Clinical and imaging features of the room tilt illusion

Abstract

Room tilt illusion (RTI) is a transient disorder of the environmental visuo-spatial perception consisting of paroxysmal tilts of the visual scene. It is attributed to an erroneous cortical mismatch of the visual and vestibular three-dimensional coordinate maps. Thirteen subjects were included in this retrospective case series. Clinical presentation was 180º rotation of the visual scene following the coronal plane in seven patients. The most common cause for RTI in our series was posterior circulation ischaemia (five cases). Cases of endolymphatic sac tumour, critical illness neuropathy, acute traumatic myelopathy and multiple 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, 135 cases previously reported in the literature were reviewed along with our series. There was a male predominance (60.2 %). Mean age was 51.2 ± 20.3 years. The most common location of the injury was the central nervous system (CNS) (61.4 %). Supratentorial and infratentorial structures accounted for the same frequency of lesions. The most common aetiology was cerebral ischaemia (infarction or transient ischaemic episode; 27.7 %). These patients were significantly older and their lesions commonly involved posterior fossa structures when compared to patients with non-vascular disorders. In summary, RTI is a manifestation of several CNS and vestibular disorders, and rarely of peripheral nervous system disorders, triggered by disruption of vestibular and sensory perception or integration. Cerebral ischaemic disorders are the most common aetiology for this rare syndrome.

Towards a concept of disorders of “higher vestibular function”

“…Transient upside-down inversion of vision—the room tilt illusion—has been repeatedly described in patients with lower brainstem infarctions (Ropper, 1983; Tiliket et al, 1996; Sierra-Hidalgo et al, 2012) or with cortical lesions (Solms et al, 1988), especially in cases of vestibular epilepsy (Smith, 1960). These illusions last for seconds or minutes, rarely up to hours.…”

Room tilt illusion: a symptom of both peripheral and central vestibular disorders

“…Acute brainstem stroke is known as a cause of RTI [1,3,4]. We found seven patients with PICA infarction, four patients with SCA infarction, three with brain stem lesions presenting with skew deviation, one with extended brainstem and cerebellar infarction, one with traumatic VA dissection, one with cerebellar hemorrhage and one with TIA, reported since 1996.…”

“…For that reason, in elderly patients with vascular risk factors presenting with RTI, MRI and MRA should be done to rule out posterior circulation stroke. RTI can be due to peripheral vestibular disorders such as Meniere's disease [1,4]. One of our patients (patient 4) had Meniere's disease and the episodes of isolated RTI without any vertigo, which decreased with intraympanic gentamicine into the affected ear.…”

“…The causes and proposed underlying mechanisms of RTI have been stated in previous reports [1][2][3][4][5]. The perception of verticality is considered to be mediated by inputs from vestibular, somatosensory and visual systems and processed in the vestibular nuclei and then projected to the cortex via thalamic nuclei [2].…”

“…Room tilt illusion (RTI) is a transient illusion that the entire room including the observer is tilted or even inverted in the coronal or sagittal plane, without any alteration in any object's colour, shape or size or relative position [1].…”