When the Heart and Brain Collide: A Case of Malignant Middle Coronary Artery Infarction and Cardiac Arrhythmias Linked to Right Insular Cortex Dysfunction.

Introduction: Stroke is a common cause of insular cortex injury, and it is associated with a rare complication of cardiac arrhythmia, which can be life-threatening. Here we present a case of this complication. Case presentation: An 88-year-old female presented to the emergency department for acute and severe abdominal pain, non-radiating, associated with 3 days of watery diarrhea with no other symptoms. The patient was adequately resuscitated and admitted for gastroenteritis. During the hospitalization, the patient had episodic hypertension requiring as needed hydralazine use. The patient was doing well until she had an episode of syncope. She was vitally stable, and examination was again unremarkable. One hour later, the patient developed slurred speech and left-sided weakness. CT angiography (CTA) revealed acute occlusion on chronic stenosis of the M2 branch corresponding to insular cortex on the right, and mild stenosis of the proximal M1 segment of the right middle cerebral artery was noted. The patient went on to become hemodynamically unstable with hypotension and bradycardia and eventually underwent cardiac arrest. The patient achieved the return of spontaneous circulation but coded again and did not survive the event. Conclusion: Stroke affecting the insular cortex can cause a variety of cardiac complications, including arrhythmia. Early recognition and prompt management of cardiac arrhythmia in patients with insular cortex stroke is crucial to prevent life-threatening complications. CTA with contrast should be carefully considered after weighing the potential benefits and risks of the procedure, as well as the implementation of strategies to minimize the risk of CIN. Further research is needed to understand mechanisms underlying these complications and to develop more effective treatments. LEARNING POINTS: The insular cortex is crucial for autonomic regulation, and strokes affecting this region are associated with deadly arrhythmias.Early cardiac monitoring, especially within the first 2-3 days after a stroke, is critical for avoiding life-threatening complications.Early stroke therapies like thrombolysis and thrombectomy with intensive post-stroke care improves recovery prospects dramatically.