Aging with Cerebral Small Vessel Disease and Dizziness: The Importance of Undiagnosed Peripheral Vestibular Disorders.

Niccolò Cerchiai,Michelangelo Mancuso,Nicola Giannini,Augusto Pietro Casani,Elena Navari

doi:10.3389/fneur.2017.00241

Abstract

Recent studies showed a link between cerebral small vessel white matter disease (SVD) and dizziness: patients whose dizziness cannot be explained by vestibular disease show severe SVD and gait abnormalities; however, little is still known about how SVD can cause this symptom. The primary aim of this study is to examine the possible underlying causes of dizziness in neurovascular patients; this is in order to assess whether treatable causes could be routinely disregarded. A secondary aim is to possibly define a central oculomotor pattern induced per se by SVD. This could help the diagnosis of SVD-related dizziness. In this single-blind prospective study, 60 patients referred to a neurovascular clinic because of dizziness and SVD on imaging were divided into an L-SVD and a H-SVD group (low and high SVD burden, respectively), and then blindly examined with vestibulometric tests. In H-SVD group, the percentage of unexplained dizziness reached 82.8%. There was a higher prevalence of peripheral vestibular abnormalities in the L-SVD patient group (51.6%) than in the H-SVD (17.2%; p = 0.012). We found no differences in central oculomotor findings between the two groups. Although oculomotricity does not show any consistent pattern, a severe SVD can directly represent a cause of dizziness. However, a patient with mild SVD is more likely to suffer by a peripheral vestibular disorder. Therefore, given the high incidence of vestibular disease in neurovascular or geriatric clinics, clinicians should be cautious when ascribing dizziness solely to the presence of SVD as easily treatable peripheral vestibular causes may be missed.

Highlights

Cerebral small vessel white matter disease (SVD) has recently generated great interest in neurovascular practice because of its possible role in the development of geriatric syndromes [1, 2]
We found that SVD burden represents a significant predictor of unexplained dizziness and gait abnormalities; we postulated that white matter lesions may induce dizziness either because patients perceive a degree of objective unsteadiness or by a cortical–subcortical disconnection syndrome, secondary to disruption of white matter tracts involved in gait and balance control [9]
We considered as signs of peripheral vestibular involvement the following: typical benign paroxysmal positional vertigo (BPPV) nystagmus, canal paresis on caloric test, and decreased gain of the vestibulo-oculomotor reflex (VOR) on video head impulse test (vHIT)

Summary

Introduction

Cerebral small vessel white matter disease (SVD) has recently generated great interest in neurovascular practice because of its possible role in the development of geriatric syndromes [1, 2]. It has been established how SVD contributes to the development of cognitive decline and dementia [3, 4] and falls [5, 6], little is known about SVD as a possible cause of dizziness. This question is of great relevance to clinicians in both neurovascular and geriatric clinics as, in patients with established SVD, some potentially treatable peripheral causes of dizziness/unsteadiness may be disregarded. The present study addresses the following research questions: [1] Are there any underlying causes of dizziness in elderly patients with already known SVD? This question is of great relevance to clinicians in both neurovascular and geriatric clinics as, in patients with established SVD, some potentially treatable peripheral causes of dizziness/unsteadiness may be disregarded. [2] Can an accurate neurotological assessment reveal any consistent central oculomotor pattern induced per se by SVD?

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