Abstract Number: Esoc2026ys277 Insular Stroke: Neuropsychological and Functional Connectivity Correlates in the Acute and Subacute Phases

Abstract Background and aims The insula plays a pivotal role in integrating emotional, cognitive, and interoceptive processes through its central position within the Salience Network (SN). Damage to this region may disrupt executive–affective regulation and the dynamic switching between large-scale brain networks. The present research aims to investigate the specific effects of insular lesions on cognitive functions, emotional processing, and cortical network reorganization. Methods To investigate these mechanisms, fifteen patients with acute ischemic stroke (2 weeks) were so far assessed through a comprehensive neuropsychological battery and resting-state fMRI (rs-fMRI). Results Patients with insular lesions showed pronounced deficits in emotion recognition and executive functioning compared to those with non-insular lesions, while other cognitive domains remained relatively preserved. Functional imaging revealed reduced intra-network SN connectivity, diminished anticorrelation between SN and Default Mode/Ventral Attention Networks, and decreased SN–Language Network coupling, indicating early disruption of network segregation and functional specialization. Moreover, Patients with insular lesions showed higher participation coefficients (PC) of visual nodes, suggesting increased cross-network integration in visual regions. A longitudinal follow-up in a subset of six insular-stroke patients demonstrated partial normalization of connectivity patterns at 3 months, including restoration of negative anticorrelations and rebalancing of inter-network interactions toward values comparable to healthy controls. The observed pattern confirms the insula’s role in affective processing and cognitive control. These findings suggest that acute insular damage leads to early SN disconnection with measurable cognitive–emotional consequences, followed by spontaneous functional reorganization that may support recovery. Conflict of interest Nothing to disclose Figure 1 - belongs to Results