The role of the insula in the Takotsubo Cardiomyopathy: A scoping review

Takotsubo cardiomyopathy (TC) is a transient cardiomyopathy secondary to emotional and/or physical stress. While its precise aetiology remains unclear, some evidence suggests a possible role for the insular cortex (IC), which modulates cardiovascular responses to stress. The IC is a key viscerosensory and visceromotor hub with widespread connections, and is implicated in interoceptive processing, emotional regulation, and autonomic control. Considering the strong link between stress and TC, and the insula involvement in stress and autonomic regulation, this scoping review aimed at exploring the role of the IC in the onset and modulation of TC. To this end, we examined the evidence derived from both lesional and neuroimaging studies. The results showed that TC can be related to strokes involving the IC, and is associated with structural and functional IC alterations, particularly in the left hemisphere and in female patients. Neuroimaging studies revealed abnormal IC connectivity during stress induction and in resting-state in patients with TC. These findings support the hypothesis that IC dysfunction contributes to autonomic changes in TC, beyond the effects of stress alone.