🦪 IDK about you but I did NOT learn about "vision tilting" as part of lateral medullary syndrome. I had a stroke code this AM where patient woke up to find the room appeared to be flipped "like a mirror image, upside down". #MedTwitter #neurotwitter
Involvement of the vestibular nuclei in lateral medullary lesions can result in nystagmus and diplopia (which we are taught), but can also result in vertical image displacement, referred to as 'environmental tilt'!!
This is due to injury to do the otolithic projections that typically help our vision to mediate "counter rolling"
As you might imagine, this doesn't really fit on the NIHSS scale, so patients may have an otherwise fairly benign exam and spontaneous resolution of tilted vision and it can sound unbelievable to the uninitiated (me), so low threshold to obtain MRI
I want to add that this will not present as the typical vertical diplopia where you have two superimposed images, upright, but on top of each other- the top image will be flipped upside down or skewed laterally (to the patient)
If I hadn't gotten this code just as I was finishing a night shift, I would have gone back and asked the patient to draw it for me because I am a) obnoxious and b) a nerd
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