Violations of the autonomic nervous system are common in patients with cerebrovascular diseases and adversely affect the quality of life. The central autonomic network combines multiple reciprocally connected cortical, subcortical and stem structures. The insular cortex is involved in visceral motor and sensory regulation, including that of the cardiovascular system. Brain lesions including insula and other prefrontal cortical areas are particularly important in provoking arrhythmia. Stroke involving insular cortex is associated with poor prognosis. The right insular cortex plays a dominant role in modulating sympathetic tone and the left insular cortex in parasympathetic tone, which clinically correlates with more frequent arrhythmias and arrhythmic death after a stroke affecting the insula in the right hemisphere. The insular cortex is located in the middle cerebral artery and its structure is exposed to a high risk of injury.