Clinical Reasoning: A 51-year-old woman with syncopal episodes and multiple cranial neuropathies

Abstract

### Case presentation. A 51-year-old right-handed woman was admitted to the hospital because of two syncopal episodes. Both events had similar features with sudden onset of loss of consciousness. There were no preceding symptoms. They lasted only few seconds and were not accompanied by any abnormal movements, incontinence, or tongue biting. There was no confusion following the events. A feeling of vertigo, which gradually dissipated over the following 2 days, was the only residual symptom following both episodes. The patient also had a history of hypertension. She was on no medications. She consumed alcohol occasionally but denied tobacco or drug abuse. Her family history was positive only for heart disease in her mother. ### Question for consideration: 1. What is the differential diagnosis of syncope in this case? GO TO SECTION 2 Syncope is a sudden and brief loss of consciousness, associated with a loss of postural tone, with spontaneous recovery. It results from transiently decreased or interrupted cerebral blood flow. Frequently, the etiology remains unknown. Among diagnosed cases, neurocardiogenic syncope (including vasovagal attack, situational syncope, and carotid sinus syncope) is the most frequent cause. It stems from reflex-mediated changes in the vascular tone or heart rate. Other causes include cardiac (organic heart disease or arrhythmia) or neurologic diseases (concussion or seizure), orthostatic hypotension, medications, or psychiatric disorders.1,2 In this patient, based on the history, both reflex-mediated and primary cardiac causes were contemplated. On admission, the patient reported 3 years of right hearing defect without tinnitus or ear pain. She denied dysphagia or hoarseness of her voice. She was otherwise asymptomatic. On neurologic examination, cranial nerves I–VII were intact. There were multiple lower cranial neuropathies (VIII–XII) on the right side. There was sig-nificant right ear hearing loss. The tuning fork tests were equivocal: the Weber test lateralized to the affected ear (suggesting a conductive hearing loss in …