A variety of fluent and nonfluent aphasias have been reported after left basal ganglia stroke. It has been speculated that this heterogeneity may reflect variations in cortical hypoperfusion resulting from large vessel stenosis. To test this hypothesis, a consecutive series of 24 patients with left caudate infarct identified with diffusion-weighted imaging underwent language testing and perfusion-weighted imaging <24h from onset of symptoms. Specific regions in perisylvian cortex were rated for the percentage of the region that was hypoperfused. Aphasia type was determined on the basis of speech fluency, comprehension, and repetition performance on the language tests. Association between aphasia type/language impairment and regions of hypoperfusion were identified with Fisher's exact tests. Results demonstrated that in patients with acute left caudate infarct, the presence and type of aphasia reflected regions of hypoperfusion, and generally followed predictions based on chronic lesion studies, regarding anatomical lesions associated with classic aphasia types.