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Is neuroimaging necessary to evaluate syncope?

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A 40-year-old woman with a history of hypertension, who was recently started on a diuretic, presents to the emergency department after a witnessed syncopal event. She reports a prodrome of lightheadedness, nausea, and darkening of her vision that occurred a few seconds after standing, followed by loss of consciousness. She had a complete, spontaneous recovery after 10 seconds, but upon arousal she noticed she had lost bladder control.

Her blood pressure is 120/80 mm Hg supine, 110/70 mm Hg sitting, and 90/60 mm Hg standing. She has no focal neurologic deficits. The cardiac examination is normal, without murmurs, and electrocardiography shows sinus tachycardia (heart rate 110 bpm) without other abnormalities. Results of laboratory testing are unremarkable.

Should you order neuroimaging to evaluate for syncope?


Syncope is an abrupt loss of consciousness due to transient global cerebral hypoperfusion, with a concomitant loss of postural tone and rapid, spontaneous recovery.1 Recovery from syncope is characterized by immediate restoration of orientation and normal behavior, although the period after recovery may be accompanied by fatigue.2

The European Society of Cardiology2 has classified syncope into 3 main categories: reflex (neurally mediated) syncope, syncope due to orthostatic hypotension, and cardiac syncope. Determining the cause is critical, as this determines the prognosis.


According to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) and the 2009 European Society of Cardiology guidelines, the evaluation of syncope should include a thorough history, taken from the patient and witnesses, and a complete physical examination. This can identify the cause of syncope in up to 50% of cases and differentiate between cardiac and noncardiac causes. Features that point to cardiac syncope include age older than 60, male sex, known heart disease, brief prodrome, syncope during exertion or when supine, first syncopal event, family history of sudden cardiac death, and abnormal physical examination.1

Features that suggest noncardiac syncope are young age; syncope only when standing; recurrent syncope; a prodrome of nausea, vomiting, and a warm sensation; and triggers such as dehydration, pain, distressful stimulus, cough, laugh micturition, defecation, and swallowing.1

Electrocardiography should follow the history and physical examination. When done at presentation, electrocardiography is diagnostic in only about 5% of cases. However, given the importance of the diagnosis, it remains an essential part of the initial evaluation of syncope.3

If a clear cause of syncope is identified at this point, no further workup is needed, and the cause of syncope should be addressed.1 If the cause is still unclear, the ACC/AHA guidelines recommend further evaluation based on the clinical presentation and risk stratification.

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