Introduction Although cerebral small vessel disease is a significant contributor to the development of imbalance and falls in the elderly, whether it also contributes to the development of dizziness is not known.

Methods A retrospective case analysis was conducted for 125 dizzy patients referred to two neuro-otology tertiary centres in London and Pisa. Specific search criteria of “white matter disease” was applied to databases and patients were divided into ‘explained’ causes of dizziness (ie benign positional vertigo, orthostatic hypotension, cerebellar ataxias) and ‘unexplained’ causes of dizziness. White matter hyperintensities (WMH) in MRI (T2 weighted and FLAIR) were blindly rated according to the Fazekas scale.

Results 61 patients (mean age=72SD=7.95 years) in the ‘unexplained’ group and 64 (mean age=72.01SD=8.28 years) in the ‘explained’ group were recruited. The overall frequency of lesions (Fazekas 1–3) differed between the groups (p=0.015). The frequency of severe lesions (Fazekas 3) was significantly higher in the unexplained group (21%) than in the explained group (5%; p=0.005).

Conclusion Increased severity of WM abnormalities in cases of unexplained dizziness suggests that such abnormalities are contributory to the development of dizziness. WM lesions may induce dizziness either because patients perceive a degree of objective unsteadiness or by a cortical-subcortical disconnection syndrome.