Effect of Vestibular Stimulation Exercises on the Level of Consciousness in Patients With Intracerebral Hemorrhage: A Systematic Review

Intracerebral hemorrhage (ICH) commonly disrupts cortical, subcortical, and brainstem arousal circuits, leaving many survivors with a reduced level of consciousness (LOC) that delays active rehabilitation. Conventional multisensory stimulation is the standard bedside approach used to promote arousal in such patients, and graded vestibular stimulation has recently been proposed as an adjunct, since vestibular afferents project extensively to brainstem reticular structures and cortical arousal networks through the vestibulo-thalamo-cortical pathway. This study aims to systematically review randomized controlled trial (RCT) and cross-sectional evidence published between 2010 and 2026 on vestibular and related sensory stimulation approaches for improving LOC in patients with ICH, and to place this evidence alongside closely related trials and validation studies in comatose, traumatic brain injury (TBI), and neuro-critical populations. PubMed, Scopus, Web of Science, ScienceDirect, and Google Scholar were searched for English-language RCTs and cross-sectional studies published from January 2010 to June 2026 that evaluated vestibular, multisensory, auditory, affective, or related sensory stimulation interventions, or that validated a bedside LOC-assessment tool in adults with ICH or closely related severe brain injury. Risk of bias in the randomized trials was appraised with the Cochrane RoB 2 tool; the cross-sectional and prospective observational studies were appraised with the Appraisal Tool for Cross-Sectional Studies (AXIS). Twelve studies met the eligibility criteria: eight RCTs and four cross-sectional/prospective observational studies. The single trial testing vestibular stimulation directly in ICH found that adding graded vestibular exercises to conventional multisensory stimulation produced significantly higher Glasgow Coma Scale (GCS) and Full Outline of UnResponsiveness (FOUR) scores at day 7 and day 14 than multisensory stimulation alone. Seven further randomized trials in comatose, TBI, or acquired brain injury (ABI) populations tested auditory/voice stimulation, family-centered affective stimulation, nurse- and family-delivered multisensory stimulation, median nerve plus auricular stimulation, and dedicated vestibular rehabilitation, and consistently reported improvement in LOC-related or closely linked functional outcomes. Four cross-sectional or prospective observational studies confirmed that GCS and FOUR scores are valid, reliable, and prognostically useful bedside measures of consciousness in neuro-critical populations, including cohorts in which ICH was the leading diagnosis. Direct evidence for vestibular stimulation in ICH remains confined to one small trial, but its findings are biologically consistent with a wider body of sensory-stimulation research in comatose and severely brain-injured patients, and with cross-sectional evidence supporting GCS and FOUR score as appropriate outcome measures. Larger, multi-center, time-matched randomized trials are required before graded vestibular stimulation can be recommended as a standard adjunct in ICH rehabilitation.