Isolated Left Insular Infarction and Acute Psychosis: A Misleading Clinical Presentation

Introduction: The insular cortex is a hidden structure located in the Sylvian fissure surrounded by the temporal, frontal, and parietal lobes. It is a complex structure interconnecting various brain regions. The insular lobe plays multiple roles including visceromotor, viscerosensory and limbic functions. These roles contribute to control autonomic, memory, behavior and language system. The arteries supplying the insular area are mainly originate from the M2 segment of the middle cerebral artery. The isolated insular infarction stroke is extremely rare. The objective was to report this case study with literature reviewed.

Clinical study: The 60-year-old patient was admitted to our tertiary hospital with behavioral complains symptoms. He had a pass history of essential thrombocythemia under hydroxyurea. The disorders were started suddenly and marked by behavioral disturbances such as self runaways, aggression and a feeling of strangulation. The clinical examination revealed personality disorders with delusions of persecution type, auditory hallucinations, unmotivated laughing and crying, and speech disorders such as tachylalia and paraphasia. There was an unpleasant sensation of the left hemi-body and no motor deficit or cranial nerves involvement. Brain magnetic resonance imaging revealed isolated infarction of the left insular cortex (Figure 1). The diagnostic of left insular infarction with psychiatric manifestations was made and the patient underwent anti platelet treatment and remote psychiatric control drugs. After three months of follow up, the patient had got good recovery of language, mood and behavioral disorders.

Conclusion: The polymorphism of insular stroke clinical presentation raises the major interest of after stroke clinical and neuropsychological follow up to improve the quality of life of patient. The prognosis of the isolated insular infarction is often favorable but under appropriate diagnostic.

Keywords: Acute psychosis; Insular infarction; Clinical symptoms; MRI findings; Stroke