Mitchell S.V. Elkind,
Sana Syed, MD
Andrew J. Westwood,
MD, MRCP (UK)
A 25-year-old man with headaches and
A 25-year-old Caucasian man with a history of head-
aches presented to the emergency room for witnessed
collapse. The emergency room physician who initially
evaluated the patient reported that the physical exam-
ination had normal results.
The patient was currently incarcerated for violent
assault and battery without any prior offenses. While
walking, he had felt his legs become weaker before col-
lapsing to the ground. Loss of consciousness occurred
for approximately 1 minute. He denied any preceding
symptoms such as chest pain, palpitations, or vision
changes, and there was no head trauma. There was
no incontinence, tongue biting, or witnessed abnormal
movements. Within a fewminutes, the patientbecame
reorientedwithout confusion or lethargyafterward.He
was able to stand and walk after the collapse.
The patient had a chronic history of headaches typ-
ically lasting a few hours, occurring once or twice per
month, holocephalic in nature and responsive to simple
analgesics. This time, however, the headache had per-
sisted for several days. The headaches had never woken
him up from sleep. In the 24 hours prior to presenta-
tion, he had been unable to eat or drink due to vomit-
loss of 30 lbs.
There was no history of hematochezia or hematuria.
There was no history of smoking, IV drug use, or alco-
hol abuse. He denied HIV risk factors or history of
travel. Family history was remarkable for pancreatic
cancer in the paternal uncle and his father had a pace-
maker (unknown reason).
Questions for consideration:
1. Given this information, what is the differential at
2. What are the red flags in this history?
Syncope is characterized by a transient loss of con-
sciousness and postural tone followed by spontaneous
recovery and is usually caused by cerebral hypoxemia.
It may result from cardiac or neurologic causes; how-
ever, the primary mechanism of syncope is typically a
response to cerebral hypoperfusion.
Neurally induced syncope or vasovagal syncope
may result from a cardioinhibitory response, a vasode-
pressor response, or a combination of the two.1A
cardioinhibitory response results from an increase in
parasympathetic tone, which may cause bradycardia.
A vasodepressor response results from a decrease in
sympathetic tone and leads to hypotension. Causes
can include processes that increase intra-abdominal
pressure, situational stressors, or dehydration. Under-
lying cardiac causes may include rhythm disturbances
or structural issues and noncardiac causes like seizures
and strokes may be a result of underlying intracranial
mass or vessel disease. Additional etiologies include
drugs, orthostasis, a pulmonary embolus, or it may be
psychogenic in origin.
The patient’s lack of relief with simple analgesia
and the prolonged duration of the headaches were
suggestive of a change in his headache pattern.
The unintentional weight loss and hemoptysis
were also concerning; in an older person, meta-
static carcinoma would be a primary concern.
However, given this history in a 25-year-old pris-
oner, an infectious etiology such as tuberculosis
needed to be considered. Chronic alcohol use
was also a possibility.
The pacemaker in the father may also suggest a
familial cardiac abnormality, placing the patient at
higher risk for a spontaneous arrhythmia and simple
GO TO SECTION 2
From the Department of Neurology (S.S.), Beth Israel Deaconess Medical Center; and Department of Neurology (A.J.W.), Boston University
School of Medicine, Boston, MA.
Go to Neurology.org forfull disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
© 2013 American Academy of Neurologye211