Journal of Neurology
https://doi.org/10.1007/s00415-018-8867-y

SHORT COMMENTARY

Letter to the editor: insular stroke presenting with acute onset
of pain
Michael Bayat1 · Allan Bayat2
Received: 20 March 2018 / Accepted: 6 April 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Post-stroke pain is a well-known neuropathic pain syndrome but pain at the onset of stroke is a very rare occurrence. We
wish to present a case where a stroke in the insular region caused acute-onset lateralized neuropathic pain.
Keywords Stroke · Pain · Neuralgia

Case
A previously healthy 90-year-old woman was admitted to our department due to acute onset of painful paresthesias in the
entire left side of her body. The pain was described as burning sensation. Clinical examination showed decreased sensation
to painful (pinprick) stimuli and impaired ability to distinguish between hot and cold stimuli on the left side of her body,
encompassing the face, truncal region, arm and leg. Pain thresholds and perception thresholds to contact heat and cold were
not investigated. An MRI showed an ischemic stroke in the right posterior insular region (Fig. 1). She was diagnosed with
atrial fibrillation which was considered to be the cause of her stroke. During admission she later developed focal seizures
with left sided convulsions without loss of awareness and was started on lamotrigine. The painful state lasted a few days and
the paresthesias gradually vanished during the next few weeks. At a follow-up telephone consultation 2 months later she no
longer experienced any symptoms.

Discussion
Central neuropathic pain arises due to a lesion affecting
the central nervous system, typically involving the spinothalamo-cortical system for pain and temperature. The lesion
may be located in the spinal cord, brainstem, subcortical or
cortical region. Post-stroke pain is a well-known neuropathic
pain syndrome occurring after a stroke and is more common
after lateral medullary (Wallenberg’s syndrome) or thalamic
infarctions. The pain can be spontaneous or evoked and is
often accompanied by abnormalities in thermal or pain sensation. Patients may describe the pain as “burning”, “aching”, “freezing”, etc. Post-stroke pain often occurs within the
* Michael Bayat
bayat86@hotmail.com
1

Department Of Neurology, Aalborg University Hospital,
Aalborg, Denmark

2

Department of Neurology, Rigshospitalet, Copenhagen,
Denmark

first few months after the stroke [1]. But pain at the onset of
stroke—as in our case—is an exceedingly rare presentation.
The opercular-insular (also called parasylvian) pain syndrome is a distinct central pain syndrome arising due to a
lesion in the parasylvian cortex (in particular the mid-posterior part of insula and the parietal operculum). The parasylvian cortex is involved in the processing of pain-temperature
sensation and lesions here may present with predominant or
isolated deficits in pain and temperature sensation [2]. It has
been shown that cortical stimulation of the operculo-insular
region can generate painful sensations [3, 4]. Traditionally the
opercular-insular pain syndrome has been termed “pseudothalamic” but this may be inaccurate since thalamic pain does not
exhibit dissociated thermo-algesic sensory loss but includes
disturbances in superficial and deep sensitivities. In this respect
the opercular-insular pain syndrome has more in common with
the lateral medulla oblongata lesion (Wallenberg’s syndrome)
which may also present with a dissociated sensory loss [2].
With this case presentation we would like to highlight
that on very rare occasions a stroke in the insular region
may present with acute-onset lateralized neuropathic pain.

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Fig. 1  MRI showing an ischemic stroke in the right insular region, DWI (left), T2 (right)

Compliance with ethical standards
Ethical standards The case report been performed in accordance with
the ethical standards laid down in the 1964 Declaration of Helsinki and
its later amendments.
Informed consent The patient has consented to the submission of this
case report to the journal.
Conflicts of interest The authors declare that they have no conflict of
interest.

References
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pain: clinical characteristics, pathophysiology, and management.

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