Neuropsychological and Cardiovascular Autonomic Findings Across Thalamic and Insular Stroke: A Narrative Review

Background: The insula and thalamus are components of the central autonomic network, which supports cardiovascular autonomic regulation and the integration of cognitive and affective processes. Both regions are therefore relevant to understanding the neuropsychological sequelae and cardiovascular autonomic dysfunction following stroke. Objective: This narrative review aimed to synthesize current evidence on the neuropsychological and cardiovascular autonomic consequences of insular and thalamic stroke using a narrative approach and to identify gaps in the integration of these domains. Methods: A structured literature search was conducted in PubMed, Scopus, and Web of Science from database inception through 3 October 2026. Eligible studies investigated domain-specific neuropsychological outcomes and/or physiological measures of cardiovascular autonomic function following thalamic or insular stroke. Data on study design, participant characteristics, assessment timing, outcome measures, main findings, and methodological limitations were synthesized according to lesion location and outcome domain. Results: Fourteen studies representing 13 independent cohorts met the eligibility criteria: 11 studies of thalamic stroke representing 10 independent cohorts and three studies of insular involvement representing three independent cohorts. Thalamic-stroke studies reported heterogeneous impairment across multiple neuropsychological domains, particularly attention, executive function, memory, and language. The three insular-stroke studies reported alterations in physiological measures relevant to cardiovascular autonomic function, including heart rate variability and circulating catecholamines, with heart rate and blood pressure additionally assessed in one study. Cardiac arrhythmias and mortality were additionally reported as secondary outcomes in individual studies. None of the included thalamic-stroke studies assessed cardiovascular autonomic function, whereas none of the included insular-stroke studies assessed domain-specific neuropsychological outcomes. No included study integrated neuropsychological and cardiovascular autonomic assessment within the same patient cohort. Interpretation is limited by the small and methodologically heterogeneous evidence base, particularly for insular stroke, as well as variability in lesion characterization, assessment timing, outcome measures, and longitudinal follow-up. Conclusions: The studies included in this review represent two distinct lines of research addressing neuropsychological outcomes following thalamic stroke and cardiovascular autonomic alterations following insular stroke. Among the included studies, none assessed both neuropsychological and cardiovascular autonomic outcomes within the same patient cohort. Larger prospective, longitudinal, and multimodal studies are needed to determine whether and how these outcomes are associated with lesion characteristics and how they evolve during post-stroke recovery.