Clinical and Imaging Features of the Room Tilt Illusion

J Neurol (2012) 259:2555–2564 DOI 10.1007/s00415-012-6536-0 ORIGINAL COMMUNICATION Clinical and imaging features of the room tilt illusion F. Sierra-Hidalgo • E. de Pablo-Fernańdez • A. Herrero-San Martıń • E. Correas-Callero • J. Herreros-Rodrı´guez • J. P. Romero-Munõz • L. Martıń-Gil Received: 26 February 2012 / Revised: 22 April 2012 / Accepted: 24 April 2012 / Published online: 16 May 2012 Ó Springer-Verlag 2012 Abstract Room tilt illusion (RTI) is a transient disorder commonly involved posterior fossa structures when com- of the environmental visuo-spatial perception consisting of pared to patients with non-vascular disorders. In summary, paroxysmal tilts of the visual scene. It is attributed to an RTI is a manifestation of several CNS and vestibular dis- erroneous cortical mismatch of the visual and vestibular orders, and rarely of peripheral nervous system disorders, three-dimensional coordinate maps. Thirteen subjects were triggered by disruption of vestibular and sensory perception included in this retrospective case series. Clinical presen- or integration. Cerebral ischaemic disorders are the most tation was 1808 rotation of the visual scene following the common aetiology for this rare syndrome. coronal plane in seven patients. The most common cause for RTI in our series was posterior circulation ischaemia Keywords Room tilt illusion Á Stroke Á Visual tilt illusion Á (five cases). Cases of endolymphatic sac tumour, critical Magnetic resonance imaging Á Computed tomography Á illness neuropathy, acute traumatic myelopathy and mul- Vestibular system Á Subjective visual vertical tiple system atrophy causing RTI are reported for the first time. No case of supratentorial focal lesion was found. In order to describe the clinical and imaging features of RTI, Introduction 135 cases previously reported in the literature were reviewed along with our series. There was a male pre- Room tilt illusion (RTI), also known as ‘visual tilt’, is a dominance (60.2 %). Mean age was 51.2 ± 20.3 years. transient disorder of environmental visuo-spatial percep- The most common location of the injury was the central tion consisting of paroxysmal tilting of the visual scene off nervous system (CNS) (61.4 %). Supratentorial and infra- the true vertical, without any alteration in objects’ colour, tentorial structures accounted for the same frequency of shape or size [1, 2]. It is a symptom attributed to a transient lesions. The most common aetiology was cerebral ischae- erroneous cortical mismatch of the visual and vestibular mia (infarction or transient ischaemic episode; 27.7 %). three-dimensional coordinate maps. ‘Visual inversion’, These patients were significantly older and their lesions ‘inverted vision’, ‘upside-down vision’ or ‘inverted metamorphopsia’ are all terms used in the literature referring to 1808 rotations in the coronal plane, but RTI may occur in F. Sierra-Hidalgo (&) Á E. de Pablo-Fernańdez Á A. Herrero-San Martıń Á E. Correas-Callero Á other planes [3]. Images usually rotate following the J. Herreros-Rodrı´guez Á J. P. Romero-Munõz Á L. Martıń-Gil coronal roll plane or the sagittal pitch plane (Fig. 1), so the Department of Neurology, Hospital Universitario 12 de Octubre, mentioned terms do not include the spectrum of manifes- and Instituto de Investigacioń Hospital 12 de Octubre (i?12), tations of the RTI phenomenon that may occur in a plane Av. Co´rdoba s/n, 28041 Madrid, Spain e-mail: [email protected] other than the coronal and/or in 908 steps [4–7]. RTI must be differentiated from other visual disorders of verticality F. Sierra-Hidalgo perception, such as subjective visual vertical (SVV) tilts. Department of Neurology, Hospital Universitario 12 de Octubre, Unlike RTI, SVV tilt is a sign of stable otolithic pathway and Neurology/Neurosciences Research Group, Instituto de Investigacioń Hospital 12 de Octubre (i?12), Av. Co´rdoba s/n, dysfunction with environmental torsion of a few degrees in 28041 Madrid, Spain the coronal plane lasting days to weeks, in contrast with the 123 2556 J Neurol (2012) 259:2555–2564 Fig. 1 a Three-dimensional representation of axes and planes of the rotation following the coronal plane; d view of the scene during a 908 space in relation to a subject; b representation of a domestic scene rotation following the coronal plane; e view of the scene during a 908 from a subject’s view; c view of the scene during an RTI of 1808 rotation following the sagittal plane brief, transient, sometimes recurrent, 90–1808 tilting of attended our department and to incorporate them into the RTI [8, 9]. previously described cases in order to analyse, all together, Bishop first described RTI in 1,805 in a patient thought to their clinical and imaging features. suffer from hysteria [10]. Since then, most descriptions of this symptom have tried to provide an anatomical and functional explanation for it. Case reports and short case Patients and methods series have been published, but they only allow a partial view of this phenomenon. Ischaemic, haemorrhagic, demyelinat- We retrospectively reviewed the cases of RTI patients ing, infectious, autoimmune, epileptic, traumatic, toxic, attending our department during the 2005–2011 period. neoplastic, neurodegenerative disorders and migraine have The revision was performed using personal records from been reported to cause RTI because of central nervous sys- the authors and medical notes. Patients with at least one tem (CNS) or peripheral vestibular system (VS) lesions [3, 5, episode of transient, paroxysmal visual illusion consisting 11–18]. Development of structural neuroimaging techniques of rotation of the visual environment, in any direction and has allowed precise localisation of the injuries in these of any duration or amount, were included. The records patients, and a wide spectrum of lesion locations causing were analysed for sex, age, RTI features (rotation plane, RTI, including supratentorial, infratentorial and peripheral degrees of rotation, duration, number of episodes), asso- vestibular structures, is now recognised. Even peripheral ciated symptoms and signs, neuroimaging studies, other nervous system (PNS) disorders have been reported to cause ancillary tests, presumed location of the injury, final RTI [19]. A better understanding of the physiology of diagnosis and short-term outcome. graviceptive pathways and integrative areas of the brain in Epidemiologic, clinical and imaging features of previ- the last 2 decades has allowed hypothesising an acute, tran- ously reported cases of RTI were recorded from the liter- sient visual and vestibular information mismatch as the ature. An extensive literature search was performed in better explanation for these paroxysmal phenomena and why February 2011 using PubMed, with the following terms: such varied lesions involving different structures and path- ‘Room tilt illusion’, ‘environmental tilt illusion’, ‘visual tilt ways may cause the same symptom [1, 20]. illusion’, ‘visual inversion’, ‘inverted vision’, ‘inverted As a rare subjective symptom, clinicians need to know metamorphopsia’, ‘upside down vision’, ‘upside down RTI’s clinical presentation in order to identify possible life- reversal of vision’, ‘reversal of vision metamorphopsia’ threatening underlying conditions. The aim of this article is and ‘visual environmental rotation’. Additional cases were to describe the characteristics of RTI in 13 patients who collected from the references of the articles reporting on 123 J Neurol (2012) 259:2555–2564 2557 RTI. The same clinical criterion described above for the right vertebral artery (Fig. 3). Intravenous heparin was then identification of RTI was used to select the cases for the started and RTI episodes disappeared within 24 h. review. Descriptions of patients with other isolated visual Patients 6, 7 and 8 were diagnosed with VS disorders. or integrative disorders (e.g. SVV tilt, visual allesthesia, Case 6 was a patient that presented with several episodes of rotated drawing) not associated to the paroxysmal phe- RTI that lasted for seconds and appeared only when lying nomena of RTI were excluded. Data regarding the fol- on his right side during an acute right vestibular syndrome lowing variables were collected: year of publication, sex, consistent with vestibular neuritis. Case 7 was a 62-year- age, features of RTI (plane, degrees of rotation, duration, old man with a previous diagnosis of Meniere’s disease number of episodes, accompanying signs), location of the who complained of recurrent episodes of upside-down injury, aetiology and neuroimaging tests performed. vision of variable duration (from minutes to hours) Data collection and statistical analysis were performed accompanying vertigo spells. Patient 8 had a first-ever by means of SPSS 14.0 (SPSS Inc., Chicago, IL, USA). episode of right posterior canal benign paroxysmal posi- Frequencies are described in total number and percentage. tional vertigo (BPPV). She reported suffering an RTI Mean and standard deviation are used for description of during Epley’s repositioning manoeuvre. The illusion las- continuous variables. All the comparisons were two-tailed. ted longer than the evoked nystagmus, and it was only Differences in proportions were tested by v2 test. All other relieved when she closed her eyes for several seconds. She comparisons between groups were made with Student’s had never experienced such a visual phenomenon, and it unpaired t test. p values \0.05 were considered to be sta- did not appear again during the manoeuvre. tistically significant. Patient 9 had a 7-year-history of right deafness without any medical assessment. He attended the emergency room because of an acute vestibular syndrome and three con- Results secutive episodes of RTI of 1808 in the coronal plane. MRI demonstrated a right ponto-cerebellar angle-occupying Ten male and three female patients aged between 35 and tumour with ipsilateral cerebellar hemisphere compression 82 years old were included. Clinical features are detailed in and oedema (Fig. 3). Biopsy proved it to be a low-grade Table 1. The illusion was described as an ‘upside-down’ endolymphatic sac tumour.

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