What is the preferred imaging for a 43-year-old female who experienced syncope (fainting) while driving and is awaiting a neurology consultation?

From the Guidelines

For a 43-year-old female who experienced syncope while driving and is awaiting neurological evaluation, the preferred initial imaging would be a transthoracic echocardiogram, as it is usually appropriate for the initial imaging of a presyncope or syncope patient with clinical suspicion for cardiovascular etiology based on history, physical examination, and ECG findings 1. This comprehensive imaging study provides detailed visualization of cardiac structures and can detect potential causes of syncope such as cardiac abnormalities, valvular disease, or structural heart disease. The echocardiogram should be accompanied by an electrocardiogram (ECG) to evaluate for arrhythmias or abnormality indicative of higher risk for arrhythmia. Additionally, a brain MRI with and without contrast may be considered if there are signs or symptoms suggesting a neurological cause, such as cerebrovascular abnormalities, space-occupying lesions, or structural abnormalities. However, according to the ACR Appropriateness Criteria, brain CT and MRI should be avoided in uncomplicated syncope 1. The combination of these imaging and diagnostic tests allows for comprehensive evaluation of neurological, cardiac, and vascular causes of syncope, which is particularly important given the occurrence during driving, representing a significant safety concern for both the patient and others. Some key points to consider in the evaluation of syncope include:

• A detailed history and physical examination to identify potential causes of syncope
• Measurement of postural changes in blood pressure to diagnose orthostatic-related syncope
• A detailed neurologic history and physical examination to exclude symptoms or signs of a separate neurologic process
• Consideration of cardiac evaluation, including ECG and echocardiogram, in patients with clinical suspicion for cardiovascular etiology
• Avoidance of routine cardiac imaging unless cardiac etiology is suspected on the basis of an initial evaluation, including history, physical examination, or ECG findings 1.

From the Research

Imaging Modalities for Vascular Malformations

The patient's symptoms, such as fainting, may be related to vascular malformations. The preferred imaging modality for diagnosing vascular malformations is:

• Magnetic Resonance Imaging (MRI) 2, 3, 4, 5, 6

Characteristics of Vascular Malformations on MRI

MRI can help characterize vascular malformations by:

• Delineating the extent and anatomic relationship of the malformation to adjacent structures 5
• Providing hemodynamic characterization, differentiating high- and low-flow vascular malformations 5
• Showing signal voids, lobulated masses, and hemodynamic flow characteristics 3

Specific MRI Sequences for Vascular Malformations

Specific MRI sequences that can be used to evaluate vascular malformations include:

• Conventional MRI sequences, including MR angiography 6
• Susceptibility-weighted imaging, black blood sequences, arterial spin labeling, and 4D flow imaging 6
• Dynamic time-resolved contrast-enhanced MR angiography 5