Perception of Verticality and Vestibular Disorders of Balance and Falls.

Marianne Dieterich,Thomas Brandt

doi:10.3389/fneur.2019.00172

Abstract

Objective: To review current knowledge of the perception of verticality, its normal function and disorders. This is based on an integrative graviceptive input from the vertical semicircular canals and the otolith organs.Methods: The special focus is on human psychophysics, neurophysiological and imaging data on the adjustments of subjective visual vertical (SVV) and the subjective postural vertical. Furthermore, examples of mathematical modeling of specific vestibular cell functions for orientation in space in rodents and in patients are briefly presented.Results: Pathological tilts of the SVV in the roll plane are most sensitive and frequent clinical vestibular signs of unilateral lesions extending from the labyrinths via the brainstem and thalamus to the parieto-insular vestibular cortex. Due to crossings of ascending graviceptive fibers, peripheral vestibular and pontomedullary lesions cause ipsilateral tilts of the SVV; ponto-mesencephalic lesions cause contralateral tilts. In contrast, SVV tilts, which are measured in unilateral vestibular lesions at thalamic and cortical levels, have two different characteristic features: (i) they may be ipsi- or contralateral, and (ii) they are smaller than those found in lower brainstem or peripheral lesions. Motor signs such as head tilt and body lateropulsion, components of ocular tilt reaction, are typical for vestibular lesions of the peripheral vestibular organ and the pontomedullary brainstem (vestibular nucleus). They are less frequent in midbrain lesions (interstitial nucleus of Cajal) and rare in cortical lesions. Isolated body lateropulsion is chiefly found in caudal lateral medullary brainstem lesions. Vestibular function in the roll plane and its disorders can be mathematically modeled by an attractor model of angular head velocity cell and head direction cell function. Disorders manifesting with misperception of the body vertical are the pusher syndrome, the progressive supranuclear palsy, or the normal pressure hydrocephalus; they may affect roll and/or pitch plane.Conclusion: Clinical determinations of the SVV are easy and reliable. They indicate acute unilateral vestibular dysfunctions, the causative lesion of which extends from labyrinth to cortex. They allow precise topographical diagnosis of side and level in unilateral brainstem or peripheral vestibular disorders. SVV tilts may coincide with or differ from the perception of body vertical, e.g., in isolated body lateropulsion.

Highlights

The perception of verticality in the roll and pitch planes is based on an integrative graviceptive input from the vertical semicircular canals and otolith organs. This input is mediated by a bilateral central circuitry connecting the vestibular nuclei with integration centers for vertical and torsional eye-head coordination located in the rostral midbrain tegmentum and the thalamus
In the current clinical review we focus on psychophysical adjustments of the subjective visual vertical (SVV) and the subjective postural vertical (SPV) for balance control in a three-dimensional space
The gravity coding which changes from a peripheral or brainstem vectorial representation in otolith coordinates to a coding of distributed population at thalamic and cortical levels is compatible with the affects of unilateral thalamic and cortical lesions that variably effect the perceived verticality. This population-coding network for the perception of the gravity vector implements the elements that are required for the described perceptual underestimation of the Subjective Visual Vertical (SVV) in tilted body positions, i.e., the Aubert effect [2] (Figure 8). It is the level of the lesion of graviceptive vestibular pathways which is critical for the control of verticality perception and the position of eye, head, and body relative to gravity in the roll plane

Summary

Introduction

The perception of verticality in the roll and pitch planes is based on an integrative graviceptive input from the vertical semicircular canals and otolith organs. This input is mediated by a bilateral central circuitry connecting the vestibular nuclei with integration centers for vertical and torsional eye-head coordination located in the rostral midbrain tegmentum (interstitial nucleus of Cajal, INC; rostral interstitial nucleus of the medial longitudinal fascicle, riMLF) and the thalamus (in particular, the paramedian and dorsolateral subnuclei). The sensory modalities involved cannot perceive different verticals at the same time independently—a visual and a vestibular one This multisensory input establishes an internal model of space and verticality, which is updated via bottom-up and top-down processes [1, 2]. Other models use Bayesian spatial-perception [3,4,5] and an inverse probabilistic approach based on an optimal observer theory [6]

Methods

Results

Conclusion