Distorted mirror reflecting varied sizes, symbolizing Alice in Wonderland Syndrome.

Alice in Wonderland Syndrome: When Reality Gets a Little Too "Curious"

Mira Elwood in Health & Wellness December 2025 • 4 min read.

"Discover how a ventriculoatrial shunt revision triggered a temporary case of Alice in Wonderland Syndrome, blurring the lines between perception and reality."

Visual misperceptions following neurosurgical procedures are rare, but intriguing. Alice in Wonderland Syndrome (AWS), typically linked to neurological and psychiatric conditions, involves distortions in perception, affecting how individuals see their own bodies and the world around them. This article explores a unique case where AWS emerged after a ventriculoatrial shunt revision, offering insights into the syndrome's potential triggers and the brain's complex visual pathways.

AWS is characterized by a range of perceptual distortions. Individuals may experience micropsia (objects appearing smaller than they are) or macropsia (objects appearing larger). Somesthetic hallucinations, where one feels their body is distorted in size, are also common. These symptoms can be unsettling, but it's important to remember they are a result of altered brain function, not a sign of psychosis.

While AWS has been associated with migraines, epilepsy, and even the Epstein-Barr virus, this article delves into a less common cause: surgical intervention. By examining this unusual case, we aim to shed light on the mechanisms behind AWS and expand our understanding of how medical procedures can impact perception.

The Case: A Post-Surgical Twist in Perception

Distorted mirror reflecting varied sizes, symbolizing Alice in Wonderland Syndrome.

Our patient, a 48-year-old male with a history of cerebrospinal fluid (CSF) diversion due to hardware failure, underwent a routine revision of his ventriculoatrial shunt. While previous revisions caused no psychological disturbances, this time was different. Shortly after the procedure, he began experiencing visual distortions characteristic of AWS.

He described feeling like his body was much larger than usual and had difficulty picking up objects. Even more peculiar, he perceived the people around him – family, nurses, and doctors – as having disproportionately small heads on normal-sized bodies. Despite these strange symptoms, the patient remained aware that these were visual distortions and not a reflection of reality, even finding the experience comical after a few hours.

Symptoms: Macrosomatognosia (feeling of an enlarged body) and micropsia (seeing small heads on others).
Cause: Post-operative, following a ventriculoatrial shunt revision.
Patient Awareness: Aware that the perceptions were not real.
Resolution: Symptoms resolved within approximately 12 hours.

The patient's symptoms were diagnosed as a transient episode of AWS, triggered by the manipulation of the parieto-occipital cortex during the shunt revision. This area of the brain is crucial for processing visual and sensory information, and any disturbance can lead to perceptual distortions.

Unlocking the Looking Glass: Implications and Future Directions

This case highlights the intricate relationship between brain surgery and perception. While visual disturbances following neurosurgery are not uncommon, AWS is a rarely reported phenomenon in this context. This suggests the condition may be more prevalent than previously thought but often goes unrecognized.

The manipulation of the parieto-occipital cortex, a region responsible for integrating visual and sensory information, appears to be a key factor in triggering AWS in this particular case. The inflammatory response resulting from the surgical intervention may have temporarily disrupted the normal functioning of this brain area, leading to the perceptual distortions.

Further research is needed to pinpoint the specific locations within the brain that, when affected, lead to AWS. Understanding the underlying mechanisms will help to better identify, manage, and potentially prevent this curious syndrome in the future. As with other patients with this self-limited syndrome, our patient's symptoms resolved without intervention.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.wneu.2018.10.041, Alternate LINK

Title: Transient Episode Of Alice In Wonderland Syndrome After Ventriculoatrial Shunt Revision

Subject: Neurology (clinical)

Journal: World Neurosurgery

Publisher: Elsevier BV

Authors: Pouya Entezami, Alexandra Paul, Matthew A. Adamo, Alan S. Boulos

Published: 2019-01-01

Everything You Need To Know

What exactly happens to someone's perception when they experience Alice in Wonderland Syndrome (AWS)?

Alice in Wonderland Syndrome (AWS) involves perceptual distortions where individuals experience alterations in how they perceive their own bodies and the world around them. This can manifest as micropsia, where objects appear smaller than they are, or macropsia, where objects appear larger. Some people with AWS also experience somesthetic hallucinations, which create a distorted sense of their body size. While these symptoms can be unsettling, it is crucial to recognize that they result from altered brain function, not from a psychotic disorder.

How can a ventriculoatrial shunt revision lead to someone experiencing Alice in Wonderland Syndrome (AWS)?

In a ventriculoatrial shunt revision, the manipulation of the parieto-occipital cortex during surgery can trigger Alice in Wonderland Syndrome (AWS). The parieto-occipital cortex is critical for processing visual and sensory information. Disturbances in this area of the brain can lead to perceptual distortions. This case highlights how medical procedures can impact perception due to the brain's complex visual pathways.

What specific visual distortions did the patient experience after his ventriculoatrial shunt revision?

The patient experienced macrosomatognosia, a sensation of feeling like his body was much larger than usual. He also experienced micropsia, where he perceived the heads of people around him as disproportionately small compared to their bodies. Despite these distortions, the patient remained aware that these perceptions were not real and even found the experience amusing after a few hours.

What are the broader implications of this case, and why might Alice in Wonderland Syndrome (AWS) be underreported?

This case suggests that Alice in Wonderland Syndrome (AWS) may be more prevalent than previously thought in post-neurosurgical contexts. The transient nature of the symptoms and the patient's awareness of the distortions could contribute to underreporting. Recognizing and documenting these cases can enhance our understanding of how brain surgery affects perception and improve patient care.

Besides neurological conditions like migraines and epilepsy, what other less common factors can trigger Alice in Wonderland Syndrome (AWS)?

Alice in Wonderland Syndrome (AWS) has been linked to various neurological and psychiatric conditions, including migraines, epilepsy, and the Epstein-Barr virus. However, this case underscores that surgical interventions, specifically ventriculoatrial shunt revisions, can also trigger AWS. This broadens our understanding of potential triggers and emphasizes the need for clinicians to consider surgical history when evaluating patients with perceptual distortions.