Lesions causing room tilt illusion link a cerebello-cingulate brain network to verticality perception
- 1University Hospital Ulm
Abstract
Verticality perception is the sense of ones body orientation relative to gravity. It can be disrupted by neurological diseases or during aviation and space flight, resulting in falls and accidents. This perception is thought to arise from integration of vestibular and visual signals, yet where this multisensory computation is spatially implemented in the human brain remains unresolved. Room tilt illusion (RTI), in which the visual environment abruptly reorients relative to gravity (typically by 90{degrees} or 180{degrees}), has been proposed as a model disorder for studying verticality perception. Here, we leverage focal brain lesions (predominantly ischemic or hemorrhagic strokes) causing RTI to localize this multisensory computation. We assembled a total of 37 patients with brain lesions causing RTI from a systematic literature search and local cases across two centers. Clinical data were tabulated and lesions were analyzed using multimodal voxel- and connectome-based lesion mapping methods. Lesion findings were further tested against an independent dataset of 509 direct electrical stimulation sites associated with vestibular or non-vestibular percepts. The RTI lesions were distributed across cortical and subcortical locations, with the cerebellum representing the most frequent lesion site (49%). Despite anatomical heterogeneity, lesion connectivity converged on two hub regions: one in the posterior cerebellum and another in the mid-cingulate cortex. This pattern was robust to methodological variations, separation of RTI subtypes, and exclusion of cerebellar lesions. This pattern was also specific to RTI when compared against 185 phenotypically matched lesions from patients with milder disturbances of verticality perception and 1,110 lesions associated with 27 other neuropsychiatric syndromes. Finally, independent direct electrical stimulation data converged on both lesion-derived RTI hubs (mid-cingulate cortex: g=0.62, p<.001; posterior cerebellum: g=0.34, p=.014, 10,000 label permutations). In conclusion, anatomically diverse RTI lesions localize to a specific cerebello-cingulate network, providing an anatomical framework for verticality perception in the human brain. Our findings generate testable hypotheses for experimentally modulating or protecting verticality perception in neurological patients or pilots.
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BibTeX
@misc{pini2026lesions,
title = {{Lesions causing room tilt illusion link a cerebello-cingulate brain network to verticality perception}},
author = {L. Pini and K. Steinmetz and C. W. Zhao and A. Garimella and Z. Dary and F. L. W. V. J. Schaper and F. Bartolomei and S. Lagarde and J. Laurens and N. Sollmann and D. S. Zee and A. Zwergal and M. Dieterich and B. Baier and C. Lopez and M. D. Fox and J. Conrad and M. U. Friedrich},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.26.26365825},
url = {https://www.medrxiv.org/content/10.64898/2026.10.26.26365825v1},
note = {CC BY-NC-ND},
}
RIS
TY - UNPB
TI - Lesions causing room tilt illusion link a cerebello-cingulate brain network to verticality perception
AU - L. Pini
AU - K. Steinmetz
AU - C. W. Zhao
AU - A. Garimella
AU - Z. Dary
AU - F. L. W. V. J. Schaper
AU - F. Bartolomei
AU - S. Lagarde
AU - J. Laurens
AU - N. Sollmann
AU - D. S. Zee
AU - A. Zwergal
AU - M. Dieterich
AU - B. Baier
AU - C. Lopez
AU - M. D. Fox
AU - J. Conrad
AU - M. U. Friedrich
PY - 2026
DA - 2026/10/26
PB - medRxiv
DO - 10.64898/2026.10.26.26365825
UR - https://www.medrxiv.org/content/10.64898/2026.10.26.26365825v1
AB - Verticality perception is the sense of ones body orientation relative to gravity. It can be disrupted by neurological diseases or during aviation and space flight, resulting in falls and accidents. This perception is thought to arise from integration of vestibular and visual signals, yet where this multisensory computation is spatially implemented in the human brain remains unresolved. Room tilt illusion (RTI), in which the visual environment abruptly reorients relative to gravity (typically by 90{degrees} or 180{degrees}), has been proposed as a model disorder for studying verticality perception. Here, we leverage focal brain lesions (predominantly ischemic or hemorrhagic strokes) causing RTI to localize this multisensory computation. We assembled a total of 37 patients with brain lesions causing RTI from a systematic literature search and local cases across two centers. Clinical data were tabulated and lesions were analyzed using multimodal voxel- and connectome-based lesion mapping methods. Lesion findings were further tested against an independent dataset of 509 direct electrical stimulation sites associated with vestibular or non-vestibular percepts. The RTI lesions were distributed across cortical and subcortical locations, with the cerebellum representing the most frequent lesion site (49%). Despite anatomical heterogeneity, lesion connectivity converged on two hub regions: one in the posterior cerebellum and another in the mid-cingulate cortex. This pattern was robust to methodological variations, separation of RTI subtypes, and exclusion of cerebellar lesions. This pattern was also specific to RTI when compared against 185 phenotypically matched lesions from patients with milder disturbances of verticality perception and 1,110 lesions associated with 27 other neuropsychiatric syndromes. Finally, independent direct electrical stimulation data converged on both lesion-derived RTI hubs (mid-cingulate cortex: g=0.62, p<.001; posterior cerebellum: g=0.34, p=.014, 10,000 label permutations). In conclusion, anatomically diverse RTI lesions localize to a specific cerebello-cingulate network, providing an anatomical framework for verticality perception in the human brain. Our findings generate testable hypotheses for experimentally modulating or protecting verticality perception in neurological patients or pilots.
ER -