Can a chronic lacunar infarct (cerebral small vessel disease) cause giddiness or dizziness in an older adult?

Can Chronic Lacunar Infarcts Cause Giddiness?

Yes, chronic lacunar infarcts can cause giddiness and dizziness in older adults, though the mechanism is typically related to progressive small vessel disease affecting balance and coordination rather than acute vestibular dysfunction.

Understanding the Connection

Lacunar infarcts result from occlusion of single penetrating arteries and account for approximately 25% of all ischemic strokes 1, 2. While these small subcortical infarcts are often considered relatively benign in the acute phase, they have significant long-term neurological consequences that can manifest as chronic dizziness 1, 3.

The key issue is that lacunar infarcts rarely occur in isolation. The presence of a chronic lacunar infarct typically indicates ongoing cerebral small vessel disease, which progresses asymptomatically over time 1, 4. This progressive white matter disease and accumulation of silent lacunes can affect:

• Executive function and psychomotor speed, which are critical for balance and spatial orientation 4
• Gait stability and coordination, particularly when multiple lacunes accumulate 4
• Cognitive processing, leading to what patients may describe as "dizziness" or feeling "off-balance" 2, 4

Critical Distinction: True Vertigo vs. Non-Specific Dizziness

You must first determine whether the patient is experiencing true vertigo (spinning sensation) versus non-specific dizziness or disequilibrium 5. This distinction is crucial because:

• True vertigo (spinning sensation) is more likely related to peripheral vestibular causes like BPPV, vestibular neuritis, or Ménière's disease rather than chronic lacunar infarcts 5, 6
• Non-specific dizziness or disequilibrium (feeling unsteady, off-balance, or lightheaded without spinning) is more consistent with chronic small vessel disease and lacunar infarcts 5, 7

When to Suspect Lacunar Infarcts as the Cause

Consider chronic lacunar infarcts as a contributor to dizziness when the patient presents with:

• Chronic, persistent dizziness lasting weeks to months rather than episodic attacks 5
• Vascular risk factors: hypertension, diabetes, age >65 years, prior stroke 1, 2
• Associated cognitive decline, particularly affecting executive function and processing speed 4
• Gait instability and increased fall risk without clear peripheral vestibular findings 5, 7
• Progressive symptoms rather than sudden onset 2, 3

Diagnostic Approach

Initial Clinical Assessment

1. Characterize the dizziness precisely: Ask about duration (seconds, minutes, hours, or constant), triggers (positional changes, standing, spontaneous), and associated symptoms (hearing loss, tinnitus, headache) 5, 7

2. Perform targeted physical examination:

   • Dix-Hallpike maneuver to rule out BPPV 5, 7
   • Orthostatic vital signs to exclude orthostatic hypotension 5
   • Focused neurological examination including gait assessment, cerebellar testing, and cognitive screening 7

3. Medication review: Antihypertensives, diuretics, sedatives, and anticonvulsants are leading reversible causes of chronic dizziness in older adults 5, 7

Imaging Decisions

MRI brain without contrast is the appropriate imaging modality when evaluating for chronic lacunar infarcts as a cause of dizziness 5. Indications include:

• Progressive neurologic symptoms or cognitive decline 5
• High vascular risk factors with chronic dizziness 8, 5
• Atypical presentation that doesn't fit peripheral vestibular causes 5
• Focal neurologic deficits on examination 5, 7

CT head has extremely low diagnostic yield (<1%) for isolated dizziness and should not be used 5. White matter hyperintensities and silent lacunar infarcts are common findings on MRI in elderly hypertensive patients and are associated with increased risk of cognitive decline 8.

Management Considerations

Primary Treatment Focus

The goal is aggressive vascular risk factor modification rather than symptomatic treatment of dizziness 1, 2:

• Blood pressure control: Target SBP <120 mmHg in high cardiovascular risk patients, though elderly patients require slower titration and monitoring for dizziness, syncope, or neurologic symptoms 8
• Antiplatelet therapy for secondary stroke prevention 1
• Statin therapy regardless of baseline cholesterol 1
• Diabetes management if present 1, 2

Symptomatic Management

• Vestibular rehabilitation therapy can significantly improve gait stability and balance, particularly beneficial for elderly patients with chronic dizziness 5
• Fall risk assessment and home safety modifications are critical, as dizziness increases fall risk 12-fold in elderly patients 5, 7
• Medication optimization: Review and discontinue or reduce doses of medications contributing to dizziness 5, 7

Common Pitfalls to Avoid

1. Assuming chronic lacunar infarcts are benign: While short-term prognosis is favorable, mid- and long-term outcomes include increased risk of death, stroke recurrence, cognitive decline, and dementia 1, 2, 3

2. Failing to distinguish true vertigo from non-specific dizziness: This leads to inappropriate workup and missed diagnoses 5, 7

3. Over-relying on imaging: Most elderly patients with chronic dizziness have incidental findings on imaging that don't explain symptoms 5

4. Neglecting medication review: Polypharmacy is a major contributor to dizziness in elderly patients and is often reversible 5, 7

5. Aggressive blood pressure lowering without monitoring: In elderly patients with chronic lacunar infarcts, overly aggressive BP reduction can cause borderzone infarcts due to loss of cerebral autoregulation 8

Long-Term Prognosis

Patients with lacunar infarcts face increased risk of:

• Cognitive decline and vascular dementia, particularly affecting executive function 2, 4
• Recurrent stroke at rates similar to other stroke subtypes 2, 3
• Death from cardiovascular causes in the mid- to long-term 1, 2

Therefore, chronic lacunar infarcts should be regarded as a potentially severe condition requiring rigorous long-term management and follow-up 1, 3.