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A man in his 70s reported a 3-month history of unsteady gait and falls. His gait was previously normal. He had no symptoms or signs of stroke. He had a 6-year history of impaired verbal fluency and mild executive dysfunctions, consistent with cerebral small vessel disease (CSVD). On examination, his gait was ataxic, and he had a positive Romberg test (Panel 1 — video 1). Power was grossly intact in his lower limbs. He demonstrated mild loss of proprioception of his left big toe. An MRI (figure 1) a year earlier demonstrated normal hippocampal volume and white matter chronic small vessel ischaemic disease. A cerebral single-photon emission computerised tomography (SPECT) was performed and demonstrated widespread CSVD. Compared with the SPECT from 14 months prior (figure 2), there were new perfusion defects in the left parietal periventricular white matter, the right thalamus and the right anterior temporal cortex as well as more evident perfusion defects in the frontal lobes (figure 3 specifically shows the defects in the frontal lobes and right thalamus). Vitamin B12 deficiency and tabes dorsalis causing Romberg sign were unlikely because B12 level and syphilis screen were normal, respectively. As there were no abnormalities to cerebellum perfusion and previous MRI demonstrated no structural cerebellar abnormality, cerebellar cause was also unlikely. Given the absence of bradykinesia, rigidity or tremor, this presentation was inconsistent with Parkinson’s disease. In consideration of this all, a diagnosis of CSVD progression causing the gait disorder and falls was therefore made. CSVD is the most common chronic and progressive vascular disease which affects capillaries, arterioles and small veins supplying the brain’s white matter and deep structures.1 This condition, if widespread and extensive, can cause gait disturbance2 3 and uncommonly, a positive Romberg sign. He opted against physiotherapy and at his most recent follow-up, his gait disturbance had not changed.
Cerebral small vessel disease (CSVD) can cause gait disturbance and uncommonly, a positive Romberg test.
Functional imaging such as single-photon emission computerised tomography can detect changes in ischaemia caused by progression of CSVD.
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Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: LKMC and DKYC.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.