the left, and a right homonymous visual field defect points to involvement of the left visual pathways. The left MCA supplies key language areas and the optic radiations as they traverse the temporal-parietal region. A stroke affecting the left MCA stem disrupts both language cortex and these visual pathways, producing aphasia plus a right homonymous hemianopia. The other territories either don’t typically cause aphasia or don’t produce a visual field defect together: left PCA would mainly cause visual field loss without language impairment; left ACA tends to cause bilateral motor/apraxia effects with little visual field deficit; right MCA inferior stroke can cause left-sided neglect and visual field issues but language centers are left-dominant, so aphasia is unlikely.