Background and purpose The aim of the study was to identify the neuroanatomical correlates and associations of neuropsychological syndromes after acute unilateral right‐hemisphere brain lesions. The neuropsychological syndromes considered were orientation in three‐dimensional space such as tilts of the subjective visual vertical or of the subjective haptic vertical, pusher syndrome, visual neglect and unawareness of paresis (anosognosia for hemiparesis). These neuropsychological phenomena have been found to occur separately or in different combinations after lesions to the right insular cortex. Method Magnetic resonance imaging scans were obtained from 82 patients with acute right‐hemispheric stroke. A lesion–behavior mapping analysis was conducted to specify the neuroanatomical correlates of the above‐mentioned neuropsychological syndromes. Results In all analyses of the individual neuropsychological syndromes the insular cortex was affected. Conclusions Thus, the insular cortex is involved in (self‐)perception and orientation within a three‐dimensional space. Since isolated lesions of the insular cortex did not induce the above neuropsychological phenomena, there have to be other regions involved.

Based on animal studies, it has been shown that the nucleus ventralis intermedius (VIM) of the thalamus plays an important role within the vestibular system. A few human studies support the vestibular role of the VIM. In this study, we aimed to test the hypothesis whether changing the stimulation status in patients with unilateral deep brain stimulation in the VIM causally modulates the vestibular system, i.e., the graviceptive vertical perception. We tested six tremor patients for tilt of subjective visual vertical (SVV) with unilateral DBS in the VIM (mean age 67 years; mean time since electrode implantation 55 months). The mean tilt of the patients during the stimulator "on" condition was 1.4° to the contraversive side [standard deviation (SD) ± 0.4°] whereas during the "off" period a mean contraversive tilt of 4.4° (SD ± 3.0°) was obtained (p = 0.02). Thus, we were able to show that otolith-dominated graviceptive vertical perception can be directly modulated by changing the status of DBS VIM stimulation, indicating that the VIM is directly involved in (contraversive) vertical perception and its thalamic pathways.

Background and purpose A sensitive and frequent clinical sign of a vestibular tone imbalance is the tilt of the perceived subjective visual vertical (SVV). There are no data yet focusing on lesion location at the cortical level as a factor for predicting compensation from the tilt of the SVV. Methods With modern voxelwise lesion behavior mapping analysis, the present study determines whether lesion location in 23 right‐hemispheric cortical stroke patients with an otolith dysfunction could predict the compensation of a vestibular tone imbalance in the chronic stage. Results Our statistical anatomical lesion analysis revealed that lesions of the posterior insular cortex are involved in vestibular otolith compensation. Conclusion The insular cortex appears to be a critical anatomical region for predicting a tilt of the SVV as a chronic disorder in stroke patients.

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