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  1. Justin Kinsella,
  2. Roisin Lonergan,
  3. Ronan Killeen,
  4. Chris McGuigan
  1. St Vincent's University Hospital


Room tilt illusion (RTI) describes the perception of ‘tilting’ of the surrounding environment. We present 2 cases in the setting of acute vertebrobasilar territory ischaemia.

Case 1: A 56-year old man was admitted with acute dyspnoea and new atrial fibrillation. On day two while lying in bed, he developed vomiting and suddenly perceived the curtain to his left was lying horizontal along the floor and felt he was sliding towards the left. MRI brain revealed acute multiterritory infarction (Figure 1). He was commenced on therapeutic anticoagulation and was well on follow-up.

Case 2: A 47-year old man awoke with acute vertigo, vomiting and ataxia, exacerbated by head movement with dysarthria and diplopia. The world appeared ‘sideways’: objects appeared tilted at 90° when lying on his left side with his head tilted to the left. This resolved when he looked ahead or to the right. MRI brain did not show acute ischaemia but MRA revealed acute vertebral dissection. The patient received short-term heparin, with continuation of aspirin and clopidogrel, due to recent coronary angioplasty. Subsequent similar symptoms prompted introduction of warfarin.

Discussion These unusual symptoms are thought to involve vestibular-otolith disconnection. These cases highlight the importance of recognising symptoms of RTI in the setting of acute cerebral ischaemia.

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