Vestibular perception following acute unilateral vestibular lesions

Bilaterally positive head-impulse tests can differentiate AICA infarction from labyrinthitis

Introduction

Video head-impulse tests (video-HITs) often fail to detect anterior inferior cerebellar artery (AICA) infarction due to peripheral and central vestibular system involvement. Anecdotal studies suggest that video-HITs may reveal bilateral impairment in AICA infarction. However, the diagnostic utility of video-HITs has not been established, particularly when compared to labyrinthitis, which accounts for the majority of acute audiovestibular syndrome (AAVS) cases.

Methods

We reviewed the medical records of consecutive patients presenting with new-onset acute hearing loss and spontaneous vertigo (i.e., AAVS) between March 2018 and July 2023 at a tertiary hospital in South Korea. Video-HIT patterns were categorized as follows: (1) ipsilaterally positive, (2) contralaterally positive, (3) bilaterally normal, and (4) bilaterally positive.

Results

Twenty-eight patients with AICA infarction (mean age ± standard deviation = 67 ± 15 years; 14 men) and 51 with labyrinthitis (63 ± 17 years, 26 men) were included in the analyses. Among the 28 patients with AICA infarction, 15 presented with AAVS in isolation, without other co-morbid neurologic deficits (15/28, 54%). The vestibulo-ocular reflex (VOR) gains of ipsilesional horizontal canals (HCs) ranged from 0.21 to 1.22 (median = 0.81, interquartile range [IQR] = 0.50-0.89). However, those for contralateral HC gain ranged from 0.57 to 1.19 (median = 0.89 [IQR = 0.73-0.97]). Collectively, HITs were bilaterally positive in 13 patients (including 12 patients with bilaterally positive HITs for the horizontal canal), normal in eight, ipsilesionally positive in six, and contralesionally positive in one patient with AICA infarction. The VOR gains were typically decreased ipsilaterally in 28 (28/51, 55%), normal in 17 (17/51, 33%), and decreased bilaterally in six patients with labyrinthitis (6/51, 12%). Logistic regression analysis revealed that bilaterally positive HITs (p = 0.004) and multiple vascular risk factors (p = 0.043) were more frequently associated with AICA infarction than labyrinthitis.

Discussion

Among patients presenting with AAVS, bilaterally positive HITs can be indicative of AICA infarction in patients with multiple vascular risk factors.

Association between Benign Paroxysmal Positional Vertigo and Thyroid Diseases: Systematic Review and Meta-Analysis

Introduction  Benign paroxysmal positional vertigo (BPPV) is the peripheral vestibular dysfunction that most affects people worldwide, but its etiopathogenesis is still not fully understood. Considering the etiological diversity, some studies highlight the association between BPPV and thyroid diseases. Objective  To investigate the association between thyroid diseases and BPPV. Data Synthesis  Systematic review and meta-analysis of epidemiological studies searched in the PubMed, Web of Science, Embase, Cochrane Library, and Scopus databases. Studies that were fully available and investigated the association between BPPV and thyroid diseases were selected. The articles that composed the meta-analysis were analyzed using the dichotomous model, the Mantel-Haenszel statistical test, odds ratio (OR), and a 95% confidence interval (CI). Of the 67 articles retrieved from the databases, 7 met the eligibility criteria of the systematic review, and 4 had data necessary to perform the meta-analysis. Qualitative analysis revealed that the studies were conducted in the European and Asian continents. The predominant methodological design was the case-control type, and thyroid dysfunctions, hypothyroidism, and Hashimoto thyroiditis occurred more frequently. The meta-analysis showed no association between hypothyroidism and BPPV; however, there was a statistically significant relationship between Hashimoto thyroiditis and BPPV. Conclusion  The meta-analysis results suggest a possible association between BPPV and Hashimoto thyroiditis. Nevertheless, we emphasize the need for further studies to elucidate the evidence obtained.

Frequency dependence of human thresholds: both perceptual and vestibuloocular reflex thresholds

Although perceptual thresholds have been widely studied, vestibuloocular reflex (VOR) thresholds have received less attention, so the relationship between VOR and perceptual thresholds remains unclear. We compared the frequency dependence of human VOR thresholds to human perceptual thresholds for yaw head rotation in both upright ("yaw rotation") and supine ("yaw tilt") positions, using the same human subjects and motion device. VOR thresholds were generally a little smaller than perceptual thresholds. We also found that horizontal VOR thresholds for both yaw rotation about an Earth-vertical axis and yaw tilt (yaw rotation about an Earth-horizontal axis) were relatively constant across four frequencies (0.2, 0.5, 1, and 2 Hz), with little difference between yaw rotation and yaw tilt VOR thresholds. For yaw tilt stimuli, perceptual thresholds were slightly lower at the lowest frequency and nearly constant at all other (higher) frequencies. However, for yaw rotation, perceptual thresholds increased significantly at the lowest frequency (0.2 Hz). We conclude 1) that VOR thresholds were relatively constant across frequency for both yaw rotation and yaw tilt, 2) that the known contributions of velocity storage to the VOR likely yielded these VOR thresholds that were similar for yaw rotation and yaw tilt for all frequencies tested, and 3) that the integration of otolith and horizontal canal signals during yaw tilt when supine contributes to stable perceptual thresholds, especially relative to the low-frequency perceptual thresholds recorded during yaw rotation.NEW & NOTEWORTHY We describe for the first time that human VOR thresholds differ from human forced-choice perceptual thresholds, with the difference especially evident at frequencies below 0.5 Hz. We also report that VOR thresholds are relatively constant across frequency for both yaw rotation and yaw tilt. These findings are consistent with the idea that high-pass filtering in cortical pathways impacts cognitive decision-making.

Postural control in gymnasts: anisotropic fractal scaling reveals proprioceptive reintegration in vestibular perturbation

Dexterous postural control subtly complements movement variability with sensory correlations at many scales. The expressive poise of gymnasts exemplifies this lyrical punctuation of release with constraint, from coarse grain to fine scales. Dexterous postural control upon a 2D support surface might collapse the variation of center of pressure (CoP) to a relatively 1D orientation-a direction often oriented towards the focal point of a visual task. Sensory corrections in dexterous postural control might manifest in temporal correlations, specifically as fractional Brownian motions whose differences are more and less correlated with fractional Gaussian noises (fGns) with progressively larger and smaller Hurst exponent H. Traditional empirical work examines this arrangement of lower-dimensional compression of CoP along two orthogonal axes, anteroposterior (AP) and mediolateral (ML). Eyes-open and face-forward orientations cultivate greater variability along AP than ML axes, and the orthogonal distribution of spatial variability has so far gone hand in hand with an orthogonal distribution of H, for example, larger in AP and lower in ML. However, perturbing the orientation of task focus might destabilize the postural synergy away from its 1D distribution and homogenize the temporal correlations across the 2D support surface, resulting in narrower angles between the directions of the largest and smallest H. We used oriented fractal scaling component analysis (OFSCA) to investigate whether sensory corrections in postural control might thus become suborthogonal. OFSCA models raw 2D CoP trajectory by decomposing it in all directions along the 2D support surface and fits the directions with the largest and smallest H. We studied a sample of gymnasts in eyes-open and face-forward quiet posture, and results from OFSCA confirm that such posture exhibits the classic orthogonal distribution of temporal correlations. Head-turning resulted in a simultaneous decrease in this angle Δθ, which promptly reversed once gymnasts reoriented their heads forward. However, when vision was absent, there was only a discernible negative trend in Δθ, indicating a shift in the angle's direction but not a statistically significant one. Thus, the narrowing of Δθ may signify an adaptive strategy in postural control. The swift recovery of Δθ upon returning to a forward-facing posture suggests that the temporary reduction is specific to head-turning and does not impose a lasting burden on postural control. Turning the head reduced the angle between these two orientations, facilitating the release of postural degrees of freedom towards a more uniform spread of the CoP across both dimensions of the support surface. The innovative aspect of this work is that it shows how fractality might serve as a control parameter of adaptive mechanisms of dexterous postural control.

Psychometrics of inertial heading perception

BACKGROUND

Inertial self-motion perception is thought to depend primarily on otolith cues. Recent evidence demonstrated that vestibular perceptual thresholds (including inertial heading) are adaptable, suggesting novel clinical approaches for treating perceptual impairments resulting from vestibular disease.

OBJECTIVE

Little is known about the psychometric properties of perceptual estimates of inertial heading like test-retest reliability. Here we investigate the psychometric properties of a passive inertial heading perceptual test.

METHODS

Forty-seven healthy subjects participated across two visits, performing in an inertial heading discrimination task. The point of subjective equality (PSE) and thresholds for heading discrimination were identified for the same day and across day tests. Paired t-tests determined if the PSE or thresholds significantly changed and a mixed interclass correlation coefficient (ICC) model examined test-retest reliability. Minimum detectable change (MDC) was calculated for PSE and threshold for heading discrimination.

RESULTS

Within a testing session, the heading discrimination PSE score test-retest reliability was good (ICC = 0. 80) and did not change (t(1,36) = -1.23, p = 0.23). Heading discrimination thresholds were moderately reliable (ICC = 0.67) and also stable (t(1,36) = 0.10, p = 0.92). Across testing sessions, heading direction PSE scores were moderately correlated (ICC = 0.59) and stable (t(1,46) = -0.44, p = 0.66). Heading direction thresholds had poor reliability (ICC = 0.03) and were significantly smaller at the second visit (t(1,46) = 2.8, p = 0.008). MDC for heading direction PSE ranged from 6-9 degrees across tests.

CONCLUSION

The current results indicate moderate reliability for heading perception PSE and provide clinical context for interpreting change in inertial vestibular self-motion perception over time or after an intervention.

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.

Vestibular perceptual testing from lab to clinic: a review

Not all dizziness presents as vertigo, suggesting other perceptual symptoms for individuals with vestibular disease. These non-specific perceptual complaints of dizziness have led to a recent resurgence in literature examining vestibular perceptual testing with the aim to enhance clinical diagnostics and therapeutics. Recent evidence supports incorporating rehabilitation methods to retrain vestibular perception. This review describes the current field of vestibular perceptual testing from scientific laboratory techniques that may not be clinic friendly to some low-tech options that may be more clinic friendly. Limitations are highlighted suggesting directions for additional research.

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.

Increased roll tilt thresholds are associated with subclinical postural instability in asymptomatic adults aged 21 to 84 years

Background

Balance assessments that intentionally alter the reliability of visual and proprioceptive feedback (e.g., standing on foam with eyes closed) have become a standard approach for identifying vestibular mediated balance dysfunction in older adults. However, such assessments cannot discern which specific element of the vestibular system (e.g., semicircular canal, otolith, or combined canal-otolith) underlies the observed age-related changes in balance performance. The present study was designed to determine the associations between specific sources of vestibular noise and quantitative measures of quiet stance postural control measured during standard "vestibular" balance conditions.

Methods

A group of 52 asymptomatic adults (53.21 ± 19.7, 21 to 84 years) without a history of vestibular or neurologic disorders volunteered for this study. We measured a battery of five vestibular perceptual thresholds that assay vestibular noise with predominant contributions from the vertical canals, lateral canals, utricles, saccules, and the centrally integrated canal-otolith signal. In addition, participants completed two standard balance assessments that were each designed to prioritize the use of vestibular cues for quiet stance postural control-eyes closed on foam (Condition 4 of the Modified Romberg Balance Test) and eyes closed, on a sway referenced support surface (Condition 5 of the Sensory Organization Test).

Results

In age adjusted models, we found strong positive associations between roll tilt vestibular thresholds, a measure of noise in the centrally integrated canal-otolith signal, and the root mean square distance (RMSD) of the anteroposterior and mediolateral center of pressure (CoP) captured during eyes closed stance on a sway referenced support surface. The strength of the association between roll tilt thresholds and the RMSD of the CoP was between 3-times and 30-times larger than the association between postural sway and each of the other vestibular thresholds measured.

Conclusion

We posit that noise in the centrally estimated canal-otolith "tilt" signal may be the primary driver of the subclinical postural instability experienced by older adults during the "vestibular" conditions of balance assessments. Additional testing in adults with clinical balance impairment are needed to identify if roll tilt thresholds may also serve as a surrogate metric by which to detect vestibular mediated balance dysfunction and/or fall risk.

Noise and vestibular perception of passive self-motion

Noise defined as random disturbances is ubiquitous in both the external environment and the nervous system. Depending on the context, noise can degrade or improve information processing and performance. In all cases, it contributes to neural systems dynamics. We review some effects of various sources of noise on the neural processing of self-motion signals at different stages of the vestibular pathways and the resulting perceptual responses. Hair cells in the inner ear reduce the impact of noise by means of mechanical and neural filtering. Hair cells synapse on regular and irregular afferents. Variability of discharge (noise) is low in regular afferents and high in irregular units. The high variability of irregular units provides information about the envelope of naturalistic head motion stimuli. A subset of neurons in the vestibular nuclei and thalamus are optimally tuned to noisy motion stimuli that reproduce the statistics of naturalistic head movements. In the thalamus, variability of neural discharge increases with increasing motion amplitude but saturates at high amplitudes, accounting for behavioral violation of Weber's law. In general, the precision of individual vestibular neurons in encoding head motion is worse than the perceptual precision measured behaviorally. However, the global precision predicted by neural population codes matches the high behavioral precision. The latter is estimated by means of psychometric functions for detection or discrimination of whole-body displacements. Vestibular motion thresholds (inverse of precision) reflect the contribution of intrinsic and extrinsic noise to perception. Vestibular motion thresholds tend to deteriorate progressively after the age of 40 years, possibly due to oxidative stress resulting from high discharge rates and metabolic loads of vestibular afferents. In the elderly, vestibular thresholds correlate with postural stability: the higher the threshold, the greater is the postural imbalance and risk of falling. Experimental application of optimal levels of either galvanic noise or whole-body oscillations can ameliorate vestibular function with a mechanism reminiscent of stochastic resonance. Assessment of vestibular thresholds is diagnostic in several types of vestibulopathies, and vestibular stimulation might be useful in vestibular rehabilitation.

Factors influencing clinical outcome in vestibular neuritis - A focussed review and reanalysis of prospective data

Following vestibular neuritis (VN), long term prognosis is not dependent on the magnitude of the residual peripheral function as measured with either caloric or the video head-impulse test. Rather, recovery is determined by a combination of visuo-vestibular (visual dependence), psychological (anxiety) and vestibular perceptual factors. Our recent research in healthy individuals has also revealed a strong association between the degree of lateralisation of vestibulo-cortical processing and gating of vestibular signals, anxiety and visual dependence. In the context of several functional brain changes occurring in the interaction between visual, vestibular and emotional cortices, which underpin the aforementioned psycho-physiological features in patients with VN, we re-examined our previously published findings focusing on additional factors impacting long term clinical outcome and function. These included: (i) the role of concomitant neuro-otological dysfunction (i.e. migraine and benign paroxysmal positional vertigo (BPPV)) and (ii) the degree to which brain lateralisation of vestibulo-cortical processing influences gating of vestibular function in the acute stage. We found that migraine and BPPV interfere with symptomatic recovery following VN. That is, dizziness handicap at short-term recovery stage was significantly predicted by migraine (r = 0.523, n = 28, p = .002), BPPV (r = 0.658, n = 31, p < .001) and acute visual dependency (r = 0.504, n = 28, p = .003). Moreover, dizziness handicap in the long-term recovery stage continued to be predicted by migraine (r = 0.640, n = 22, p = .001), BPPV (r = 0.626, n = 24, p = .001) and acute visual dependency (r = 0.667, n = 22, p < .001). Furthermore, surrogate measures of vestibulo-cortical lateralisation were predictive of the amount of cortical suppression exerted over vestibular thresholds. That is, in right-sided VN patients, we observed a positive correlation between visual dependence and acute ipsilesional oculomotor thresholds (R² 0.497; p < .001), but not contralateral thresholds (R² 0.017: p > .05). In left-sided VN patients, we observed a negative correlation between visual dependence and ipsilesional oculomotor thresholds (R² 0.459; p < .001), but not for contralateral thresholds (R² 0.013; p > .05). To surmise, our findings illustrate that in VN, neuro-otological co-morbidities retard recovery, and that measures of the peripheral vestibular system are an aggregate of residual function and cortically mediated gating of vestibular input.

Induction and Cancellation of Self-Motion Misperception by Asymmetric Rotation in the Light

Asymmetrical sinusoidal whole-body rotation sequences with half-cycles at different velocities induce self-motion misperception. This is due to an adaptive process of the vestibular system that progressively reduces the perception of slow motion and increases that of fast motion. It was found that perceptual responses were conditioned by four previous cycles of asymmetric rotation in the dark, as the perception of self-motion during slow and fast rotations remained altered for several minutes. Surprisingly, this conditioned misperception remained even when asymmetric stimulation was performed in the light, a state in which vision completely cancels out the perceptual error. This suggests that vision is unable to cancel the misadaptation in the vestibular system but corrects it downstream in the central perceptual processing. Interestingly, the internal vestibular perceptual misperception can be cancelled by a sequence of asymmetric rotations with fast/slow half-cycles in a direction opposite to that of the conditioning asymmetric rotations.

Effect of a False Inertial Cue in the Velocity-Storage Circuit on Head Posture and Inertia Perception

The velocity-storage circuit participates in the vestibulopostural reflex, but its role in the postural reflex requires further elucidation. The velocity-storage circuit differentiates gravitoinertial information into gravitational and inertial cues using rotational cues. This implies that a false rotational cue can cause an erroneous estimation of gravity and inertial cues. We hypothesized the velocity-storage circuit is a common gateway for all vestibular reflex pathways and tested that hypothesis by measuring the postural and perceptual responses from a false inertial cue estimated in the velocity-storage circuit. Twenty healthy human participants (40.5 ± 8.2 years old, 6 men) underwent two different sessions of earth-vertical axis rotations at 120°/s for 60 s. During each session, the participants were rotated clockwise and then counterclockwise with two different starting head positions (head-down and head-up). During the first (control) session, the participants kept a steady head position at the end of rotation. During the second (test) session, the participants changed their head position at the end of rotation, from head-down to head-up or vice versa. The head position and inertial motion perception at the end of rotation were aligned with the inertia direction anticipated by the velocity-storage model. The participants showed a significant correlation between postural and perceptual responses. The velocity-storage circuit appears to be a shared neural integrator for the vestibulopostural reflex and vestibular perception. Because the postural responses depended on the inertial direction, the postural instability in vestibular disorders may be the consequence of the vestibulopostural reflex responding to centrally estimated false vestibular cues.SIGNIFICANCE STATEMENT The velocity-storage circuit appears to participate in the vestibulopostural reflex, which stabilizes the head and body position in space. However, it is still unclear whether the velocity-storage circuit for the postural reflex is in common with that involved in eye movement and perception. We evaluated the postural and perceptual responses to a false inertial cue estimated by the velocity-storage circuit. The postural and perceptual responses were consistent with the inertia direction predicted in the velocity-storage model and were correlated closely with each other. These results show that the velocity-storage circuit is a shared neural integrator for vestibular-driven responses and suggest that the vestibulopostural response to a false vestibular cue is the pathomechanism of postural instability clinically observed in vestibular disorders.

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.

Adaptive perceptual responses to asymmetric rotation for testing otolithic function

This study aimed to test the role of the otolithic system in self-motion perception by examining adaptive responses to asymmetric off-axis vertical rotation. Self-movement perception was examined after a conditioning procedure consisting of prolonged asymmetric sinusoidal yaw rotation of the head on a stationary body with hemicycle faster than the other hemicycle. This asymmetric velocity rotation results in a cumulative error in spatial self-motion perception in the upright position that persists over time. Head yaw rotation conditioning was performed in different head positions: in the upright position to activate semicircular canals and in the supine and prone positions to activate both semicircular canals and otoliths with the phase of otolithic stimulation reversed with respect to activation of the semicircular canals. The asymmetric conditioning influenced the cumulative error induced by four asymmetric cycles of whole-body vertical axis yaw rotation. The magnitude of this error depended on the orientation of the head during the conditioning. The error increased by 50% after upright position conditioning, by 100% in the supine position, and decreased by 30% in the prone position. The enhancement and reduction of the perceptual error are attributed to otolithic modulation because of gravity influence of the otoliths during the conditioning procedure in supine and prone positions. These findings indicate that asymmetric velocity otolithic activation induces adaptive perceptual errors such as those induced by semicircular canals alone, and this adaptation may be useful in testing dynamic otolithic perceptual responses under different conditions of vestibular dysfunction.

Electroencephalographic response to transient adaptation of vestibular perception

Abstract

When given a series of sinusoidal oscillations in which the two hemicycles have equal amplitude but asymmetric velocity, healthy subjects lose perception of the slower hemicycle (SHC), reporting a drift towards the faster hemicycle (FHC). This response is not reflected in the vestibular–ocular reflex, suggesting that the adaptation is of higher order. This study aimed to define EEG correlates of this adaptive response. Twenty‐five subjects underwent a series of symmetric or asymmetric oscillations and reported their perceived head orientation at the end using landmarks in the testing room; this was converted into total position error (TPE). Thirty‐two channel EEG was recorded before, during and after adaptation. Spectral power and coherence were calculated for the alpha, beta, delta and theta frequency bands. Linear mixed models were used to determine a region‐by‐condition effect of the adaptation. TPE was significantly greater in the asymmetric condition and reported error was always in the direction of the FHC. Regardless of condition, alpha desynchronised in response to stimulation, then rebounded back toward baseline values. This pattern was accelerated and attenuated in the prefrontal and occipital regions, respectively, in the asymmetric condition. Functional connectivity networks were identified in the beta and delta frequency bands; these networks, primarily comprising frontoparietal connections, were more coherent during asymmetric stimulation. These findings suggest that the temporary vestibulo‐perceptual ‘neglect’ induced by asymmetric vestibular stimulation may be mediated by alpha rhythms and frontoparietal attentional networks. The results presented further our understanding of brain rhythms and cortical networks involved in vestibular perception and adaptation.

Key points

Whole‐body asymmetric sinusoidal oscillations, which consist of hemicycles with equal amplitude but differing velocities, can induce transient ‘neglect’ of the slower hemicycle in the vestibular perception of healthy subjects.

In this study, we aimed to elucidate EEG correlates of this ‘neglect’, thereby identifying a cortical role in vestibular perception and adaptation.

We identified a desynchronisation–resynchronisation response in the alpha frequency band (8–14 Hz) that was accelerated in the prefrontal region and attenuated in the occipital region when exposed to asymmetric, as compared to symmetric, rotations.

We additionally identified functional connectivity networks in the beta (14–30 Hz) and delta (1–4 Hz) frequency bands consisting primarily of frontoparietal connections.

These results suggest a prominent role of alpha rhythms and frontoparietal attentional networks in vestibular perception and adaptation.

Impaired Duration Perception in Patients With Unilateral Vestibulopathy During Whole-Body Rotation

This study aimed to evaluate vestibular perception in patients with unilateral vestibulopathy. We recruited 14 patients (9 women, mean age = 59.3 ± 14.3) with unilateral vestibulopathy during the subacute or chronic stage (disease duration = 6 days to 25 years). For the evaluation of position perception, the patients had to estimate the position after whole-body rotation in the yaw plane. The velocity/acceleration perception was evaluated by acquiring decisions of patients regarding which direction would be the faster rotation after a pair of ipsi- and contra-lesional rotations at various velocity/acceleration settings. The duration perception was assessed by collecting decisions of patients for longer rotation directions at each pair of ipsi- and contra-lesional rotations with various velocities and amplitudes. Patients with unilateral vestibulopathy showed position estimates and velocity/acceleration discriminations comparable to healthy controls. However, in duration discrimination, patients had a contralesional bias such that they had a longer perception period for the healthy side during the equal duration and same amplitude rotations. For the complex duration task, where a longer duration was assigned to a smaller rotation amplitude, the precision was significantly lower in the patient group than in the control group. These results indicate persistent impairments of duration perception in unilateral vestibulopathy and favor the intrinsic and distributed timing mechanism of the vestibular system. Complex perceptual tasks may be helpful to disclose hidden perceptual disturbances in unilateral vestibular hypofunction.

Exploring emotional-modulation of visually evoked postural responses through virtual reality

Exposure to postural threat has been documented to influence the sensory contributions of proprioceptive and vestibular information in standing balance control. Contributions from the visual system to balance are also crucial, yet the degree to which postural threat may modulate visual control of balance is not well characterized. Therefore, the aims of this study were to assess the feasibility of eliciting visual evoked postural responses (VEPRs) using head-mounted virtual reality (VR) and use this method to examine the potential influence of virtual postural threat on the visual control of balance. 36 healthy young adults were exposed to a pseudorandom, translational visual stimulus of a real-world environment in VR. The visual stimulus was presented in virtual conditions of LOW and HIGH postural threat in which participants stood at ground level, and on a 7m elevated platform, respectively. VEPRs were successfully produced in both postural threat conditions. When exposed to the visual stimulus while at an elevated surface height, participants demonstrated significant changes to their physiological arousal and emotional state. Despite significant coherence across the stimulus' frequency range, stimulus correlated VEPRs were not significantly modulated during exposure to the visual stimulus under virtual postural threat. This study supports the future utility of VR head-mounted displays in examining emotional influences on the visual control of balance.

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

Imbalance and dizziness are disabling symptoms for many patients with vestibular schwannomas (VS) but symptom severity typically does not correlate with the vestibulo-ocular reflex (VOR) amplitude-based metrics used to assess peripheral vestibular damage. In this study, we tested the hypothesis that imbalance and dizziness in patients with VS relate to VOR metrics that are not based on response amplitude. Twenty-four patients with unilateral, sporadic VS tumors were studied, and objective (balance) and subjective (dizziness) vestibular dysfunction was quantified. The VOR was tested using two yaw-axis motion stimuli, low-frequency en-bloc sinusoidal, and high-frequency head-on-body impulsive rotations. Imbalance correlated with VOR precision (the inverse of the trial-to-trial variability) and with low-frequency VOR dynamics (quantified with the time constant), and these two metrics were also strongly correlated. Dizziness correlated with the VOR bias caused by an imbalance in static central vestibular tone, but not with dynamic VOR metrics. VOR accuracy (mean response amplitude relative to the ideal response) was not correlated with the severity of imbalance or dizziness or with measures of VOR precision or time constant. Imbalance in patients with VS, therefore, scales with VOR precision and time constant, both of which appear to reflect the central vestibular signal-to-noise ratio, but not with VOR slow-phase accuracy, which is based on the magnitude of the central vestibular signals. Dizziness was related to the presence of a static central tone imbalance but not to any VOR metrics, suggesting that abnormal perception in VS may be affected by factors that are not captured by yaw-axis VOR measurements.NEW & NOTEWORTHY The severity of symptoms associated with unilateral vestibular schwannomas (VS) is poorly correlated with standard yaw-axis vestibulo-ocular reflex (VOR) metrics that are based on response amplitude. In this study, we show that the balance and perceptual dysfunction experienced by patients with VS scales with VOR metrics that capture information about the central signal-to-noise ratio (balance) and central static tone (dizziness), but are not correlated with the VOR gain, which reflects central signal amplitude.

Altered Resting-State Intranetwork and Internetwork Functional Connectivity in Patients With Chronic Unilateral Vestibulopathy

BACKGROUND

Chronic unilateral vestibulopathy (CUVP) is often accompanied by dizziness and postural instability, which restrict patients' daily activities. It is important to understand central compensation mechanisms underlying these symptoms in patients with CUVP by evaluating their brain functional status.

PURPOSE

To analyze the changes in resting-state intranetwork and internetwork functional connectivity (FC) and explore the state of central vestibular compensation in patients with CUVP.

STUDY TYPE

Retrospective.

POPULATION

Eighteen patients with right-sided CUVP and 18 age- and sex-matched healthy controls.

FIELD STRENGTH/SEQUENCE

A 3.0 T, three-dimensional magnetization-prepared rapid gradient-echo (MP-RAGE) and resting-state echo-planar imaging (EPI) functional MRI sequences.

ASSESSMENT

FC alterations were explored using independent component analysis (ICA). Twelve independent components were identified via ICA. Dizziness Handicap Inventory (DHI) score for all patients was determined.

STATISTICAL TESTS

Two-sample t test, family-wise error (FWE) correction, Pearson correlation coefficient (r). A P value <0.05 was considered statistically significant.

RESULTS

Compared with healthy controls, patients with CUVP showed significantly decreased FC in the right middle occipital gyrus within the lateral visual network, and significantly increased FC in the right supplementary motor area within the sensorimotor network. The FC was decreased between the medial visual and auditory networks, the right frontoparietal and posterior default networks, as well as the sensorimotor and auditory networks. There was a significant negative correlation between the FC changes in the visual, auditory networks and the DHI score in patients with CUVP (r = -0.583).

DATA CONCLUSION

Compared to healthy controls, the FC was significantly decreased in the right visual cortex and significantly enhanced in the right sensorimotor network in patients with CUVP. Patients with CUVP showed decreased FC between multiple whole-brain networks, suggesting that abnormal integration of multisensory information may be involved in the occurrence of chronic dizziness and instability in patients with CUVP.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 2.

Subjective visual vertical imprecision during lateral head tilt in patients with chronic dizziness

Most prior studies of the subjective visual vertical (SVV) focus on inaccuracy of subjects' SVV responses with the head in an upright position. Here we investigated SVV imprecision during lateral head tilt in patients with chronic dizziness compared to healthy controls. Forty-five dizzy patients and 45 healthy controls underwent SVV testing wearing virtual reality (VR) goggles, sitting upright (0°) and during head tilt in the roll plane (± 30°). Ten trials were completed in each of three static head positions. The SVV inaccuracy and SVV imprecision were analyzed and compared between groups, along with systematic errors during head tilt, i.e., A-effect and E-effect (E-effect is a typical SVV response during head tilts of ± 30°). The SVV imprecision was found to be affected by head position (upright/right head tilt/left head tilt, p < 0.001) and underlying dizziness (dizzy patients/healthy controls, p = 0.005). The SVV imprecision during left head tilt was greater in dizzy patients compared to healthy controls (p = 0.04). With right head tilt, there was a trend towards greater SVV imprecision in dizzy patients (p = 0.08). Dizzy patients were more likely to have bilateral (6.7%) or unilateral (22.2%) A-effect during lateral head tilt than healthy controls (bilateral (0%) or unilateral (6.7%) A-effect, p < 0.01). Greater SVV imprecision in chronically dizzy patients during head tilts may be attributable to increased noise of vestibular sensory afferents or disturbances of multisensory integration. Our findings suggest that SVV imprecision may be a useful clinical parameter of underlying dizziness measurable with bedside SVV testing in VR.

Vestibular Precision at the Level of Perception, Eye Movements, Posture, and Neurons

Precision and accuracy are two fundamental properties of any system, including the nervous system. Reduced precision (i.e., imprecision) results from the presence of neural noise at each level of sensory, motor, and perceptual processing. This review has three objectives: (1) to show the importance of studying vestibular precision, and specifically that studying accuracy without studying precision ignores fundamental aspects of the vestibular system; (2) to synthesize key hypotheses about precision in vestibular perception, the vestibulo-ocular reflex, posture, and neurons; and (3) to show that groups of studies that are thoughts to be distinct (e.g., perceptual thresholds, subjective visual vertical variability, neuronal variability) are actually "two sides of the same coin" - because the methods used allow results to be related to the standard deviation of a Gaussian distribution describing the underlying neural noise. Vestibular precision varies with age, stimulus amplitude, stimulus frequency, body orientation, motion direction, pathology, medication, and electrical/mechanical vestibular stimulation, but does not vary with sex. The brain optimizes precision during integration of vestibular cues with visual, auditory, and/or somatosensory cues. Since a common concern with precision metrics is time required for testing, we describe approaches to optimize data collection and provide evidence that fatigue and session effects are minimal. Finally, we summarize how precision is an individual trait that is correlated with clinical outcomes in patients as well as with performance in functional tasks like balance. These findings highlight the importance of studying vestibular precision and accuracy, and that knowledge gaps remain.

New Frontiers in Managing the Dizzy Patient

Despite progress in vestibular research in the last 20 years, much remains poorly understood about vestibular pathophysiology and its management. A shared language is a critical first step in understanding vestibular disorders and is under development. Telehealth will continue for patients with dizziness, and ambulatory monitoring of nystagmus will become a diagnostic tool. In the next 2 decades, it is anticipated that vestibular perceptual threshold testing will become common in tertiary centers, imaging with improved spatial resolution will yield better understanding of vestibular pathophysiology, and that vestibular implants will become a part of clinical practice.

Bilateral vestibulopathy decreases self-motion perception

Objective

Current diagnostic criteria for bilateral vestibulopathy (BV) primarily involve measurements of vestibular reflexes. Perceptual self-motion thresholds however, are not routinely measured and their clinical value in this specific population is not yet fully determined. Objectives of this study were (1) to compare perceptual self-motion thresholds between BV patients and control subjects, and (2) to explore patterns of self-motion perception performance and vestibular function in BV patients.

Methods

Thirty-seven BV patients and 34 control subjects were included in this study. Perceptual self-motion thresholds were measured in both groups using a CAREN platform (Motek Medical BV, Amsterdam, The Netherlands). Vestibular function was evaluated (only in BV patients) by the caloric test, torsion swing test, video head impulse test of all semicircular canals, and cervical- and ocular vestibular-evoked myogenic potentials. Differences in thresholds between both groups were analyzed. Hierarchical cluster analysis was performed to visualize patterns between self-motion perception and vestibular function within the group of BV patients.

Results

Perceptual self-motion thresholds were significantly higher in BV patients compared to control subjects, regarding nearly all rotations and translations (depending on the age group) (p ≤ 0.001). Cluster analysis showed that within the group of BV patients, higher perceptual self-motion thresholds were generally associated with lower vestibular test results (significant for yaw rotation, caloric test, torsion swing test, and video head impulse test (p ≤ 0.001)).

Conclusion

Self-motion perception is significantly decreased in BV patients compared to control subjects regarding nearly all rotations and translations. Furthermore, decreased self-motion perception is generally associated with lower residual vestibular function in BV patients.

Trial registration

Trial registration number NL52768.068.15/METC

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10695-3.

Disruption of self-motion perception without vestibular reflex alteration in ménière's disease

BACKGROUND

Self-motion misperception has been observed in vestibular patients during asymmetric body oscillations. This misperception is correlated with the patient's vestibular discomfort.

OBJECTIVE

To investigate whether or not self-motion misperception persists in post-ictal patients with Ménière's disease (MD).

METHODS

Twenty-eight MD patients were investigated while in the post-ictal interval. Self-motion perception was studied by examining the displacement of a memorized visual target after sequences of opposite directed fast-slow asymmetric whole body rotations in the dark. The difference in target representation was analyzed and correlated with the Dizziness Handicap Inventory (DHI) score. The vestibulo-ocular reflex (VOR) and clinical tests for ocular reflex were also evaluated.

RESULTS

All MD patients showed a noticeable difference in target representation after asymmetric rotation depending on the direction of the fast/slow rotations. This side difference suggests disruption of motion perception. The DHI score was correlated with the amount of motion misperception. In contrast, VOR and clinical trials were altered in only half of these patients.

CONCLUSIONS

Asymmetric rotation reveals disruption of self-motion perception in MD patients during the post-ictal interval, even in the absence of ocular reflex impairment. Motion misperception may cause persistent vestibular discomfort in these patients.

Vestibular Thresholds: A Review of Advances and Challenges in Clinical Applications

Vestibular disorders pose a substantial burden on the healthcare system due to a high prevalence and the severity of symptoms. Currently, a large portion of patients experiencing vestibular symptoms receive an ambiguous diagnosis or one that is based solely on history, unconfirmed by any objective measures. As patients primarily experience perceptual symptoms (e.g., dizziness), recent studies have investigated the use of vestibular perceptual thresholds, a quantitative measure of vestibular perception, in clinical populations. This review provides an overview of vestibular perceptual thresholds and the current literature assessing use in clinical populations as a potential diagnostic tool. Patients with peripheral and central vestibular pathologies, including bilateral vestibulopathy and vestibular migraine, show characteristic changes in vestibular thresholds. Vestibular perceptual thresholds have also been found to detect subtle, sub-clinical declines in vestibular function in asymptomatic older adults, suggesting a potential use of vestibular thresholds to augment or complement existing diagnostic methods in multiple populations. Vestibular thresholds are a reliable, sensitive, and specific assay of vestibular precision, however, continued research is needed to better understand the possible applications and limitations, especially with regard to the diagnosis of vestibular disorders.

Cathodal Transcranial Direct Current Stimulation Over the Right Temporoparietal Junction Suppresses Its Functional Connectivity and Reduces Contralateral Spatial and Temporal Perception

The temporoparietal junction plays key roles in vestibular function, motor-sensory ability, and attitude stability. Conventional approaches to studying the temporoparietal junction have drawbacks, and previous studies have focused on self-motion rather than on vestibular spatial perception. Using transcranial direct current stimulation, we explored the temporoparietal junction’s effects on vestibular-guided orientation for self-motion and vestibular spatial perception. Twenty participants underwent position, motion, and time tasks, as well as functional magnetic resonance imaging scans. In the position task, cathodal transcranial direct current stimulation yielded a significantly lower response in the −6, −7, −8, −9, −10, −11, and −12 stimulus conditions for leftward rotations (P < 0.05). In the time task, the temporal bias for real transcranial direct current stimulation significantly differed from that for sham stimulation (P < 0.01). Functional magnetic resonance imaging showed that cathodal transcranial direct current stimulation suppressed functional connectivity between the temporoparietal junction, right insular cortex, and right supplementary motor area. Moreover, the change in connectivity between the right temporoparietal junction seed and the right insular cortex was positively correlated with temporal bias under stimulation. The above mentioned results show that cathodal transcranial direct current stimulation induces immediate and extended vestibular effects, which could suppress the functional connectivity of the temporoparietal junction and in turn reduce contralateral spatial and temporal perception. The consistent variation in temporal and spatial bias suggested that the temporoparietal junction may be the cortical temporal integrator for the internal model. Moreover, transcranial direct current stimulation could modulate the integration process and may thus have potential clinical applications in vestibular disorders caused by temporoparietal junction dysfunction.

Proprioception and the predictive sensing of active self-motion

As we actively explore the environment, our motion relative to the world stimulates numerous sensory systems. Notably, proprioceptors provide feedback about body and limb position, while the vestibular system detects and encodes head motion. When the vestibular system is functioning normally, we are unaware of a distinct sensation because vestibular information is integrated with proprioceptive and other sensory inputs to generate our sense of motion. However, patients with vestibular sensory loss experience impairments that provide important insights into the function of this essential sensory system. For these patients, everyday activities such as walking become difficult because even small head movements can produce postural and perceptual instability. This review describes recent research demonstrating how the proprioceptive and vestibular systems effectively work together to provide us with our “6^th sense” during everyday activities, and in particular considers the neural computations underlying the brain’s predictive sensing of head movement during voluntary self-motion.

Pathophysiological dissociation of the interaction between time pressure and trait anxiety during spatial orientation judgments

Spatial orientation is achieved by integrating visual, vestibular and proprioceptive cues. Individuals that rely strongly upon visual cues to facilitate spatial orientation are termed visually dependent. Heightened visual reliance commonly occurs in patients following vestibular dysfunction and can influence clinical outcome. Additionally, psychological factors, including anxiety, are associated with poorer clinical outcome following vestibular dysfunction. Given that visual dependency measures are affected by psychological and contextual influences, such as time pressure, we investigated the interaction between time pressure and anxiety upon visual dependency in healthy controls and vestibular migraine patients. Visual dependency was assessed using a "Rod and Disk" task at baseline and under time pressure (3 s to complete the task). Non-situational (trait) and situational (state) anxiety levels were quantified using the Spielberg State-Trait Anxiety Inventory. We calculated the change in visual dependency (VD) [∆VD = VD_{time pressure}  - VD_baseline ] and correlated it with participants' trait anxiety scores. We observed a significant negative correlation between trait anxiety and the change in VD (R²  = .393, p < .001) in healthy controls and a positive correlation in dizzy patients (R²  = .317, p < .001). That is, healthy individuals that were more anxious became less visually dependent under time pressure (i.e., more accurate), whereas less anxious individuals became more visually dependent. The reverse was observed in vestibular migraine patients. Our results illustrate that anxiety can differentially modulate task performance during spatial orientation judgements under time pressure in healthy individuals and dizzy patients. These findings have potential implications for individualised patient rehabilitation therapies.

The "broken escalator" phenomenon: Vestibular dizziness interferes with locomotor adaptation

BACKGROUND

Although vestibular lesions degrade postural control we do not know the relative contributions of the magnitude of the vestibular loss and subjective vestibular symptoms to locomotor adaptation.

OBJECTIVE

To study how dizzy symptoms interfere with adaptive locomotor learning.

METHODS

We examined patients with contrasting peripheral vestibular deficits, vestibular neuritis in the chronic stable phase (n = 20) and strongly symptomatic unilateral Meniere's disease (n = 15), compared to age-matched healthy controls (n = 15). We measured locomotor adaptive learning using the "broken escalator" aftereffect, simulated on a motorised moving sled.

RESULTS

Patients with Meniere's disease had an enhanced "broken escalator" postural aftereffect. More generally, the size of the locomotor aftereffect was related to how symptomatic patients were across both groups. Contrastingly, the degree of peripheral vestibular loss was not correlated with symptom load or locomotor aftereffect size. During the MOVING trials, both patient groups had larger levels of instability (trunk sway) and reduced adaptation than normal controls.

CONCLUSION

Dizziness symptoms influence locomotor adaptation and its subsequent expression through motor aftereffects. Given that the unsteadiness experienced during the "broken escalator" paradigm is internally driven, the enhanced aftereffect found represents a new type of self-generated postural challenge for vestibular/unsteady patients.

Cerebellar ataxia, neuropathy, vestibular areflexia syndrome due to RFC1 repeat expansion

Ataxia, causing imbalance, dizziness and falls, is a leading cause of neurological disability. We have recently identified a biallelic intronic AAGGG repeat expansion in replication factor complex subunit 1 (RFC1) as the cause of cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS) and a major cause of late onset ataxia. Here we describe the full spectrum of the disease phenotype in our first 100 genetically confirmed carriers of biallelic repeat expansions in RFC1 and identify the sensory neuropathy as a common feature in all cases to date. All patients were Caucasian and half were sporadic. Patients typically reported progressive unsteadiness starting in the sixth decade. A dry spasmodic cough was also frequently associated and often preceded by decades the onset of walking difficulty. Sensory symptoms, oscillopsia, dysautonomia and dysarthria were also variably associated. The disease seems to follow a pattern of spatial progression from the early involvement of sensory neurons, to the later appearance of vestibular and cerebellar dysfunction. Half of the patients needed walking aids after 10 years of disease duration and a quarter were wheelchair dependent after 15 years. Overall, two-thirds of cases had full CANVAS. Sensory neuropathy was the only manifestation in 15 patients. Sixteen patients additionally showed cerebellar involvement, and six showed vestibular involvement. The disease is very likely to be underdiagnosed. Repeat expansion in RFC1 should be considered in all cases of sensory ataxic neuropathy, particularly, but not only, if cerebellar dysfunction, vestibular involvement and cough coexist.

Abnormal visuo-vestibular interactions in vestibular migraine: a cross sectional study

Vestibular migraine is among the commonest causes of episodic vertigo. Chronically, patients with vestibular migraine develop abnormal responsiveness to both vestibular and visual stimuli characterized by heightened self-motion sensitivity and visually-induced dizziness. Yet, the neural mechanisms mediating such symptoms remain unknown. We postulate that such symptoms are attributable to impaired visuo-vestibular cortical interactions, which in turn disrupts normal vestibular function. To assess this, we investigated whether prolonged, full-field visual motion exposure, which has been previously shown to modulate visual cortical excitability in both healthy individuals and avestibular patients, could disrupt vestibular ocular reflex and vestibular-perceptual thresholds of self-motion during rotations. Our findings reveal that vestibular migraine patients exhibited abnormally elevated reflexive and perceptual vestibular thresholds at baseline. Following visual motion exposure, both reflex and perceptual thresholds were significantly further increased in vestibular migraine patients relative to healthy controls, migraineurs without vestibular symptoms and patients with episodic vertigo due to a peripheral inner-ear disorder. Our results provide support for the notion of altered visuo-vestibular cortical interactions in vestibular migraine, as evidenced by vestibular threshold elevation following visual motion exposure.

Perception of threshold-level whole-body motion during mechanical mastoid vibration

BACKGROUND

Vibration applied on the mastoid has been shown to be an excitatory stimulus to the vestibular receptors, but its effect on vestibular perception is unknown.

OBJECTIVE

Determine whether mastoid vibration affects yaw rotation perception using a self-motion perceptual direction-recognition task.

METHODS

We used continuous, bilateral, mechanical mastoid vibration using a stimulus with frequency content between 1 and 500 Hz. Vestibular perception of 10 healthy adults (M±S.D. = 34.3±12 years old) was tested with and without vibration. Subjects repeatedly reported the perceived direction of threshold-level yaw rotations administered at 1 Hz by a motorized platform. A cumulative Gaussian distribution function was fit to subjects' responses, which was described by two parameters: bias and threshold. Bias was defined as the mean of the Gaussian distribution, and equal to the motion perceived on average when exposed to null stimuli. Threshold was defined as the standard deviation of the distribution and corresponded to the stimulus the subject could reliably perceive.

RESULTS

The results show that mastoid vibration may reduce bias, although two statistical tests yield different conclusions. There was no evidence that yaw rotation thresholds were affected.

CONCLUSIONS

Bilateral mastoid vibration may reduce left-right asymmetry in motion perception.

Intralabyrinthine Schwannoma: Distinct Features for Differential Diagnosis

Objectives: The aim of this study was to delineate the clinical and laboratory features suggestive of intralabyrinthine schwannoma (ILS). Methods: We compared the clinical features of 16 patients with ILS, who had been diagnosed at the Seoul National University Bundang Hospital from 2003 to 2018, with those of 18 patients with symptomatic unilateral intracanalicular schwannoma and randomly selected 20 patients with definite or probable unilateral Meniere's disease (MD). Results: Patients with ILS presented with either recurrent spontaneous dizziness/vertigo combined with auditory symptoms (n = 8), isolated auditory symptoms without dizziness/vertigo (n = 7), or recurrent spontaneous dizziness/vertigo without auditory symptoms (n = 1). Most patients reported no improvement (n = 11) or worsening (n = 1) of the symptoms despite medical treatments including intratympanic (n = 5) or intravenous steroids (n = 2). Conventional brain MRIs failed to detect ILS in about a half of the patients (7/16, 44%). However, ILS showed a filling defect on 3-dimensional (3D) heavily T2-weighted MRIs (n = 12), and nodular enhancement on 3D contrast-enhanced T1 (n = 15) or FLAIR MRIs (n = 13) targeted for the inner ear. Compared to MD or intracanalicular schwannoma, ILS showed mostly abnormal head-impulse tests (HITs, p = 0.001). In contrast, the incidence of canal paresis did not differ among the groups (p = 0.513). Conclusion: ILS may mimic MD by presenting recurrent dizziness/vertigo and auditory symptoms. ILS should be suspected in patients with recurrent audiovestibulopathy especially when (1) the duration of the dizziness is not typical for MD, (2) the patients do not respond to medical treatments, or (3) HITs are abnormal.

Subjective stability perception is related to postural anxiety in older subjects

BACKGROUND

Under static conditions, the objective and subjective measures of postural stability correlate well. However, age-related changes in postural control and task-related anxiety may modify the relationship between these subjective and objective measures. Ultimately, patients' symptoms represent subjective reports, thus understanding this relationship has clinical implications.

AIMS

This study investigates the relationship between subjective-objective measures of postural stability in dynamic conditions and whether this relationship is influenced by age or task-related anxiety.

METHODS

50 healthy participants (aged 18-83 years) stood on a platform oscillating at variable amplitudes, with-without a fall-preventing harness to modulate task-related anxiety. Trunk sway path, hip velocity and foot lifts (objective measures) and subjective scores of instability and task-related anxiety were recorded.

RESULTS

The subjective perception of stability accurately matched objective body sway, following a logarithmic function profile (r² = 0.72, p < 0.001). This function did not change significantly with age, harness or task presentation order. A strong relationship was observed between subjective measures of stability and task-related anxiety for all subjects (r = 0.81, p < 0.001). Task repetition reduced anxiety in the young, uncoupling anxiety changes from subjective instability, but not in the elderly who retained higher anxiety levels in line with subjective unsteadiness.

DISCUSSION

Subjects accurately rate their own instability during dynamic postural challenges, irrespective of age and actual fall risk. However, anxiety may selectively modulate the perception of instability in older subjects. The perception of stability relies upon the integration of sensory afferents but also recruits emotional-cognitive processes, particularly in older individuals. The use of a safety harness has no influence on subjective or objective postural stability.

An fMRI study of visuo-vestibular interactions following vestibular neuritis

Vestibular neuritis (VN) is characterised by acute vertigo due to a sudden loss of unilateral vestibular function. A considerable proportion of VN patients proceed to develop chronic symptoms of dizziness, including visually induced dizziness, specifically during head turns. Here we investigated whether the development of such poor clinical outcomes following VN, is associated with abnormal visuo-vestibular cortical processing. Accordingly, we applied functional magnetic resonance imaging to assess brain responses of chronic VN patients and compared these to controls during both congruent (co-directional) and incongruent (opposite directions) visuo-vestibular stimulation (i.e. emulating situations that provoke symptoms in patients). We observed a focal significant difference in BOLD signal in the primary visual cortex V1 between patients and controls in the congruent condition (small volume corrected level of p < .05 FWE). Importantly, this reduced BOLD signal in V1 was negatively correlated with functional status measured with validated clinical questionnaires. Our findings suggest that central compensation and in turn clinical outcomes in VN are partly mediated by adaptive mechanisms associated with the early visual cortex.

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VN clinical status related to V1 response to congruent visuo-vestibular stimuli

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Reduced V1 BOLD signal during congruent stimulation correlates with subjective dizziness scores

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No association between V1 BOLD signal and incongruent visuo-vestibular stimulation

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Changes in V1 activity may reflect cortical adaptive mechanisms following VN

Variability in the Vestibulo-Ocular Reflex and Vestibular Perception

The vestibular system enables humans to estimate self-motion, stabilize gaze and maintain posture, but these behaviors are impacted by neural noise at all levels of processing (e.g., sensory, central, motor). Despite its essential importance, the behavioral impact of noise in human vestibular pathways is not completely understood. Here, we characterize the vestibular imprecision that results from neural noise by measuring trial-to-trial vestibulo-ocular reflex (VOR) variability and perceptual just-noticeable differences (JNDs) in the same human subjects as a function of stimulus intensity. We used head-centered yaw rotations about an Earth-vertical axis over a broad range of motion velocities (0-65°/s for VOR variability and 3-90°/s peak velocity for JNDs). We found that VOR variability increased from approximately 0.6°/s at a chair velocity of 1°/s to approximately 3°/s at 65°/s; it exhibited a stimulus-independent range below roughly 1°/s. Perceptual imprecision ("sigma") increased from 0.76°/s at 3°/s to 4.7°/s at 90°/s. Using stimuli that manipulated the relationship between velocity, displacement and acceleration, we found that velocity was the salient cue for VOR variability for our motion stimuli. VOR and perceptual imprecision both increased with stimulus intensity and were broadly similar over a range of stimulus velocities, consistent with a common noise source that affects motor and perceptual pathways. This contrasts with differing perceptual and motor stimulus-dependent imprecision in visual studies. Either stimulus-dependent noise or non-linear signal processing could explain our results, but we argue that afferent non-linearities alone are unlikely to be the source of the observed behavioral stimulus-dependent imprecision.

Vestibulo-cortical hemispheric dominance: The link between anxiety and the vestibular system?

Vestibular processing and anxiety networks are functionally intertwined, as demonstrated by reports of reciprocal influences upon each other. Yet whether there is an underlying link between these two systems remains unknown. Previous findings have highlighted the involvement of hemispheric lateralisation in processing of both anxiety and vestibular signals. Accordingly, we explored the interaction between vestibular cortical processing and anxiety by assessing the relationship between anxiety levels and the degree of hemispheric lateralisation of vestibulo-cortical processing in 64 right-handed, healthy individuals. Vestibulo-cortical hemispheric lateralisation was determined by gaging the degree of caloric-induced nystagmus suppression following modulation of cortical excitability using trans-cranial direct current stimulation targeted over the posterior parietal cortex, an area implicated in the processing of vestibular signals. The degree of nystagmus suppression yields an objective biomarker, allowing the quantification of the degree of right vestibulo-cortical hemisphere dominance. Anxiety levels were quantified using the Trait component of the Spielberger State-Trait Anxiety Questionnaire. Our findings demonstrate that the degree of an individual's vestibulo-cortical hemispheric dominance correlates with their anxiety levels. That is, those individuals with greater right hemispheric vestibulo-cortical dominance exhibited lower levels of anxiety. By extension, our results support the notion that hemispheric lateralisation determines an individual's emotional processing, thereby linking cortical circuits involved in processing anxiety and vestibular signals, respectively.

Neuronal network-based mathematical modeling of perceived verticality in acute unilateral vestibular lesions: from nerve to thalamus and cortex

Acute unilateral lesions of vestibular graviceptive pathways from the otolith organs and semicircular canals via vestibular nuclei and the thalamus to the parieto-insular vestibular cortex regularly cause deviations of perceived verticality in the frontal roll plane. These tilts are ipsilateral in peripheral and in ponto-medullary lesions and contralateral in ponto-mesencephalic lesions. Unilateral lesions of the vestibular thalamus or cortex cause smaller tilts of the perceived vertical, which may be either ipsilateral or contralateral. Using a neural network model, we previously explained why unilateral vestibular midbrain lesions rarely manifest with rotational vertigo. We here extend this approach, focussing on the direction-specific deviations of perceived verticality in the roll plane caused by acute unilateral vestibular lesions from the labyrinth to the cortex. Traditionally, the effect of unilateral peripheral lesions on perceived verticality has been attributed to a lesion-based bias of the otolith system. We here suggest, on the basis of a comparison of model simulations with patient data, that perceived visual tilt after peripheral lesions is caused by the effect of a torsional semicircular canal bias on the central gravity estimator. We further argue that the change of gravity coding from a peripheral/brainstem vectorial representation in otolith coordinates to a distributed population coding at thalamic and cortical levels can explain why unilateral thalamic and cortical lesions have a variable effect on perceived verticality. Finally, we propose how the population-coding network for gravity direction might implement the elements required for the well-known perceptual underestimation of the subjective visual vertical in tilted body positions.

Why acute unilateral vestibular midbrain lesions rarely manifest with rotational vertigo: a clinical and modelling approach to head direction cell function

A retrospective clinical study focused on the frequency of rotational vertigo in 63 patients with acute unilateral midbrain strokes involving the vestibular and ocular motor systems. In contrast to unilateral pontomedullary brainstem lesions, rotational vertigo in midbrain lesions occurred with a low frequency (14%) and transient (< 1 day) course. Swaying vertigo or unspecific dizziness (22%) and postural imbalance (31%) were more frequent. Midbrain strokes with transient rotational vertigo manifested with lesions chiefly in the caudal midbrain tegmentum, while manifestations with swaying, unspecific, or no vertigo chiefly occurred in rostral mesencephalic or meso-diencephalic lesions. We hypothesize that these different manifestations can be explained by the distribution of two separate cell systems based on semicircular canal function: the angular head-velocity cells and the head direction cells, both of which code for head rotation. Animal experiments have shown that angular head-velocity cells are located mainly in the lower brainstem up to the midbrain, whereas the head direction cells are found from the midbrain and thalamic level up to cortical regions. Due to the differences in coding, unilateral dysfunction of the angular velocity cell system should result in the sensation of rotation, while unilateral dysfunction of the head direction cell system should result in dizziness and unsteadiness. We simulated the different manifestations of vestibular dysfunction using a mathematical neural network model of the head direction cell system. This model predicted and confirmed our clinical findings that unilateral caudal and rostral brainstem lesions have different effects on vestibular function.

Bayesian optimal adaptation explains age-related human sensorimotor changes

The brain uses information from different sensory systems to guide motor behavior, and aging is associated with simultaneous decline in the quality of sensory information provided to the brain and deterioration in motor control. Correlations between age-dependent decline in sensory anatomical structures and behavior have been demonstrated in many sensorimotor systems, and it has recently been suggested that a Bayesian framework could explain these relationships. Here we show that age-dependent changes in a human sensorimotor reflex, the vestibuloocular reflex, are explained by a Bayesian optimal adaptation in the brain occurring in response to death of motion-sensing hair cells. Specifically, we found that the temporal dynamics of the reflex as a function of age emerge from ( r = 0.93, P < 0.001) a Kalman filter model that determines the optimal behavioral output when the sensory signal-to-noise characteristics are degraded by death of the transducers. These findings demonstrate that the aging brain is capable of generating the ideal and statistically optimal behavioral response when provided with deteriorating sensory information. While the Bayesian framework has been shown to be a general neural principle for multimodal sensory integration and dynamic sensory estimation, these findings provide evidence of longitudinal Bayesian processing over the human life span. These results illuminate how the aging brain strives to optimize motor behavior when faced with deterioration in the peripheral and central nervous systems and have implications in the field of vestibular and balance disorders, as they will likely provide guidance for physical therapy and for prosthetic aids that aim to reduce falls in the elderly. NEW & NOTEWORTHY We showed that age-dependent changes in the vestibuloocular reflex are explained by a Bayesian optimal adaptation in the brain that occurs in response to age-dependent sensory anatomical changes. This demonstrates that the brain can longitudinally respond to age-related sensory loss in an ideal and statistically optimal way. This has implications for understanding and treating vestibular disorders caused by aging and provides insight into the structure-function relationship during aging.

Asymmetric vestibular stimulation reveals persistent disruption of motion perception in unilateral vestibular lesions

Self-motion perception was studied in patients with unilateral vestibular lesions (UVL) due to acute vestibular neuritis at 1 wk and 4, 8, and 12 mo after the acute episode. We assessed vestibularly mediated self-motion perception by measuring the error in reproducing the position of a remembered visual target at the end of four cycles of asymmetric whole-body rotation. The oscillatory stimulus consists of a slow (0.09 Hz) and a fast (0.38 Hz) half cycle. A large error was present in UVL patients when the slow half cycle was delivered toward the lesion side, but minimal toward the healthy side. This asymmetry diminished over time, but it remained abnormally large at 12 mo. In contrast, vestibulo-ocular reflex responses showed a large direction-dependent error only initially, then they normalized. Normalization also occurred for conventional reflex vestibular measures (caloric tests, subjective visual vertical, and head shaking nystagmus) and for perceptual function during symmetric rotation. Vestibular-related handicap, measured with the Dizziness Handicap Inventory (DHI) at 12 mo correlated with self-motion perception asymmetry but not with abnormalities in vestibulo-ocular function. We conclude that 1) a persistent self-motion perceptual bias is revealed by asymmetric rotation in UVLs despite vestibulo-ocular function becoming symmetric over time, 2) this dissociation is caused by differential perceptual-reflex adaptation to high- and low-frequency rotations when these are combined as with our asymmetric stimulus, 3) the findings imply differential central compensation for vestibuloperceptual and vestibulo-ocular reflex functions, and 4) self-motion perception disruption may mediate long-term vestibular-related handicap in UVL patients.

NEW & NOTEWORTHY A novel vestibular stimulus, combining asymmetric slow and fast sinusoidal half cycles, revealed persistent vestibuloperceptual dysfunction in unilateral vestibular lesion (UVL) patients. The compensation of motion perception after UVL was slower than that of vestibulo-ocular reflex. Perceptual but not vestibulo-ocular reflex deficits correlated with dizziness-related handicap.

Effects of vestibular disorders on vestibular reflex and imagery

The aim of this study was to establish the effect of vestibular lesion on vestibular imagery. Subjects were required to estimate verbally their passively travelled rotation angles in complete darkness, i.e., to activate vestibular imagery. During motion, the vestibulo-ocular reflex (VOR) was measured. Thus, we examined the coherence between the vestibulo-ocular reflex and self-rotation imagery, with vestibular-lesioned patients and healthy participants. Unilateral acute and chronic patients, bilateral patients, and healthy subjects were compared. The stimulus was a sequence of eight successive passive rotations, with four amplitudes (from 90° to 360°) in two directions. The VOR gain was lower in patients with unilateral lesions, for ipsilateral rotations. The healthy subjects had the highest gain and the bilateral group the lowest, on both rotation sides. Thanks to vestibular compensation after acute unilateral neuritis, the VOR gain increased in lesion side and decreased in healthy side, resulting in a similar gain in both sides. A deficit of vestibular imagery was found exclusively in patients with bilateral hyporeflexia, on both sides. The performance in vestibular imagery was good in the control group and correct in the unilateral patients. Finally, we found a significant correlation between the efficiency of the VOR and that of vestibular imagery, exclusively in the bilateral patients. The present study shows the complex relationship between vestibular imagery and the VOR. This imagery test contributes to another assessment of the spatial handicap of vestibular patients. It seems particularly interesting for patients with bilateral canal paresis and could be used to confirm this diagnosis.

Predictors of clinical recovery from vestibular neuritis: a prospective study

We sought to identify predictors of symptomatic recovery in vestibular neuritis. Forty VN patients were prospectively studied in the acute phase (median = 2 days) and 32 in the recovery phase (median = 10 weeks) with vestibulo‐ocular reflex, vestibular‐perceptual, and visual dependence tests and psychological questionnaires. Clinical outcome was Dizziness Handicap Inventory score at recovery phase. Acute visual dependency and autonomic arousal predicted outcome. Worse recovery was associated with a combination of increased visual dependence, autonomic arousal, anxiety/depression, and fear of bodily sensations, but not with vestibular variables. Findings highlight the importance of early identification of abnormal visual dependency and concurrent anxiety.

Vestibular implants studied in animal models: clinical and scientific implications

Damage to the peripheral vestibular system can result in debilitating postural, perceptual, and visual symptoms. A potential new treatment for this clinical problem is to replace some aspects of peripheral vestibular function with an implant that senses head motion and provides this information to the brain by stimulating branches of the vestibular nerve. In this review I consider animal studies performed at our institution over the past 15 years, which have helped elucidate how the brain processes information provided by a vestibular (semicircular canal) implant and how this information could be used to improve the problems experienced by patients with peripheral vestibular damage.