Room tilt illusion. A central otolith dysfunction

BACKGROUND: We report a sudden 90 degrees room tilt illusion (RTI) following vestibular stimulation in 3 patients with persistent skew deviation caused by a brain stem lesion. Room tilt illusion is a transient tilt perception of the visual surrounding, on its side or even upside down, that is often reported with brain stem lesions. Although its pathophysiologic cause is not well known, the RTI suggests an impairment of otolith pathways, as reported in skew deviation. METHODS: The 3 patients with brain stem lesions were reexamined as part of a follow-up of patients with signs of otolith dysfunction. A registration of vestibular function was performed with a rotatory chair, including earth-vertical axis rotation for canal stimulation and off-vertical axis rotation (OVAR) for otolith stimulation. Measurement of the subjective visual vertical (SVV) was also performed. RESULTS: The otolith-ocular reflex registered by OVAR was impaired in the 3 patients with skew deviation and the SVV in 2 patients. After each direction of OVAR stimulation, the 3 patients reported an RTI as the room was illuminated. CONCLUSIONS: The coexistence of otolith oculomotor (skew deviation and impaired otolith-ocular reflex) and perceptual (tilt of SVV and RTI) disorders suggests a common otolith dysfunction. However, an RTI occurred specifically after vestibular stimulation and when the room was illuminated. We thus suggest that RTI reflects a dynamic visuo-otolith mismatch.