The subjective horizontal at different angles of roll-tilt in patients with unilateral vestibular impairment

The subjective visual horizontal is mainly dependent on the otolithic system. A group of 11 patients with sudden unilateral vestibular impairment were asked to set a dimly illuminated bar according to their subjective horizontal when they were seated upright and tilted 10, 20, and 30 degrees to the right and left in a completely darkened room (Bias test). The patients were examined within 1 week, after 3 and 6 weeks, and 9 patients consented to the 11-week follow-up. The results were compared with ENG examinations. In the acute stage of the disease all patients, when they were in upright position, set the light bar tilted towards the affected side. At roll tilt to the affected side, 9 of the 11 patients set the light bar in the same direction as their body tilt (undercorrection). At a tilt to the unaffected side 6 of the 11 patients made an undercorrection. For the group of patients the magnitude of undercorrection was larger at tilt to the affected side than to the unaffected side. The patients' ability to correctly align the light bar with the true horizontal gradually improved but was found normal in both upright and tilted positions in only three of the nine patients at the last follow-up. In four of the six patients who still demonstrated pathologic results, these were met only in tilted positions. No significant correlation was found between the intensity of spontaneous nystagmus or the degree of caloric side difference and the deviation in setting of the light bar in upright or tilted positions. The large asymmetric perceptual responses at tilt found at onset might be explained by the two-directional organisation of the utricle.