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Background An internal capsule genu infarct has been rarely reported to cause cognitive impairment and behavioral changes. This clinical picture can be explained on anatomical and functional basis because important subcortical-cortical pathways traverse the internal capsule genu. We report 2 previously non-demented patients who developed acute confusional state, abulia, and moderate cognitive decline after the occurrence of an infarct in the capsular genu. Methods Clinical, neuropsychological, and MRI evaluation at baseline and 12-month follow-up. Results Abulia and cognitive impairment were still present 1 year after stroke. In 1 patient there were associated multiple lacunar infarcts and leukoaraiosis. In the other an old small left frontal infarct was also present. In both moderate cortical atrophy co-existed. Conclusions We hypothesize that co-existing lesions, possibly associated with a sub-clinical reduction of cognitive functions, facilitate the development of a persistent clinically evident mental deficit after the occurrence of an infarct in the capsular genu.