Imbalance and dizziness caused by unilateral vestibular schwannomas correlate with vestibulo-ocular reflex precision and bias

Innovative approaches for managing patients with chronic vestibular disorders: follow-up indicators and predictive markers for studying the vestibular error signal

Introduction

Despite significant advancements in understanding the biochemical, anatomical, and functional impacts of vestibular lesions, developing standardized and effective rehabilitation strategies for patients unresponsive to conventional therapies remains a challenge. Chronic vestibular disorders, characterized by permanent or recurrent imbalances and blurred vision or oscillopsia, present significant complexity in non-pharmacological management. The complex interaction between peripheral vestibular damage and its impact on the central nervous system (CNS) raises questions about neuroplasticity and vestibular compensation capacity. Although fundamental research has examined the consequences of lesions on the vestibular system, the effect of a chronic peripheral vestibular error signal (VES) on the CNS remains underexplored. The VES refers to the discrepancy between sensory expectations and perceptions of the vestibular system has been clarified through recent engineering studies. This deeper understanding of VES is crucial not only for vestibular physiology and pathology but also for designing effective measures and methods of vestibular rehabilitation, shedding light on the importance of compensation mechanisms and sensory integration.

Methods

This retrospective study, targeting patients with chronic unilateral peripheral vestibulopathy unresponsive to standard treatments, sought to exclude any interference from pre-existing conditions. Participants were evaluated before and after a integrative vestibular exploratory and rehabilitation program through questionnaires, posturographic tests, and videonystagmography.

Results

The results indicate significant improvements in postural stability and quality of life, demonstrating positive modulation of the CNS and an improvement of vestibular compensation.

Discussion

Successful vestibular rehabilitation likely requires a multifaceted approach that incorporates the latest insights into neuroplasticity and sensory integration, tailored to the specific needs and clinical progression of each patient. Focusing on compensating for the VES and enhancing sensory-perceptual-motor integration, this approach aims not just to tailor interventions but also to reinforce coherence among the vestibular, visual, and neurological systems, thereby improving the quality of life for individuals with chronic vestibular disorders.

Postural impairments in unilateral and bilateral vestibulopathy

Chronic imbalance is a major complaint of patients suffering from bilateral vestibulopathy (BV) and is often reported by patients with chronic unilateral vestibulopathy (UV), leading to increased risk of falling. We used the Central SensoriMotor Integration (CSMI) test, which evaluates sensory integration, time delay, and motor activation contributions to standing balance control, to determine whether CSMI measures could distinguish between healthy control (HC), UV, and BV subjects and to characterize vestibular, proprioceptive, and visual contributions expressed as sensory weights. We also hypothesized that sensory weight values would be associated with the results of vestibular assessments (vestibulo ocular reflex tests and Dizziness Handicap Inventory scores). Twenty HCs, 15 UVs and 17 BVs performed three CSMI conditions evoking sway in response to pseudorandom (1) surface tilts with eyes open or, (2) surface tilts with eyes closed, and (3) visual surround tilts. Proprioceptive weights were identified in surface tilt conditions and visual weights were identified in the visual tilt condition. BVs relied significantly more on proprioception. There was no overlap in proprioceptive weights between BV and HC subjects and minimal overlap between UV and BV subjects in the eyes-closed surface-tilt condition. Additionally, visual sensory weights were greater in BVs and were similarly able to distinguish BV from HC and UV subjects. We found no significant correlations between sensory weights and the results of vestibular assessments. Sensory weights from CSMI testing could provide a useful measure for diagnosing and for objectively evaluating the effectiveness of rehabilitation efforts and future treatments designed to restore vestibular function such as hair cell regeneration and vestibular implants.

Your Vestibular Thresholds May Be Lower Than You Think: Cognitive Biases in Vestibular Psychophysics

PURPOSE

Recently, there has been a surge of interest in measuring vestibular perceptual thresholds, which quantify the smallest motion that a subject can reliably perceive, to study physiology and pathophysiology. These thresholds are sensitive to age, pathology, and postural performance. Threshold tasks require decisions to be made in the presence of uncertainty. Since humans often rely on past information when making decisions in the presence of uncertainty, we hypothesized that (a) perceptual responses are affected by their preceding trial; (b) perceptual responses tend to be biased opposite of the "preceding response" because of cognitive biases but are not biased by the "preceding stimulus"; and (c) when fits do not account for this cognitive bias, thresholds are overestimated. To our knowledge, these hypotheses are unaddressed in vestibular and direction-recognition tasks.

CONCLUSIONS

Results in normal subjects supported each hypothesis. Subjects tended to respond opposite of their preceding response (not the preceding stimulus), indicating a cognitive bias, and this caused an overestimation of thresholds. Using an enhanced model (MATLAB code provided) that considered these effects, average thresholds were lower (5.5% for yaw, 7.1% for interaural). Since the results indicate that the magnitude of cognitive bias varies across subjects, this enhanced model can reduce measurement variability and potentially improve the efficiency of data collection.

Identification of Follow-Up Markers for Rehabilitation Management in Patients with Vestibular Schwannoma

This study delves into the absence of prognostic or predictive markers to guide rehabilitation in patients afflicted with vestibular schwannomas. The objective is to analyze the reweighting of subjective and instrumental indicators following surgery, at 7 days and 1 month postoperatively. This retrospective cohort encompasses 32 patients who underwent unilateral vestibular schwannoma surgery at the Marseille University Hospital between 2014 and 2019. Variations in 54 indicators and their adherence to available norms are calculated. After 1 month, one-third of patients do not regain the norm for all indicators. However, the rates of variation unveil specific responses linked to a preoperative error signal, stemming from years of tumor adaptation. This adaptation is reflected in a postoperative visual or proprioceptive preference for certain patients. Further studies are needed to clarify error signals according to lesion types. The approach based on variations in normative indicators appears relevant for post-surgical monitoring and physiotherapy.

Vestibular dysfunction in neurofibromatosis type 2-related schwannomatosis

Neurofibromatosis type 2-related schwannomatosis is a genetic disorder characterized by neurologic tumours, most typically vestibular schwannomas that originate on the vestibulo-cochlear nerve(s). Although vestibular symptoms can be disabling, vestibular function has never been carefully analysed in neurofibromatosis type 2-related schwannomatosis. Furthermore, chemotherapy (e.g. bevacizumab) can reduce tumour volume and improve hearing in neurofibromatosis type 2-related schwannomatosis, but nothing is known about its vestibular effects. In this report, we studied the three primary vestibular-mediated behaviours (eye movements, motion perception and balance), clinical vestibular disability (dizziness and ataxia), and imaging and hearing in eight untreated patients with neurofibromatosis type 2-related schwannomatosis and compared their results with normal subjects and patients with sporadic, unilateral vestibular schwannoma tumours. We also examined how bevacizumab affected two patients with neurofibromatosis type 2-related schwannomatosis. Vestibular schwannomas in neurofibromatosis type 2-related schwannomatosis degraded vestibular precision (inverse of variability, reflecting a reduced central signal-to-noise ratio) but not vestibular accuracy (amplitude relative to ideal amplitude, reflecting the central signal magnitude) and caused clinical disability. Bevacizumab improved vestibular precision and clinical disability in both patients with neurofibromatosis type 2-related schwannomatosis but did not affect vestibular accuracy. These results demonstrate that vestibular schwannoma tumours in our neurofibromatosis type 2-related schwannomatosis population degrade the central vestibular signal-to-noise ratio, while bevacizumab improves the signal-to-noise ratio, changes that can be explained mechanistically by the addition (schwannoma) and suppression (bevacizumab) of afferent neural noise.

How Peripheral Vestibular Damage Affects Velocity Storage: a Causative Explanation

Velocity storage is a centrally-mediated mechanism that processes peripheral vestibular inputs. One prominent aspect of velocity storage is its effect on dynamic responses to yaw rotation. Specifically, when normal human subjects are accelerated to constant angular yaw velocity, horizontal eye movements and perceived angular velocity decay exponentially with a time constant circa 15-30 s, even though the input from the vestibular periphery decays much faster (~ 6 s). Peripheral vestibular damage causes a time constant reduction, which is useful for clinical diagnoses, but a mechanistic explanation for the relationship between vestibular damage and changes in these behavioral dynamics is lacking. It has been hypothesized that Bayesian optimization determines ideal velocity storage dynamics based on statistics of vestibular noise and experienced motion. Specifically, while a longer time constant would make the central estimate of angular head velocity closer to actual head motion, it may also result in the accumulation of neural noise which simultaneously degrades precision. Thus, the brain may balance these two effects by determining the time constant that optimizes behavior. We applied a Bayesian optimal Kalman filter to determine the ideal velocity storage time constant for unilateral damage. Predicted time constants were substantially lower than normal and similar to patients. Building on our past work showing that Bayesian optimization explains age-related changes in velocity storage, we also modeled interactions between age-related hair cell loss and peripheral damage. These results provide a plausible mechanistic explanation for changes in velocity storage after peripheral damage. Results also suggested that even after peripheral damage, noise originating in the periphery or early central processing may remain relevant in neurocomputations. Overall, our findings support the hypothesis that the brain optimizes velocity storage based on the vestibular signal-to-noise ratio.

Low Gain Values of the Vestibulo-Ocular Reflex Can Optimize Retinal Image Slip

The angular vestibulo-ocular reflex (aVOR) stabilizes retinal images by counter-rotating the eyes during head rotations. Perfect compensatory movements would thus rotate the eyes exactly opposite to the head, that is, eyes vs. head would exhibit a unity gain. However, in many species, but also in elderly humans or patients with a history of vestibular damage, the aVOR is far from compensatory with gains that are in part considerably lower than unity. The reason for this apparent suboptimality is unknown. Here, we propose that low VOR gain values reflect an optimal adaptation to sensory and motor signal variability. According to this hypothesis, gaze stabilization mechanisms that aim at minimizing the overall retinal image slip must consider the effects of (1) sensory and motor noise and (2) dynamic constraints of peripheral and central nervous processing. We demonstrate that a computational model for optimizing retinal image slip in the presence of such constraints of signal processing in fact predicts gain values smaller than unity. We further show specifically for tadpoles of the clawed toad, Xenopus laevis with particularly low gain values that previously reported VOR gains quantitatively correspond to the observed variability of eye movements and thus constitute an optimal adaptation mechanism. We thus hypothesize that lower VOR gain values in elderly human subjects or recovered patients with a history of vestibular damage may be the sign of an optimization given higher noise levels rather than a direct consequence of the damage, such as an inability of executing fast compensatory eye movements.