(Kiosk 3) Autonomic Dysfunction and Myocardial Injury Arising from Right Insular Stroke: A Case Report

Case Diagnosis: Autonomic dysfunction and myocardial injury arising from ischemic stroke of the right insula

Case Description or Program Description: A 71-year-old female with a history of hypertension and obesity presented to the emergency department with impaired speech and left-sided weakness upon awakening with last known normal the night prior. Admission evaluation noted for blood pressure 228/118, elevated troponin with normal sinus rhythm on ECG. CT was negative for intracranial hemorrhage or large vessel occlusion; MRI brain revealed acute ischemic infarct of the right insula. The patient was started on dual antiplatelet therapy. Her rehabilitation course was complicated by urinary retention, constipation, orthostatic hypotension, circadian rhythm disruption, and movement and tactile allodynia of the left upper and lower extremities.

Setting: Acute rehabilitation hospital

Assessment/Results: Patient required active management for symptoms related to autonomic dysregulation, which were initial barriers to therapy participation. Neurogenic bladder was managed with tamsulosin and timed voids. She required stool softeners, laxatives, and enemas for constipation. Orthostatic hypotension was managed with abdominal binder and compression stockings. Scheduled melatonin and sleep hygiene education improved the patient’s sleep onset, latency, and duration. Ultimately, her autonomic symptoms were responsive to conservative management. Her allodynia improved with gabapentin and desensitization therapy.

Discussion (relevance): Isolated right insular strokes are rare and underreported since most strokes also encompass adjacent regions. Right insular involvement has been associated with autonomic dysfunction, characterized by increased sympathetic and decreased parasympathetic tone. Notably, due to the right dorsal anterior insular cortex’s role in parasympathetic control of the heart, right insular infarction often leads to troponin elevation on initial presentation and myocardial injury in the absence of myocardial ischemia. Patients with this stroke syndrome require a comprehensive rehabilitation plan to address multifaceted autonomic dysfunction and may benefit from cardiac monitoring.

Conclusions: Physiatrists should recognize right insular infarcts as a distinct stroke syndrome characterized by non-ischemic myocardial injury and multisystem autonomic dysregulation.