Disclosures: Malcolm J. Winkle, MD: No financial relationships or conflicts of interest

Case Description: Initial assessment revealed that she was bradycardic to the 40’s and lethargic. Electrocardiogram demonstrated Mobitz type 1 heart block. These findings prompted cardiology consultation as she was symptomatically bradycardic and a transvenous pacer was placed; despite this intervention she was found to remain altered. Subsequent computed tomography of the head demonstrated diffuse subarachnoid hemorrhage and hydrocephalus. Neurosurgery and neuroradiology were consulted. She was admitted to the neurological intensive care unit and an emergent external ventricular drain was placed. Computed tomography angiogram demonstrated right middle cerebral aneurysm. Her physical exam greatly improved after drainage insertion. Patient underwent coil embolization of 6mm right posterior communicating artery aneurysm. Endovascular findings include successful coil embolization with near complete aneurysm occlusion and preservation of patent adjacent arteries. Subsequent magnetic resonance imaging of the head demonstrated multiple small foci of recent ischemic infarction in right middle cerebral artery and posterior cerebral artery territories suspicious for vasospasm. Multiple transcranial Dopplers demonstrated no vasospasm. Repeat brain imaging was negative and patient was stable for acute rehabilitation.

Setting: Level one Trauma Center

Patient: Patient is a 63-year-old female presenting with loss of consciousness while at home. Prior to loss of consciousness patient complained of headache. Assessment/

Results: After admission to inpatient rehabilitation, she continued to have some behavioral disturbance requiring the continued use of Seroquel, however neurologic examination was otherwise within normal limits. Therapists noted good functional independence with activities of daily living and patient was able to return home for outpatient follow up.

Discussion: This case highlights the difficulty in syncope work up as the differential is so broad. Reassessment and timely monitoring of response to therapy is key to determining likely diagnosis and subsequent treatment strategies.

Conclusion: The presentation of cerebral hemorrhage can mimic other systemic processes at initial presentation and requires careful assessment in its management.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/symptomatic-bradycardia-masking-the-presentation-of-ruptured-posterior-communicating-artery-aneurysm-a-case-report/