Translational Research in Stroke Cerebrovasc Dis 2020;49:10–18 Isolated Insular Stroke: Clinical Presentation Fabrizio Giammello a Domenico Cosenza a Carmela Casella a Francesca Granata b Cristina Dell’Aera a Maria Carolina Fazio a Paolino La Spina a Francesco Grillo a Masina Cotroneo a Antonio Toscano a Rosa Fortunata Musolino a a U.O.S.D. Stroke Unit, Department of Clinical and Experimental Medicine, AOU Policlinico G. Martino, University of Messina, Messina, Italy; b Neuroradiology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy Received: June 25, 2019 Accepted: November 13, 2019 Published online: February 5, 2020 Carmela Casella Stroke Unit, Department of Clinical and Experimental Medicine University of Messina, Policlinico “G. Martino” Via Consolare Valeria, 1, IT–98124 Messina (Italy) E-Mail ccasella @unime.it © 2020 S. Karger AG, Basel karger@karger.com www.karger.com/ced DOI: 10.1159/000504777 Keywords Insular stroke · Autonomic activation after stroke · Stroke diagnostics · Neurointensive care Abstract The symptoms related to insular ischemia have been the ob- ject of several studies in patients affected by stroke, al- though they are often accompanied by other ischemic al- teration of adjacent brain structures supplied by the middle cerebral artery (MCA). The insula is vulnerable because of an ischemia due to thromboembolic vascular occlusion of the M1 MCA segment and the 2 main MCA branches (M2), main- ly when they abruptly arise from the principal stem at a right angle. This topographical and anatomical peculiarity could enable an embolic formation, especially due to atrial fibrilla- tion (AF), to occlude the transition pathway between M1 and M2, while the proximal origin of vascular supply pro- tects the insula from ischemia due to hemodynamic factors. The aim of the study is to characterize the clinical aspects of acute ischemic strokes as a first event in the insular territory with specific attention to atypical manifestation. We have considered 233 patients with a first event stroke involving the insular territory and 13 cases of isolated insular stroke (IIS), from the stroke registry of the Policlinico “G.Martino”, University of Messina, between the February 10, 2014 and the February 7, 2018. IIS patients showed CT/MRI lesions re- stricted to the insular region. Exclusion criteria were coexist- ing neurological diseases, structural brain lesions, extension to the subinsular area >50% of the total infarct volume. We identified 13 IIS patients (mean age 74 years), with an iso- lated symptom or a combination of typical and atypical as- pects. Furthermore, we observed high frequency detection of cardiac disturbances. To our knowledge, just a few previ- ous studies have described IIS; their incidence is still not well defined. IIS manifested with a combination of deficits in- cluding motor, somatosensory, speaking, coordination, au- tonomic and cognitive disturbances. After an ischemic stroke, AF manifestation could follow briefly the major event and its duration could be very short, as an autonomic dys- function due to an insular infarction. This clinical condition requires a continuous cardiac monitoring for this dangerous occurrence. © 2020 S. Karger AG, Basel Introduction The human insular cortex (IC) is a complex structure that has been implicated in a large number of functions and in the pathophysiology of a variety of neurologic disorders [1].