TITLE:
A Sinister Cause of Recurrent Syncope
AUTHORS:
Brian L. Risavi, Erin M. Reese, Maryrose Kuo
KEYWORDS:
Neurology, Acute Medicine, Stroke
JOURNAL NAME:
Case Reports in Clinical Medicine,
Vol.14 No.10,
October
11,
2025
ABSTRACT: Background: Posterior circulation strokes represent a minority of strokes but are the most difficult to diagnose. Posterior circulation stroke presentations are widely variable, often suggesting benign disorders. History and physical examination are key to timely diagnosis. Case Report: A 58 year-old white male presented to the emergency department via Emergency Medical Services (EMS) after experiencing a syncopal event while standing at work. The patient had no symptoms prior to the event. He experienced several additional syncopal episodes while lying on the stretcher in the ambulance. Approximately 25 minutes post-arrival, the patient experienced a 15-second episode of unresponsiveness with extensor posturing during which time his skin became flushed and diaphoretic, although his eyes remained open without deviation. He subsequently had four or five more episodes. Of note, he became bradycardic and apneic with these episodes, often as low as 34 beats per minute. Magnetic resonance imaging of the brain showed multiple supra/infratentorial posterior circulation infarcts bilaterally. A follow-up magnetic resonance imaging study 24 hours later demonstrated worsening diffusion abnormalities. Computed tomography (CT) angiogram of the neck demonstrated occlusion of the proximal basilar artery. The patient’s mental status declined and intubation was required. The family decided on a do-not-resuscitate order for the patient, and he passed away nine days after admission. Conclusion: When a patient has a benign presentation, clinicians should look for high-risk signs and symptoms and exclude them. Posterior circulation strokes should remain high on the differential of patients presenting with recurrent syncope, dizziness, vertigo, nausea, sudden hearing loss, sudden hoarseness, gait disturbances, and focal deficits.