Correlation between recurrence of benign paroxysmal positional vertigo and imaging markers of cerebral small vessel disease in middle‑aged and elderly patients

Background Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder in middle‑aged and elderly individuals, with a high recurrence rate that severely impairs quality of life. Cerebral small vessel disease (CSVD) may contribute to BPPV recurrence by impairing vestibular microcirculation, but the correlation between CSVD imaging markers and BPPV recurrence remains unclear. This study aimed to explore their relationship and identify independent risk factors for BPPV recurrence. Methods A retrospective study was conducted including 131 middle‑aged and elderly patients with newly diagnosed BPPV from December 2024 to October 2025. All patients underwent diagnosis and repositioning treatment using the SRM‑IV system and were followed for 4 months. Cranial 3.0T MRI was performed to evaluate CSVD imaging markers according to the 2023 STRIVE‑2 criteria. Clinical and imaging data were compared between recurrence and non‑recurrence groups. Statistical analyses were performed using SPSS 26.0, including t‑test, Mann‑Whitney U test, χ² test, and binary logistic regression. Results The 4‑month recurrence rate was 29.0%. The recurrence group had significantly higher prevalence of hypertension, diabetes mellitus, hyperlipidemia, migraine, and higher 24‑hour systolic blood pressure variability (all P < 0.05). The recurrence group also showed higher rates of lacunar infarction and recent subcortical small infarcts, as well as more severe white matter hyperintensities and enlarged perivascular spaces (all P < 0.05). Logistic regression identified hypertension, diabetes mellitus, hyperlipidemia, migraine, and 24‑hour systolic blood pressure variability as independent risk factors. Enlarged perivascular spaces and lacunar infarction were independent imaging predictors of BPPV recurrence. Conclusions Vascular risk factors and CSVD imaging markers, especially enlarged perivascular spaces and lacunar infarction, are closely associated with BPPV recurrence, likely mediated by microcirculatory ischemic injury. Clinical evaluation and individualized intervention of these factors may help reduce recurrence risk and improve prognosis in middle‑aged and elderly patients. Trial registration Not applicable (retrospective observational study without health care intervention).