Compensatory changes in static and dynamic subjective visual vertical in patients following vestibular schwanoma surgery

Objective: Among patients with vestibular schwanoma (VS), vestibular function is nonhomogenous, both before and after surgical removal of the VS. This paper reports investigations of neural changes, especially changes in the contribution of visual input to vestibular system integration, after VS surgery. Methods: We examined 33 patients who underwent VS surgery via a middle fossa approach. Static and dynamic subjective visual vertical (SVV) was measured once after surgery and compared to those measured in control subjects. SVVs were assessed using a paradigm requiring the subject to manually adjust an image of a bar to the perceived vertical alignment. SVVs were measured when the background was stationary or rotating. Results: In almost all patients, static SVV deviated toward the operated side. In VS subjects, the mean static SVV was 1.8±2.2°; the amount of deviation in the dynamic SVV toward the operated side (11.7±8.3°) was significantly larger than that to the intact side (8.8±5.5°). In VS subjects, static SVV was correlated with dynamic SVV only in cases of bar adjustments toward the operated side (R=0.67, P<0.001), but not in cases of adjustments toward the intact, unoperated side. The axis of rotation was defined as the mean value of dynamic SVV for adjustments toward either side. There was only a weak correlation between the static SVV and the axis of rotation (R=0.31; P<0.05) in the control subjects. On the other hand, a more robust correlation between static SVV and axis of rotation was found (R=0.67, P<0.001) in VS subjects. There was no correlation between the static SVV and the deviation of dynamic SVV from static SVV for CCW and CW in control subjects. In contrast, there were significant correlations between static SVV and deviation of dynamic SVV from static SVV for adjustments made toward both operated (r=0.48, P<0.001) and intact sides (r=038, P<0.05). Conclusion: It is assumed that the amount of deviation in static SVV reflects the individual level of compensation. In addition, increased visual dependency evoked a symmetrical bias of the dynamic SVV from the measures at initial SVV assessment (i.e. static SVV or the center of tilt). As a result, we conclude that the contribution of visual inputs had changed after surgery, while at the same time, each patient used their static SVV as their reference point for orientation.