Insula stroke: the weird and the worrisome

Raghu, Ashley L B; Parker, Tariq; Wyk, A. Van; Green, Alexander Laurence

doi:10.1136/postgradmedj-2019-136732

Cited by 9 publications

(7 citation statements)

References 111 publications

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“…Injury to these interconnected systems, which are located in the brainstem with connections to the somatosensory cortex, insular cortex, thalamus, amygdala, and hypothalamus, might have immediate negative repercussions on respiratory and cardiac function. 3,[30][31][32][33] Onset of type 3 hypersensitivity vasculitis can follow antigenic challenge by days to weeks. 16 Factors that might influence the timing of the onset of acute endotheliitis could include patient age, unique genome, the pace of disease due to comorbidities, or all of these factors.…”

Section: Discussionmentioning

confidence: 99%

Acute Endotheliitis (Type 3 Hypersensitivity Vasculitis) in Ten COVID-19 Autopsy Brains

Rhodes

Love

Lameira

et al. 2021

Preprint

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Central nervous system (CNS) involvement in COVID-19 may occur through direct SARS-CoV-2 invasion through peripheral or cranial nerves or through vascular endothelial cell infection. The renin-angiotensin system may play a major part in CNS morbidity. Effects of hypoxia have also been implicated in CNS lesions in COVID-19. This communication reports on ten consecutive autopsies of individuals with death due to COVID-19 with decedent survival ranging from 30 minutes to 84 days after admission. All ten brains examined had neutrophilic microvascular endotheliitis present in variable amounts and variably distributed. Importantly, this acute stage of type 3 hypersensitivity vasculitis can be followed by fibrinoid necrosis and inner vascular wall sclerosis, but these later stages were not found. These results suggest that a vasculitis with autoimmune features occurred in all ten patients. It is possible that viral antigen in or on microvascular walls or other antigen-antibody complexes occurred in all ten patients proximate to death as a form of autoimmune vasculitis.

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Section: Discussionmentioning

confidence: 99%

Acute Endotheliitis (Type 3 Hypersensitivity Vasculitis) in Ten COVID-19 Autopsy Brains

Rhodes

Love

Lameira

et al. 2021

Preprint

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“…32 The importance of bilateral insular cortex was somewhat surprising but may be attributed to altered consciousness/emotions, autonomic dysregulation, and possibly aspiration. 31,33 Opercular cortex, involving inferior precentral, inferior postcentral, and Heschl gyri, 31 also stood out for its relevance to functional outcomes. Recently, right central opercular lesions were associated with depressive symptoms after stroke.…”

Section: Discussionmentioning

confidence: 99%

Association of Infarct Topography and Outcome After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke

et al. 2022

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Background and Objectives:The care of patients with large vessel occlusion (LVO) stroke has been revolutionized by endovascular thrombectomy (EVT). While EVT has a large effect size, most patients treated with EVT remain disabled or die within 90 days. A better understanding of outcomes may influence EVT selection criteria, novel therapies, and prognostication. We sought to identify associations between outcomes and brain regions involved in ischemic lesions.Methods:For this cohort study, consecutive patients with LVO who were treated with EVT and underwent post-EVT MRI were identified from a tertiary referral center (2011-2019). Acute ischemic lesions were manually segmented from DWI and spatially normalized. Individual lesions were parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and reduced to ten essential lesion patterns using unsupervised dimensionality reduction techniques. Ninety-day modified Rankin Scale (mRS>2) was modeled via Bayesian regression, taking the ten lesion patterns as inputs, and controlling for lesion size, age, sex, acute NIH Stroke Scale (NIHSS), alteplase, prior stroke, intracerebral hemorrhage, and good reperfusion (TICI2b-3). In comparative analyses, 90-day mRS was modeled considering covariates and compartment-wise relevance for acute stroke severity and 90-day mRS were evaluated.Results:There were 151 patients with LVO identified (age: 68±15 years; 52% female). The median NIHSS was 16 (IQR 13-20); 56% had mRS>2. Lesion locations predictive of 90-day mRS involved bilateral, but left-hemispherically more pronounced pre- and postcentral gyri, insular and opercular cortex, as well as left putamen and caudate (area under the curve: 0.91, highest probability density interval (HPDI) covering 90%-certainty: 0.90–0.92). The lesion location model outperformed the simpler model relying on covariates only (Bayesian model comparison of weight: 97% to the model with vs. 3% to that without lesion location). While lesions affecting subcortical nuclei had the highest relevance for stroke severity (posterior distribution mean: 0.75, 90%-HDPI=0.256–1.31), lesions affecting white matter tracts had the highest relevance for 90-day mRS (0.656, 90%-HDPI=0.0864–1.12).Discussion:These data describe the significance for outcomes of specific brain regions involved in ischemic lesions on MRI after EVT. Future work in additional datasets is needed to confirm these granular findings.

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“…Although arrhythmias are generally considered as the cause of stroke, in some patients they occur several days after the stroke [ 131 , 132 ]. In these patients, the arrhythmias may be the consequence of an insular dysfunction rather than the cause of stroke [ 133 , 134 , 135 , 136 , 137 ].…”

Section: Brain Appraisal Systemsmentioning

confidence: 99%

Mental Stress and Cardiovascular Health—Part I

Vancheri¹,

Longo²,

Vancheri

et al. 2022

JCM

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Epidemiological studies have shown that a substantial proportion of acute coronary events occur in individuals who lack the traditional high-risk cardiovascular (CV) profile. Mental stress is an emerging risk and prognostic factor for coronary artery disease and stroke, independently of conventional risk factors. It is associated with an increased rate of CV events. Acute mental stress may develop as a result of anger, fear, or job strain, as well as consequence of earthquakes or hurricanes. Chronic stress may develop as a result of long-term or repetitive stress exposure, such as job-related stress, low socioeconomic status, financial problems, depression, and type A and type D personality. While the response to acute mental stress may result in acute coronary events, the relationship of chronic stress with increased risk of coronary artery disease (CAD) is mainly due to acceleration of atherosclerosis. Emotionally stressful stimuli are processed by a network of cortical and subcortical brain regions, including the prefrontal cortex, insula, amygdala, hypothalamus, and hippocampus. This system is involved in the interpretation of relevance of environmental stimuli, according to individual’s memory, past experience, and current context. The brain transduces the cognitive process of emotional stimuli into hemodynamic, neuroendocrine, and immune changes, called fight or flight response, through the autonomic nervous system and the hypothalamic–pituitary–adrenal axis. These changes may induce transient myocardial ischemia, defined as mental stress-induced myocardial ischemia (MSIMI) in patients with and without significant coronary obstruction. The clinical consequences may be angina, myocardial infarction, arrhythmias, and left ventricular dysfunction. Although MSIMI is associated with a substantial increase in CV mortality, it is usually underestimated because it arises without pain in most cases. MSIMI occurs at lower levels of cardiac work than exercise-induced ischemia, suggesting that the impairment of myocardial blood flow is mainly due to paradoxical coronary vasoconstriction and microvascular dysfunction.

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Insula stroke: the weird and the worrisome

Cited by 9 publications

References 111 publications

Acute Endotheliitis (Type 3 Hypersensitivity Vasculitis) in Ten COVID-19 Autopsy Brains

Acute Endotheliitis (Type 3 Hypersensitivity Vasculitis) in Ten COVID-19 Autopsy Brains

Association of Infarct Topography and Outcome After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke

Mental Stress and Cardiovascular Health—Part I

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