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Insights into evolution of cerebral small vessel disease on neuroimaging might advance knowledge of the natural disease course. Data on evolution of sporadic symptomatic lacunar infarcts are limited. We investigated long-term changes of symptomatic lacunar infarcts and surrounding white matter on structural magnetic resonance imaging.From 2 nonoverlapping, single-center, prospective observational stroke studies, we selected patients presenting with lacunar stroke symptoms with a recent small subcortical (lacunar) infarct on baseline structural magnetic resonance imaging and with follow-up magnetic resonance imaging available at 1 to 5 years. We assessed changes in imaging characteristics of symptomatic lacunar infarcts and surrounding white matter.We included 79 patients of whom 32 (41%) had complete and 40 (51%) had partial cavitation of the index lesion at median follow-up of 403 (range, 315–1781) days. In 42 of 79 (53%) patients, we observed a new white matter hyperintensity adjacent to the index infarct, either superior (white matter hyperintensity cap, n=17), inferior (white matter hyperintensity track, n=13), or both (n=12).Half of the sporadic symptomatic lacunar infarcts developed secondary changes in superior and inferior white matter. These white matter hyperintensity caps and tracks may reflect another aspect of cerebral small vessel-related disease progression. The clinical and prognostic values remain to be determined.