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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 4  |  Page : 423-424

Room tilt illusion in superior cerebellar artery stroke: Are we missing the classical neurological examination?


Department of Neurology, Hospital de Torrejón de Ardoz, Torrejón de Ardoz, Madrid, Spain

Date of Web Publication6-Sep-2012

Correspondence Address:
Míriam Eimil-Ortiz
Department of Neurology, Hospital de Torrejón de Ardoz, Torrejón de Ardoz, Madrid
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.100709

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How to cite this article:
Eimil-Ortiz M, González-Salaices M, Heras IP, Sáiz-Sepúlveda MA, de Miguel CL. Room tilt illusion in superior cerebellar artery stroke: Are we missing the classical neurological examination?. Neurol India 2012;60:423-4

How to cite this URL:
Eimil-Ortiz M, González-Salaices M, Heras IP, Sáiz-Sepúlveda MA, de Miguel CL. Room tilt illusion in superior cerebellar artery stroke: Are we missing the classical neurological examination?. Neurol India [serial online] 2012 [cited 2021 May 6];60:423-4. Available from: https://www.neurologyindia.com/text.asp?2012/60/4/423/100709


Sir,

Room tilt illusion is an uncommon anomaly consisting of rotation of the visual surroundings. Patients perceive the visual fields turning through a variable arc between 45-180 degrees.

A healthy 35-year-old Caucasian male presented with a sudden lateralized tinnitus, after a valsalva maneuver, immediately followed by dizziness and vomiting. He was unable to walk and developed in-coordination of right limbs. Whenever he lay on the floor, he realized that everything was rotated at 90 degrees. The illusion appeared every time he opened his eyes and lasted 30 min. On admission he presented with slurred speech, unstable gait and right-sided dysmetria. The four following days he had significant improvement and was discharged with mild right dysmetria. Computed tomography (CT) and magnetic resonance imaging (MRI) with angiogram showed bilateral hemispheric cerebellar infarction in the territory of the superior cerebellar artery (SCA) [Figure 1]a-e. Further evaluation showed a patent foramen ovale.
Figure 1: (a) MRI. T2 coronal view. Hemosiderine deposition into right hemisphere due to hemorhagic transformation. (b) Diffusion. Damage into territories of both superior cerebellar arteries. Cortical hypersignal because of cytotoxic edema. Subacute ischemia. (c) MRA: Axial reconstruction. Left posterior cerebral artery of fetal origin. Hyperplasic left posterior communicant artery. Severe hypoplasia of left P1 segment. (d) Coronal reconstruction. There is no union between intracranial vertebral arteries (V4 segment). Left vertebral dominance. Right posteroinferior cerebellar artery merges from ipsilateral vertebral ar tery. Antero-inferior cerebellar artery looks thin, with scarce dista l flow. Hypoplasic left P1 segment, with fetal origin. (e) FLAIR. Axial view of subacute ischemia in both cerebellar hemispheres, in the territory of anterior superior cerebellar arteries

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The spatial representation of visual stimuli is formed by information coming in from different sources. The retinal inflow is combined with ocular position information to produce head-centered representations. The retina receives an inverted picture and normal vision requires reinversion of this image according to body coordinates in the space. To represent these body coordinates, the parietal cortex has neurons that respond to eye and head position. This information reaches these centers via vestibular inputs together with proprioceptive information from neck muscles. [1] One of the proposed regions that is concerned with the reversal of vision process is the posterior parietal region, whose cells may be concerned with space perception as well as spatial control of movements. The other proposal is the dysfunction of the multisensory parieto-insular vestibular cortex, or its afferents or a disorder of visuospatial integration. [2]

This unusual phenomenon is described with different lesions: peripheral vestibular area, vestibule cochlear nerve, lateral medulla, pons, cerebellum, right parietal lobe, left occipitotemporal area, occipitoparietal zone, second sensory cortex, left posterior thalamus, and left frontal and right mediobasal frontal lobe. The room tilt illusion has been described in posterior inferior cerebellar artery (PICA) and anterior inferior cerebellar artery (AICA) infarctions, affecting the internal part of the caudal cerebellar lobuli and the inferior vermis, mainly the nodulus. Unfortunately, many previous reports just refer to "vertebrobasilar territory" without specification of the affected artery. To our knowledge, this is the first report of a "room tilt illusion" related to the SCA territory. [3],[4],[5] The SCA supplies the upper surface of the cerebellar hemisphere, superior vermis, dentate nucleus, upper portions of the middle cerebellar peduncle, superior cerebellar peduncle and lateral pontine tegmentum. Efferent fibers of the inferior cerebellar peduncle are mainly cerebellovestibular pathways. There are afferent and efferent fibers in the superior cerebellar peduncle which carry auditory, visual and vestibular information. Our patient reinforces the vestibular theory about the genesis of the upside down phenomenon and shows the importance of an accurate medical history. The patient did not voluntarily admit to the hallucination until the following day when he was visited by the neurologist and asked about visual phenomena. This fact reinforces the importance of a formal neurological examination. It begs the question... are we missing the classical neurology exploration because of the rarity of certain signs or symptoms…or because of a lack of curiosity or knowledge when facing a neurological patient?!

 
 » References Top

1.River Y, Ben Hur T, Steiner I. Reversal of vision metamorphopsia. Clinical and anatomical characteristics. Arch Neurol 1998;55:1362-8.  Back to cited text no. 1
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2.Arjona A, Fernández Romero E. Ilusicón de la inclinación de una imagaen visual. Descripción de dos casos y revisión de la literatura. Neurología 2002;17:338-41.  Back to cited text no. 2
    
3.Horga Hernández A, Pujadas F, Purroy F, Delgado P, Huertas R, Álvarez-Sabín J. Upside down reversal of vision due to an isolated acute cerebellar Ischemic infarction. J Neurol 2006;253:953-4.  Back to cited text no. 3
    
4.Stracciari A, Guarino M, Ciucci G, Pazzaglia P. Acute upside down reversal of vision in vertebrobasilar ischaemia. J Neurol Neurosurg Psychiatry 1993;56:423-9.  Back to cited text no. 4
    
5.Charles N, Froment C, Rode G, Vighetto A, Turjman F, Trillet M, et al. Vertigo and upside down vision due to an infarct in the territory of the medial branch of the posterior inferior cerebellar artery caused by dissection of a vertebral artery. J Neurol Neurosurg Psychiatry1992;55:188-9.  Back to cited text no. 5
    


    Figures

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2 „Room tilt illusion“: Wenn die Welt auf einmal Kopf steht
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