Insular cortex stimulation produces lethal cardiac arrhythmias: a mechanism of sudden death?

Oppenheimer, Stephen; Wilson, John X.; Guiraudon, C; Cechetto, David F.

doi:10.1016/0006-8993(91)90412-o

Cited by 272 publications

(172 citation statements)

References 32 publications

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“…An alternative interpretation of HEP changes during mental stress is that they reflect ''central command'' processes controlling myocardial function. Cardiac efferent responses including tachycardia, bradycardia (49)(50)(51), and the induction of lethal arrhythmias (52) have been demonstrated after insular cortex stimulation, consistent with centralized cardiac efferent control (53,54). Although it is also possible that alterations in HEPs reflect sympathetic outflow underlying cardiac output, independent of sympathetically mediated increases in skin conductance, blood pressure, and heart rate (55), considering that cardiac output may directly index baroreceptor activation on a beat-by-beat basis, and the specific expression of our effects within each cardiac cycle, we favor an afferent representation interpretation.…”

Section: Discussionmentioning

confidence: 99%

A cortical potential reflecting cardiac function

Gray

Taggart

Sutton

et al. 2007

Proc. Natl. Acad. Sci. U.S.A.

179

125

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Emotional trauma and psychological stress can precipitate cardiac arrhythmia and sudden death through arrhythmogenic effects of efferent sympathetic drive. Patients with preexisting heart disease are particularly at risk. Moreover, generation of proarrhythmic activity patterns within cerebral autonomic centers may be amplified by afferent feedback from a dysfunctional myocardium. An electrocortical potential reflecting afferent cardiac information has been described, reflecting individual differences in interoceptive sensitivity (awareness of one's own heartbeats). To inform our understanding of mechanisms underlying arrhythmogenesis, we extended this approach, identifying electrocortical potentials corresponding to the cortical expression of afferent information about the integrity of myocardial function during stress. We measured changes in cardiac response simultaneously with electroencephalography in patients with established ventricular dysfunction. Experimentally induced mental stress enhanced cardiovascular indices of sympathetic activity (systolic blood pressure, heart rate, ventricular ejection fraction, and skin conductance) across all patients. However, the functional response of the myocardium varied; some patients increased, whereas others decreased, cardiac output during stress. Across patients, heartbeat-evoked potential amplitude at left temporal and lateral frontal electrode locations correlated with stress-induced changes in cardiac output, consistent with an afferent cortical representation of myocardial function during stress. Moreover, the amplitude of the heartbeat-evoked potential in the left temporal region reflected the proarrhythmic status of the heart (inhomogeneity of left ventricular repolarization). These observations delineate a cortical representation of cardiac function predictive of proarrhythmic abnormalities in cardiac repolarization. Our findings highlight the dynamic interaction of heart and brain in stress-induced cardiovascular morbidity. afferent homeostatic feedback ͉ electroencephalography ͉ heart beat-evoked potential ͉ insula cortex ͉ ischemia

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Section: Discussionmentioning

confidence: 99%

A cortical potential reflecting cardiac function

Gray

Taggart

Sutton

et al. 2007

Proc. Natl. Acad. Sci. U.S.A.

179

125

View full text Add to dashboard Cite

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“…Stimulation of the insula in experimental primates and in humans leads to activation of cardiac and systemic autonomic phenomena. 23,24 Although the autonomic system conveys a survival advantage against internal and external threats, its activation can lead to a number of undesirable events, some of which could even be life-threatening. 25 Some sequela of sympathetic system activation was listed in Table 2.…”

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confidence: 99%

Middle Cerebral Artery Infarcts Encompassing the Insula Are More Prone to Growth

Arsava

Koroshetz

et al. 2008

Stroke

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Background and Purpose-Based on previous observations that infarcts encompassing the insula were linked to unfavorable clinical outcome, we hypothesized that insular damage was directly associated with worsened infarction in ischemic but potentially viable neighboring brain tissue. Methods-Using acute diffusion-and perfusion-weighted MRI within the first 12 hours of symptom onset and a follow-up MRI on day 5 or later, we calculated the percentage of mismatch lost (PML) in 61 consecutive patients with ischemic stroke within the middle cerebral artery territory. PML denoted the percentage of mismatch tissue between diffusion-weighted imaging and mean transit time maps that eventually underwent infarction. We explored the relationship between PML and insular location using a regression model. Results-The median PML was 17.7% (interquartile range, 3.5% to 54.2%) in insular and 2.5% (0.0% to 12.7%) in noninsular infarcts (PϽ0.01 Key Words: cerebral infarct Ⅲ diffusion-weighted imaging Ⅲ heart-brain relationships Ⅲ insula Ⅲ MRI Ⅲ neurocardiology Ⅲ sympathetic nervous system T he insula, or the island of Reil, is an invaginated portion of the cortex that is completely enclosed within the sylvian fissure. Although the first description of the insula dates back 200 years ago, 1 insular infarcts and their clinicanatomic features have not been studied in depth. This is partly because insular infarcts are only occasionally exclusively limited to the insula 2,3 ; more frequently, they occur as a part of large middle cerebral artery (MCA) territory infarcts. 3 Despite the infrequency of solitary insular infarction, infarcts that encompass the insula are associated with higher stroke severity and poorer clinical outcome compared with infarcts sparing the insula. [3][4][5][6] The exact means by which insular infarcts are associated with unfavorable outcome is not known. At first glance, the large size of infarcts due to proximal MCA occlusions that accompany insular infarcts may be a reason for unfavorable outcome. However, alternative approaches may also be worthy of consideration. The insula is a functional integration site for autonomic responses and therefore, unlike most other brain regions, it has a unique ability to provoke systemic responses. 7 Autonomic responses such as alterations in blood glucose, blood pressure, myocardial contractility, and body temperature can in turn contribute to adverse tissue outcome in cerebral ischemia. 4,8 -10 In the current study, we sought to test the hypothesis that insular damage is a risk factor for increased conversion of ischemic but potentially viable neighboring tissues into infarction in patients with MCA stroke. Methods Study PopulationThe current study was a retrospective analysis of a prospective, ongoing, National Institutes of Health-funded study evaluating the use of diffusion-weighted imaging (DWI) and perfusion-weighted imaging in predicting tissue risk of infarction in acute stroke. The study enrolled consecutive patients who were admitted within the first 12 hours of s...

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“…Microstimulation of a rat left insula resulted in QT interval prolongation, ST depression, bradycardia and complete heart block. On examination, the plasma noradrenaline levels were elevated without a change in adrenaline, indicating a neural rather than an adrenal origin [7]. Lesions in the right posterior insula have been shown to increase blood pressure and heart rate without altering baroreceptor sensitivity [8].…”

Section: Discussionmentioning

confidence: 99%

Acute Stroke of the Insular Cortex Leading to Heart Failure

et al. 2016

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In humans, the limbic and paralimbic systems, including the insular cortex, are the central autonomic networks responsible for maintaining cardiovascular autonomic control. The right insular cortex plays a predominant role in establishing sympathetic tone while the left insular cortex in establishing parasympathetic tone of the heart. Disturbances in the autonomic system due to cerebrovascular diseases, such as an ischemic stroke in the territory of the middle cerebral artery, could lead to impairment in the cardiovascular balance, consequently increasing the incidence of tachyarrhythmia. Abnormalities of cardiovascular autonomic control may retain prognostic relevance, as they have been associated with adverse clinical outcomes after stroke. Acute ischemic stroke has been shown to increase the rate of cardiac-related mortality as a pathophysiological consequence of an acute stress response in patients with no cardiovascular comorbidities due to the dysfunction of the brain-heart axis. This case report highlights an instance when this axis was disturbed leading to non-ischemic cardiomyopathy.

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Insular cortex stimulation produces lethal cardiac arrhythmias: a mechanism of sudden death?

Cited by 272 publications

References 32 publications

A cortical potential reflecting cardiac function

A cortical potential reflecting cardiac function

Middle Cerebral Artery Infarcts Encompassing the Insula Are More Prone to Growth

Acute Stroke of the Insular Cortex Leading to Heart Failure

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