What is the management plan for an 84-year-old female with mild multifocal white matter disease and diffuse volume loss on brain MRI, presenting with dizziness?

Management of Dizziness in an 84-Year-Old with White Matter Disease and Brain Atrophy

The immediate priority is to determine whether this patient has benign paroxysmal positional vertigo (BPPV) versus a central cause of dizziness through bedside examination, specifically the Dix-Hallpike maneuver and neurologic assessment, as the MRI findings of white matter disease and atrophy are common age-related changes that do not directly explain acute dizziness symptoms. 1, 2

Critical Initial Assessment

Rule Out Red Flags First

• Perform a focused neurologic examination immediately to identify any focal deficits (diplopia, dysarthria, facial numbness, limb weakness, sensory changes, or inability to walk independently), as these indicate posterior circulation stroke or central pathology requiring urgent intervention 1
• Assess for central nystagmus patterns including downbeating nystagmus or direction-changing nystagmus, which indicate brainstem or cerebellar pathology 1, 2
• A critical pitfall: 75-80% of patients with posterior circulation stroke present with isolated dizziness WITHOUT focal neurologic deficits on standard examination, so absence of focal signs does not rule out stroke 1

Characterize the Dizziness Pattern

• Determine if this is true vertigo (spinning sensation) versus vague dizziness or presyncope, as elderly patients often describe atypical "vestibular disturbance" rather than classic spinning 2, 3
• Ask about precise duration of episodes: seconds suggest BPPV, minutes suggest stroke/TIA or vestibular migraine, and days-to-weeks suggests vestibular neuritis versus posterior circulation infarction 2, 3
• Identify triggers, particularly head position changes, which strongly suggest BPPV 2, 3

Bedside Diagnostic Testing

Perform the Dix-Hallpike Maneuver

• This is the single most important diagnostic test for BPPV, which is the most common cause of vertigo in elderly patients 4, 2, 3
• A positive test shows characteristic torsional, upbeating nystagmus and reproduces the patient's symptoms 3
• If positive for BPPV, no imaging is necessary 3

HINTS Examination (If Acute Vestibular Syndrome Present)

• If the patient has continuous vertigo lasting days with nystagmus and gait instability, perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) 1, 2
• This bedside examination has 100% sensitivity for stroke when performed by trained examiners 1, 2
• A normal head impulse test in acute vertigo suggests central (stroke) cause 1

Interpreting the MRI Findings

The White Matter Disease and Atrophy Are Likely Age-Related

• Mild multifocal white matter disease and diffuse volume loss are extremely common in 84-year-old patients and typically represent small vessel ischemic changes rather than acute pathology 4
• These findings do not directly cause acute dizziness episodes 4
• However, vascular risk factors associated with white matter disease increase stroke risk, so this patient requires more careful evaluation for posterior circulation ischemia 4, 1

When to Obtain Additional Imaging

• If the patient has focal neurologic deficits, atypical nystagmus patterns, or fails to respond to appropriate BPPV treatment, obtain MRI with diffusion-weighted imaging 1, 3
• Do not rely on CT head—it misses 60-80% of posterior circulation strokes 1, 3
• MRI with diffusion-weighted imaging is the appropriate study for suspected stroke 1, 3

Treatment Algorithm

If BPPV is Diagnosed (Positive Dix-Hallpike)

• Perform the Epley maneuver (canalith repositioning procedure), which has 90-98% success rate 3
• Counsel the patient about 10-18% recurrence rate at 1 year and up to 36% long-term recurrence 4
• Counsel about fall risk, which is particularly important in elderly patients—assess home safety and consider supervision until symptoms resolve 4
• Schedule follow-up to ensure resolution and monitor for recurrence 4

If Central Cause is Suspected

• Obtain urgent MRI with diffusion-weighted imaging 1, 3
• Initiate stroke workup including vascular imaging of vertebral and basilar arteries 5
• Consider aggressive vascular risk factor management given the white matter disease burden 4

If Diagnosis Remains Unclear

• Consider vestibular rehabilitation, which is helpful for many peripheral and central causes 6
• Avoid pharmacologic treatment initially, as it impairs central nervous system compensation for vestibular dysfunction 6
• Ensure close follow-up with re-evaluation if symptoms persist or worsen 4

Vascular Risk Factor Management

Address Modifiable Risk Factors

• Given the white matter disease on MRI, aggressively control vascular risk factors including hypertension, diabetes, hyperlipidemia, and smoking 4
• These patients have higher risk for rapid cognitive decline and stroke 4
• Consider more frequent follow-up given the vascular burden 4

Common Pitfalls to Avoid

• Do not assume the MRI findings explain the dizziness—acute symptoms require specific vestibular evaluation 1, 2
• Do not skip the Dix-Hallpike maneuver—it provides more diagnostic value than imaging for most dizziness cases 1, 3
• Do not order routine imaging for isolated dizziness with typical peripheral features—diagnostic yield is extremely low 1
• Do not assume normal neurologic exam rules out stroke in an elderly patient with vascular risk factors and acute vestibular syndrome 1