Neurologic clinics
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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. ⋯ 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.
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Data from randomized therapeutic trials often provide little relevant evidence for therapeutic decisions physicians make daily. By illustrating the nuances of these four complex cases involving cerebrovascular disease, the authors stress the importance of more time spent by specialists at the bed-side, exploring patients' symptoms and learning their thoughts, fears, biases, and wishes.