The bilateral central vestibular system: its pathways, functions, and disorders

The bilateral anatomical organization of the vestibular system provides three functional advantages: optimal differentiation of head motion and orientation, sensory substitution of a unilateral peripheral failure, and central compensation of a peripheral or central vestibular tone imbalance. The structure is based on bilaterally ascending and descending pathways and at least four crossings: three in the brain stem and one in the cortex. The resulting sensorimotor functions can be subdivided into three major groups: (1) reflexive control of gaze, head, and body in three spatial planes (yaw, pitch, roll) at the brain stem/cerebellar level; (2) perception of self-motion and control of voluntary movement and balance at the cortical/subcortical level; and (3) higher vestibular cognitive functions (e.g., spatial memory and navigation). The bilateral representation of the vestibular system in multiple multisensory cortical areas and the vestibular dominance of the nondominant hemisphere raise the question of how one global percept of motion and orientation in space is formed.