Syncope: case studies

In this series of clinical vignettes, the authors have attempted to provide a "feel" for the varied causes of syncope. The neurologist should be able to diagnose most causes of syncope using a simple algorithmic approach. Initial evaluation includes detailed clinical history, physical examination, and 12-lead ECG. Following initial evaluation, the cause of syncope is usually immediately apparent (typical story for vasovagal syncope, clinically demonstrable autonomic failure, long QT), strongly suspected (syncope preceded by chest pain or palpitations), or uncertain. In the latter group of patients, further workup will depend on the suspicion or documented presence of heart disease. In those with a single episode of syncope and no evidence of heart disease, further workup may not be necessary. In patients over 60 years of age with recurrent episodes and no cardiac history or abnormal ECG, tilt-table testing and carotid sinus massage may be diagnostic. If no diagnosis is found, an implantable loop monitor may be needed. Patients with heart disease will need the most comprehensive evaluations, possibly including exercise testing, cardiac electrophysiology, and tilt-table testing. As better understanding of pathophysiology and epidemiology emerge, under-standing of the diagnosis and treatment of syncope will improve. In the meantime, there is no substitute for astute clinical acumen.