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Endgames Picture Quiz

Recurrent loss of consciousness

BMJ 2008; 337 doi: (Published 11 December 2008) Cite this as: BMJ 2008;337:a2703
  1. John Cooke, specialist registrar (geriatric medicine/general (internal) medicine),
  2. Sheila Carew, registered general nurse,
  3. Aine Costello, clinical nurse manager,
  4. Tina Sheehy, clinical nurse specialist (functional gerontology),
  5. Declan Lyons, professor of medical science
  1. 1Clinical Age Assessment Unit, Mid-Western Regional Hospital, Dooradoyle, Limerick, Republic of Ireland
  1. Correspondence to: J Cooke johncooke_cork{at}

    An electrocardiograph and beat-to-beat blood pressure recordings were performed during right sided supine carotid sinus massage on a 78 year old man (figure). He reported frequent episodes of loss of consciousness, which were typically of sudden onset followed within minutes by rapid recovery to full health. Some were associated with jerking movements of his limbs. He linked some of these episodes to turning his head. He had no important comorbidities but had recently fallen and sustained a fracture.

    Simultaneous beat-to-beat blood pressure (above) and electrocardiograph (below) tracings performed during right sided supine carotid sinus massage. Arrow indicates onset of 5 second carotid sinus massage. Image created with BeatScope software, using data obtained from a Finometer device


    • 1 What is the most likely cause for this patient’s recurrent episodes of loss of consciousness?

    • 2 Outline the assessment he should have before carotid sinus massage.

    • 3 Outline the treatment options available.


    Short answers

    • 1 This patient has carotid sinus syndrome (predominantly cardioinhibitory subtype) causing convulsive syncope.

    • 2 He should have a full history and examination (orthostatic blood pressure and cardiac and carotid auscultation) with 12 lead electrocardiography.

    • 3 General treatments are education and avoidance of triggers. Specific treatments are reserved for difficult cases: for pure cardioinhibition, a permanent pacemaker; for pure vasodepression, …

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