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We present the case of a 76-year-old woman with multiple comorbidities, including dementia and a history of pacemaker implantation, who presented with dizziness. The case underscores the importance of recognizing the underlying cause of stroke, particularly in patients with pacemakers, as it may necessitate a specialized approach in their management.

A 76-year-old woman with arterial hypertension presented to the emergency department with dizziness. Patient felt dizzy after getting up from the couch, with a sensation of being pulled to the right, and needed significant assistance from her husband while walking. She has a known history of mild dementia and a pacemaker implantation 11 years ago for second-degree AV block. Upon examination, she was not fully oriented, with a blood pressure of 180/100 mmHg. The ECG showed a sinus rhythm without abnormalities. The cranial CT scan revealed signs of cortical atrophy and bilateral hypodense white matter changes. A neurological consultation was conducted, diagnosing a suspected recent cardioembolic lacunar infarct with acute balance disturbances and apraxic deficits on the right side.

Echocardiography revealed a globally reduced left ventricular function of 45%. The pacemaker lead was mispositioned in the left ventricle, confirmed by TEE, likely passing through a PFO. The extracranial examination showed atherosclerotic changes without evidence of stenosis. Given the patient’s multiple comorbidities and dementia, a comprehensive discussion was held with the family regarding the further course of action. It was collectively decided to continue with conservative therapy, without pursuing surgical revision or adjustment of the pacemaker lead. The patient was subsequently initiated on therapeutic anticoagulation therapy.