Background: Late-onset epilepsy (LOE), onset over 60, is often attributed to cerebrovascular disease (CVD), and is associated with increased stroke risk. We investigated the radiological prevalence of CVD in LOE. Methods: We undertook a retrospective case-control study of patients with LOE and age and sex-matched controls, also matched for imaging modality. Radiological CVD was recorded, with radiological findings by an experienced consultant neuroradiologist usi a structured proforma. Results: 105 cases and 105 controls were studied, comprising 61 (58.1%) males, mean (±SD) age (years) 72.7 ± 7.48 (cases), 72.4 ± 7.02 (controls). 9 cases had isolated seizures rather than LOE. Imaging modality (in cases and controls) was CT in 59 and MRI in 46. Radiological CVD was more prevalent amongst cases (65.7%) than controls (33.3%) (p <0.0001, Chi-square), odds ratio 3.83 (95% CI 2.16-6.79). Large vessel disease (LVD) (single or multiple cortical or subcortical infarcts > 1.5 cm) was present in 23 (21.9%) cases and 2 (1.9%) (p <0.001) controls, with small vessel disease (SVD) (periventricular or subcortical white matter lesions (WMLs), including leukoaraiosis (LA)) present in 52 (49.5%) cases (LA in 4) and 34 (32.3%) controls (LA in 0) (p <0.05). When WMLs were rated using a semiquantitative visual rating scale, a trend towards greater severity was observed amongst cases compared to controls. Conclusions: Radiological CVD is significantly more prevalent in patients with LOE than controls, including signs of both LVD and SVD. SVD also appears to be of greater severity. Further studies are needed in this area.