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Our perception of our orientation relative to the vertical and horizontal coordinates of the earth is determined by several sensory inputs: 1) gravity receptors in the utricles of the inner ear; 2) proprioceptive receptors in our trunk and limbs, and graviceptors in the viscera; and 3) visual information from our retinas. The brain integrates these sensory modalities to yield our conscious idea of orientation relative to the earth vertical. Peripheral or central disease may be expected to cause altered perception of vertical orientation, but patients rarely complain of it. Bugs Bunny’s proverbial query to Elmer Fudd—“What’s up, doc?”—is seldom a question asked of neurologists.
Rarely, a pathologic “tilt illusion,” in which the world is seen to be on its side or inverted, is experienced transiently by patients with lateral medullary, thalamic, or even cerebral infarct or hemorrhage.1 However, central or peripheral lesions typically do not cause complaints of an abnormal sense of …
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