Case report

Paramedics admitted an 82-year-old woman to the emergency room, who had a first event of a syncope. At time of admission the patient still suffered from a horrible headache and vertigo. When admitted her vital signs were stable and physical exam only showed a bruise at the back of her head. Her medical history showed a medically treated hypertension and a diet-controlled type 2 diabetes.
The suspected diagnose was a cerebrovascular event, but the immediate cranial CT scan was unremarkable for stroke and intracranial hemorrhage. Laboratory was unremarkable except for an elevated troponin level (32,4 pg/ml, norm < 14 pg/ml) and a very high D-Dimer level (7,4 mg/l, norm < 0,5 mg/l). Therefore, I added a CT thorax angiography that showed a relevant pulmonary embolism. 
TTE showed normal bi-ventricular function without signs for a right side impairment. At the emergency room symptoms improved and the patient was symptom-free.
According to the guidelines, the risk assessment revealed an intermediate-low risk situation with a PESI Score of 102 points. Following the guideline recommendations, I decided to hospitalize the patient and to start the oral anticoagulation immediately. Due to a busy emergency room, the patient was transferred to the ward as soon as possible.

At the same night, I was called for the clinical assessment of the patient, because she woke up from extraordinary vertigo and nausea. Vital signs were stable, but I found a spontaneous nystagmus to the right. Taking the whole story into account, I suspected an intracranial hemorrhage after her trauma and new onset of oral anticoagulation. The emergency cranial CT scan showed no signs of intracranial hemorrhage, edema as well as no signs of ischemia. 
Under medical therapy the symptoms improved. The reason for the nystagmus stayed unclear. 

Literature

First, syncope can be a symptom of acute pulmonary embolism (PE). According to the “PESIT-Trial“(2016, NEJM), first event syncopes are in 17,3% the main symptom of an acute PE, way more than I would have expected. Therefore, doctors should keep the PE in mind, when treating an unclear syncope.

Secondly, the therapy and classification of patients with a syncope and a PE are not enough in the focus of the current guidelines even though the combination is not unusual as stated before. Barco and colleagues (2018, EHJ) published a meta-analysis, which discovered that a syncope is mainly a risk factor for hemodynamic instability in patients with PE and an increased risk for PE-associated adverse outcome. However, they did not comment on possible intracranial complications as a complication of the primary trauma. 

Learning Points
First, doctors at the emergency room need to have the acute pulmonary embolism in mind, when a patient is admitted with a first event of syncope. The prevalence is higher than expected.
Secondly, these patients need a higher level of care because they could have had an additional trauma and therefore, they have a relevantly increased risk of bleeding complications especially through the needed anticoagulation. These patients ought to be monitored more invasively and anticoagulation may be started with unfractionated heparin or low molecular weight heparin, giving the possibility to give an antidote in case of relevant bleeding complication.

At last, these patients need to be informed more thoroughly because of their ongoing increased risk of bleeding complications even after their release from the hospital.