1535 - Modulation of Addiction Behaviors following Insular Stroke

Ischemic infarcts of the posterior left insula, operculum, and corona radiata; Methamphetamine use disorder 


Case Description: A 27-year-old male with prior polysubstance use including methamphetamine use, presented with acute-onset aphasia and right-sided weakness.  MRI revealed posterior left insula/operculum and corona radiata infarcts, with punctate, scattered infarcts suggesting embolic source.  Urine toxicology was positive for amphetamines and TEE was without vegetations. On admission to inpatient rehabilitation, he conveyed a strong desire to cease methamphetamine use and reconnect with his family, from whom he was estranged during a 10-year period of homelessness. The patient was followed by rehabilitation psychology and throughout all encounters maintained he had no cravings for methamphetamine. He participated well in therapies and reconciled with his family, discharging to his mother’s home.  Following discharge, he established consistent outpatient care, was treated for subacute endocarditis, and underwent mitral valve repair. He was adherent through his extended treatment course, and per family report several months post-discharge he continued to avoid methamphetamine use with noted lack of cravings.

Discussions: The insula has been posited to contribute to reward and control pathways that underlie addiction, and as such the insula has been suggested as a therapeutic target to help modulate addictive behaviors.  This case provides an example of stimulant craving cessation following insular stroke, and the importance of recognizing the potential opportunity for multidisciplinary substance abuse interventions in the acute rehabilitation setting.

Conclusions: We report the case of a young patient with methamphetamine use disorder who suffered an acute infarction of his insular cortex and subsequently denied all cravings for methamphetamine, with continuing cessation of use following cerebrovascular insult.