A Case of Infarct Connecting the Insular Cortex and the Heart

Cho and colleagues have published a case study linking the insular cortex with the heart. The paper is titled ‘Takotsubo Cardiomyopathy Following Cerebral Infarction Involving the Insular Cortex’ and is freely available here. The link between the insular cortex and the cardiovascular system has been known for quite a while now. For instance, the insular cortex is thought to have a role in regulation of blood pressure as well as other autonomic functions. This has been elaborated on by A Craig in several of his papers.

This is a case of 52 year-old man who presents with symptoms including

chest pain, speech disturbance and right hemiparesis

The authors note that while having features of an acute myocardial infarct they are unable to demonstrate obstruction of the coronary arteries on angiography but echocardiography reveals

hypokinesia of the middle and apical walls of the left ventricle

There is also ST elevation on the ECG. Digitalisation and heparinisation were associated with improvement on the echocardiogram and in the ST elevation. The term takotsubo refers to a Japanese fishing pot used to catch Octupus and in this case refers to the appearances identified on the ventriculogram. In their discussion the authors discuss Takotsubo Cardiomyopathy in more detail and then draw links with the insular cortex and suggest that these links should be further investigated. This reminded me of another study reviewed here.  There were associations with homocysteine elevation in this other report and T-wave inversion although this is the later phase of T-wave changes in the current report. Although there is hemiparesis in the current study, the other findings are different. While its difficult to disentangle cause and effect given the other areas involved, the authors conclusions are persuasive in the context of other literature in this area and assuming no confounding factors.

The implication is that an infarct to the Insular Cortex is sufficient in itself to change the manner in which the walls of the heart contract. The authors draw links with the sympathetic nervous system and if this is correct then it suggests that the insular cortex is able to influence the contraction of the heart through its role in the sympathetic nervous system. What is even more intriguing is that the contraction normalises despite the persistence of the infarct suggesting either rapid adaptation or an acute role for the insular cortex in changes in cardiac contractions. This latter interpretation is supported by studies showing rapid changes in insular cortex activity which correlate with exercise-induced changes in blood-pressure. How this all relates to emotions is another matter although here as Craig would suggest there is an important role for the insular cortex. The case report raises interesting questions as well as building up the evidence for the relationship between the insular cortex and sympathetic control of cardiac contractions.

Index: An index of the site can be found here. The page contains links to all of the articles in the blog in chronological order. Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link. Podcast: You can listen to this post on Odiogo by clicking on this link (there may be a small delay between publishing of the blog article and the availability of the podcast). It is available for a limited period. TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link. Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk. Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

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