Case of a 96-year-old woman with tilt of the subjective vertical axis

Abstract

interACTN Case #44: Available: https://interactn.org/2025/01/30/case-44-the-case-of-a-96-year-old-woman-with-tilt-of-subjective-vertical-axis/

A 96-year-old woman presents to the University Hospital Emergency Department by ambulance with hypertension and a tendency to fall to the left. The latter symptom had been present for 11 days and had worsened in the last few days. On clinical examination, the patient had a blood pressure of 230/110 mmHg, a tendency to fall to the left, and an inability to walk independently. Testing the subjective visual vertical (SVV) perception with the bucket test, the vertical visual axis was tilted about 20 degrees to the left. Brain MRI showed an ischemic infarct in the left dorsal spinocerebellar tract responsible for the SVV tilt.^{1, 2} The patient was transferred to the neuro-geriatric unit for 2 weeks. Early rehabilitation geriatric complex treatment focused on training of vertical axis perception and gait. She could be discharged home without any need for additional support.

A tilt of the SVV can be caused by central lesions in different locations. The main structures in the network for verticality perception are graviceptive pathways running from the inner ear via vestibular nuclei, midline midbrain, the dorsolateral thalamus to the parieto-insular vestibular cortex (PIVC). Besides the vestibular system, a modulating network of different cerebral structures that integrates visual, spinal, and cerebellar information contributes to verticality perception. Depending on the lesion site, the tilt of the SVV can be ipsilateral (medullary brainstem lesions) or contralateral (midbrain lesions). Lesions of the vestibular thalamus, cerebellum, vestibulo-cerebellar tracts, and cortical areas can cause ipsilateral or contralateral tilt.¹

Ischemic infarcts in the left dorsal spinocerebellar tract and subinsular right (see Fig. 1) close to the parieto-insular vestibular cortex (PIVC). The medullary lesion was likely causing the tilt in verticality perception.²